CARDIOVASCULAR EXAMINATION Learning Document

Last updated: July 2019

By Aaron Ho (Final Year, Class of 2020) 1

Introduction (WIPE) - Wash Hands - Introduction

o “Good morning, I am Aaron Ho, a final year medical student from UCC.” o “Today, I am going to perform a heart (layman term) examination on you, and it will involve

examination of your hands, eyes, chest. Would that be okay with you?” o “May I have you name and DOB please? (Double check patient wristband ID)”

- Position, Pain o “Now I will adjust the bed and lie you down at a 45-degree angle”

§ 45-degree for Cardiac and Respiratory, Flat for GIT o “Are you in any pain right now?”

- Expose o “Would you please take out your top for me?”

§ NB: Some UCC tutors would prefer exposing only during the actual chest examination, as it can be rather cold for the patient. We suggest taking the top off at the start, and use a blanket to cover the torso while examining the peripheries.

General Inspection

- Well and comfortable, not cyanosed, not in respiratory distressed, not cachectic o Cachexia = Severe weight loss and muscle wasting due to cardiac failure/malignant disease

- No O2 lines, no IV drips, no telemetry, no GTN lying on the table - No Marfan’s, Turner’s, Down’s Syndrome

o Marfan’s syndrome is associated with Mitral Valve Prolapse (MVR) & Aortic Regurgitation (AR)

o Turner’s syndrome is associated with Bicuspid aortic valve & Dilated ascending aorta o Down’s syndrome is associated with AV septal defect & Tetralogy of Fallot

Hands (Dorsum)

- Finger Clubbing o Pathology: Cyanotic congenital heart disease, Infective Endocarditis o 4 stages of finger clubbing [Tutor favourite]

§ Stage I: Increased nail bed fluctuancy § Stage II: Loss of nail bed angle § Stage III: Increased nail curvature § Stage IV: Drumstick appearance

o NB: Traditionally, Schamroth’s sign would be elicited. However, it is increasingly phased out as it can be difficult for older patients with decreased mobility or tremors. Hence, we suggest looking at the curvature of the nail from the side instead. It is much more elegant.

- Tobacco staining o Pathology: Tobacco Smoker o NB: It is the tar stain, and not the nicotine stain, that causes tobacco staining. The usefulness

of this sign remains dubious as it largely depends on the way the smoker holds the cigarette.

- Splinter haemorrhage o Pathology: Infective Endocarditis

- Peripheral cyanosis

o Pathology: Atherosclerosis, PVD, Dehydration

CARDIOVASCULAR EXAMINATION Learning Document

Last updated: July 2019

By Aaron Ho (Final Year, Class of 2020) 2

- Capillary refill <3s o Pathology: Atherosclerosis, PVD, Dehydration

- Tendon Xanthomata

o Pathology: Hyperlipidaemia

Hands (Palmar) - Pallor in the crease

o Pathology: Anemia o NB: Please be as EXAGGERATIVE as possible to separate the skin overlying the crease!

- Palmar Xanthomata

o Pathology: Hyperlipidaemia

- Osler node + Janeway lesion o Pathology: Infective Endocarditis

o NB: Examiner favourite to ask about the difference between Osler Nodes and Janeway lesion

Characteristics Osler Nodes Janeway lesion

Tenderness Tender Non-tender Location Finger Tips & Toes Palm & Soles

Type of Infective Endocarditis Subacute Acute

Tobacco Staining Splinter hemorrhages Peripheral Cyanosis

Tendon Xanthomata Schamroth’s Sign

CARDIOVASCULAR EXAMINATION Learning Document

Last updated: July 2019

By Aaron Ho (Final Year, Class of 2020) 3

Pulse + Offer BP and RR - Pulse

o For educational purposes, know that there are 4 things you need to know when you feel the pulse, which are Rate, Rhythm, Volume and Character.

§ Rate and Rhythm via radial pulse • For rate, we recommend measuring for 10s, and then multiply by 6 to

calculate HR/min § Character and Volume via carotid pulse, as it is a larger and stronger pulse, hence

easier to feel.

- Radio-radial delay o Pathology: PVD or Aortic Coarctation

- Collapsing pulse (Aka Water-hammer pulse)

o Pathology: Aortic Regurgitation (AR) o Technique

§ Palpate brachial pulse with one hand and radial pulse with the other (Same arm) § “Do you have any shoulder pain? Mind if I raise your hand up?” § Raise the arm up § Radial pulse will collapse and

- Offer Radio-Femoral delay, BP, RR

Eyes

- Conjunctiva pallor o Pathology: Anemia o “Do you mind if I pull down your eyelid?” o NB: We recommend doing on one eyelid at a time, for elegance

- Jaundice

o Pathology: Congestive liver failure secondary to congestive heart failure

- Cornea arcus o Pathology: Increased cardiac risk o NB: It is a very common benign sign for elderly patient, hence its clinical usefulness remains

dubious.

- Xantholasmata o Pathology: Hyperlipidaemia

Palmar Xanthoma Janeway Lesion (Palm) Osler Nodes (Fingers)

CARDIOVASCULAR EXAMINATION Learning Document

Last updated: July 2019

By Aaron Ho (Final Year, Class of 2020) 4

- Offer to check for Roth spots using fundoscopy o Pathology: Bacterial Infective Endocarditis

Face

- Malar flush o Pathology: Mitral Stenosis

§ Appear as Blue-Red discolouration on the cheeks • Blue due to CO2 retention • Red due to vasodilation (CO2 is a vasodilator)

Conjunctival Pallor Cornea Arcus

Roth Spots Xantholasmata

Malar Flush (Side) Malar Flush (Front)

CARDIOVASCULAR EXAMINATION Learning Document

Last updated: July 2019

By Aaron Ho (Final Year, Class of 2020) 5

Mouth

- Dental caries and Petechiae o Pathology: Infective endocarditis

- High arched palate

o Pathology: Marfan’s Syndrome § As explained earlier, Marfan’s syndrome is associated with MVR and AR

- Central cyanosis

o Pathology: Heart failure § Decreased cardiac output results in decreased oxygenated blood being pumped out

into the rest of the body.

Neck

- JVP o Ensure patient at 45 degrees, head turned left and down to relax SCM

§ Not too excessively as it may contract the SCM instead o If JVP >3cm from zero point (Sternal angle),

§ Pathology: Right heart failure o Hepatojugular reflex

§ “Do you have any stomach pain? Mind if I press?” § If JVP >4cm persistently = Right heart failure

o NB: It is important to know the difference between venous (JVP) & arterial pulse (Carotid) Venous (JVP) Arterial (Carotid)

Palpation Non-palpable Palpable Waveform Double Single

Change with Inspiration Decreases during Inspiration No change Occlusion Occludable, fill from above Non-Occludable

Central Cyanosis

Dental Caries

High-arched Palate

Petechiae Mucosa

CARDIOVASCULAR EXAMINATION Learning Document

Last updated: July 2019

By Aaron Ho (Final Year, Class of 2020) 6

Chest Inspection (Hands on the Hips)

- Scars o Pacemaker

§ Pathology: Arrhythmias o Median sternotomy

§ Pathology: Hx of CABG (Coronary Artery Bypass Graft), Hx of Valvotomy § NB: Check if there is any graft scar at the limbs secondary to graft harvesting for

CABG. It will allow you to differentiate if the median sternotomy is due to CABG or Valvotomy.

- Deformities o Pectus excavatum + Kyphoscoliosis

§ Pathology: Marfan’s Syndrome • As explained earlier, Marfan’s syndrome is associated with MVR and AR

Chest palpation

- Apex Beat o Straight away put 3 fingers below the nipple to feel for the apex beat, starting laterally and

moving medially. o Once apex beat is palpated, do the routine “5th intercostal space + Mid-clavicular line” to

confirm that apex beat is not displaced o If apex beat can’t be felt, reinforce by asking the patient to lean to the left side. This will

bring the heart forward and accentuate the apex beat § If it still can’t be felt, just know that apex beat cannot be felt in more than 50% of

the patient

Pectus Excavatum Kyphoscoliosis

Pacemaker Scar Graft Harvest scar of great

saphenous vein Median Sternotomy

CARDIOVASCULAR EXAMINATION Learning Document

Last updated: July 2019

By Aaron Ho (Final Year, Class of 2020) 7

o If apex beat is Displaced, § Pathology: Dilatation of the heart (Remember, D for D)

- Heaves o Use the heels of your palm to feel for heaves on either side of the sternum o If you feel the heart beating “Up & Down”, Heaves are present.

§ Pathology: Hypertrophy of the heart (Remember, H for H) - Thrills

o Use your fingers to feel for thrills on either side of the sternum o If you feel “butterflies” (Turbulence) below, there are Thrills present

§ Pathology: Palpable Murmurs (Indicative of valvular disease) o NB: Different tutors will teach you different things, just adopt the one you think makes most

sense. We suggest doing on the either side of the sternum, as it is the same as for heaves. Less confusing!

§ Z pattern (Combination of heels, fingers, heels) § Palpate over every heart valves (APTM) § Either side of the sternum

Chest Auscultation (At last…...I can use my stethoscope!)

- General o Start by placing bell at mitral valve

§ Pathology: Low-pitch mitral stenosis murmur o Then place diaphragm at mitral valve, tricuspid valve, pulmonary valve and aortic valve

§ Pathology: Any type of murmurs (Too broad to be covered here) - Radiation

o Place bell at carotid § Pathology: Radiation from Aortic Stenosis § NB: The supposedly correct way is to use the diaphragm. But because the bell is

smaller and can have a better fit, we use bell instead. o Place diaphragm at Axilla

§ Pathology: Mitral Regurgitation - Manoeuvre

o While the diaphragm is still at the axilla, and ask the patient to lean to the left side § Pathology: This would accentuate Mitral Stenosis

o Place diaphragm at the *left side of the sternum, and ask the patient to lean forward § Pathology: This would accentuate Aortic Regurgitation § NB: Placing the stethoscope on the left might sound counterintuitive, because we

auscultate the right side of the sternum for aortic murmurs. Just know that by leaning forward, it will “bring the aortic valve to the front”, thereby accentuating its Aortic Regurgitation Murmur

Radiation to Carotid AS Radiation to Axilla MR Manoeuver (Lean left) MS Manoeuver (Lean forward) AR

CARDIOVASCULAR EXAMINATION Learning Document

Last updated: July 2019

By Aaron Ho (Final Year, Class of 2020) 8

LL Pulse (Dorsalis pedis)

- Pathology: PVD o If you cannot feel the dorsalis pedis pulse, then move proximally and feel for posterior tibial

artery pulse, then popliteal artery pulse, then femoral pulse, and so on…

Sacral and Ankle edema - Pathology: Right heart failure - NB: Sacral edema would be prominent if the patient is always sitting, while Ankle edema would be

prominent if patient is always standing Reverse WIPE

- Expose o “You can wear back your clothes”

- Position o Return the patient to starting position

- “Introduction” o “Thank you for your time, and I will report the findings to the consultant”

- Wash hands Summary

- The patient is Mary Murphy, a 60-year old lady who complained of chest pain. I have completed a normal cardiac examination and there are no stigmata of CVD in the hands, face and neck. Upon chest inspection, there are no scars or deformities. Palpation of the chest reveals normal apex beat, with no heaves or thrills. Auscultation of the chest reveals normal S1 and S2 sounds with no murmurs or added sounds.

- To follow up with the patient, I would recommend a FBC, Cardiac enzymes, BNP, 12 lead ECG, Chest X-ray and full peripheral vascular examination.

Disclaimer: All the pictures used in this document do not belong to us and we do not intend to infringe any copyrights. It is entirely for educational purposes only. The information contained in this document has been gathered from different textbooks and online sources, and is accurate to the best of my knowledge at the time of last edit.