Cardiovascular ExaminationSESSION 2

Overview of Session

• An introduction to physical examinations

• Systematic run through of cardiovascular examination

• Chance to practise in the sessions

Introduction to Physical Examination

“Inspection, palpation, percussion, auscultation”

“Looking, feeling, moving”

Introduction to Physical Examination

• Tell/show the patient exactly what you want them to do with clear instructions

• Cover the patient up when you’re not examining them

• Always exam from the patients right hand side

Beginning a Physical Examination

• Introduce yourself: Full name, position and intent

•Explain what is going to happen and state that they can ask you to stop at any time

• Gain the patients consent and ask if they have any questions

• Confirm patient’s full name and DOB

• Position the patient appropriately• 45 degrees for CV examination

WASH YOUR HANDS

General Inspection Looking

• Stand at the end of the bed and look• Does this patient look unwell?• Is there anything to indicate disease around them?

• “The patient is in no obvious signs of discomfort”

• “Nothing around the bed indicating cardiac pathology”

Schedule for CVS examination

• Hands• Arms• Neck• Face• Chest • Back• Legs/Feet• Other Examinations

HandsExamine the patients hands do not turn the patient’s hands over, ask them to do it themselves (ask if they have pain in hands or wrists)• Capillary refill – Gently press the nail/ back of the hand for 5s: it should refill within 2s.Any evidence of?• Clubbing• Janeway lesions (palmar), Osler’s nodes (on finger pulps) and splinter haemorrhages (indicate infective endocarditis) • What's the appearance of the palmar creases?

Hands

http://emergencymedic.blogspot.com/2008/11/peripheral-signs-of-infective.html - janeway

http://morningreporttwh.blogspot.com/2008/09/hopingkong-isms-1.html - oslersnode

http://vasculitis.med.jhu.edu/typesof/polyangiitis.html

http://jama.ama-assn.org/content/304/2/159/F1.expansion.html

Arms• Radial Pulse – pads of digits 2,3 & 4 placed lateral to the tendon of flexor carpi radialis

• Note the rate and rhythm – time for 15 seconds• ‘Collapsing’ pulse – ask patient if they’ve had any problems with their shoulder. If no, raise arm and check for collapsing pulse

• Compare both sides for radial-radial delay• Brachial Pulse – extend the arm at the elbow and place thumb medial to the tendon of biceps brachii

• Note the character and volume

• Take the patient’s BP (not in the OSCE)

Neck• Jugular Venous Pressure (JVP)

• This is why your patient needs to be at 45 degrees• Ask patient to turn their head to their left• (Try not to say ‘look’; they will look…)• Get eyes down below neck and look upwards• The height of pulsation along the right internal jugular vein is measured vertically in cm from the sternal angle, then 5cm is added to this to give the JVP• Normal JVP is 8cm of blood

• Carotid Pulse:•Don’t palpate both at once…!

Face• Eyes

•Pale conjunctiva – ask pt to look up. Gently pull lower lids down – sign of anaemia• Xanthelasma• Corneal Arcus

• Mitral ‘facies’ – associated with mitral stenosis• A facies is a distinctive facial appearance associated with a condition

• Mouth• Look for central cyanosis (below tongue) and peripheral cyanosis (lips)• Note dental hygiene

Face

http://www.stmellionclinic.com/index.php?page=xanthelasma

http://www.kardionet.com/Herzkrankheiten/Klappenfehler_Int.html

Chest – Inspection & Palpation

• Expose the patient at this point• Look closely for any abnormalities

• Scars/ deformities•Ensure you also look at the lateral aspects of the thorax

• Apex beat:• Place R. hand flat on chest, inferior to the R. nipple• Practice!• 5th ICS, L. MCL. • Always find apex first, then check it’s position, not the other way around

• Heaves and Thrills• Thrill – due to a murmur• Heave – Suggestive of hypertrophy of the heart

Counting Ribs

http://parkin09.wikis.birmingham.k12.mi.us/Ecosystems+Glossary

• Feel sternal angle and move laterally – this is the 2nd rib

• Now move inferolaterally and count down the ribs

• The ‘x’th intercostal space is the space below the ‘x’th rib

Using Your Stethoscope• Earpieces facing anteriorly in the ear• ‘Diaphragm’ – Large face with membrane

• Tap it (gently) to check you’re listening through the right part• Most heart sounds

• ‘Bell’ – Looks like a bell…• Twist the tubing 180° to change to the bell• Deep sounds – Mitral stenosis

• Place it on the patients skin – no need to press. • Find a way you’re comfortable with

Chest – Auscultation• “All Prostitutes Take Money” – start at ‘A’

• Aortic – 2nd ICS, RSE• Pulmonary – 2nd ICS, LSE• Tricuspid – 4th ICS, LSE• Mitral – 5th ICS, L. MCL

•You need to practise listening to these sounds• ‘Lub’ HS 1 – Beginning of systole: inflow valves closing• ‘Dup’ HS 2 – End of systole: outflow valves closing

• If you cannot tell which is which, palpate the carotid pulse

• This HS 1

Valves

http://parkin09.wikis.birmingham.k12.mi.us/Ecosystems+Glossary

• Mitral

• Tricuspid

• Pulmonary

• Aortic

Chest – Auscultation• Specific Tests:

• Mitral regurgitation – Auscultate in L. axilla.

•Mitral stenosis – Roll patient onto left hand side. Re-palpate the apex beat. Listen over this place with the bell.

•Aortic regurgitation – Sit patient forward. Listen over the 4-5th ICS, LSE.

• Ask patient to take a deep breath in and hold

•Aortic stenosis – Ask patient to hold their breath and auscultate over the R. common carotid artery use the bell.

Chest Exam – Problems

Breasts

Back•With the patient sitting forward auscultate the lungs

• Ask patient to take deep breaths in and out – then tell to breathe normally

• Listen for ‘crackles’ over the lung bases on posterior thoracic wall

• Due to pulmonary oedema: fluid within the interstitium of the lungs – this closes the small airways in expiration.• Crackles are due to the airways ‘snapping’ back open on inspiration this is heard on inspiration∴

• Press gently over sacrum (‘lower back’) to check for pitting oedema

Legs • Re-cover the patient• Press over the tibia to check for pitting oedema

http://www.ptconsultants.biz/photos.html

Other examinationsThe conclusion

• Thank the patient• WASH YOUR HANDS• Conclude with stating what other investigations you would do• A full peripheral vascular examination• Fundoscopy• Temperature• Urine Dipstick• Abdominal examination for ascites and hepatosplenomegaly

Schedule for CVS examination

• Hands• Arms• Neck• Face• Chest • Back• Legs/Feet• Other Examinations

The OSCE • You will be performing a full CVS examination in the OSCE

• You have to do the full examination in 5 minutes

• Practise Practise Practise

Countdown timer...

5 min.

End 2 min. 4 min.

3 min.1 min.

START