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cvs examination in detail
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Cardiovascular ExaminationProcedure and what to be looking for at each stage
Observation
? Marfan's -> aortic regurgitation? Rheumatological disorders eg ank. spond -> aortic regurgitation? Down's -> ASD or VSD? Turner's -> coarctation of aorta? Thyrotoxic -> predisposed to AF and high output heart failure? Alcoholism -> dilated cardiomyopathy
Hands
ClubbingCyanotic congential heart diseaseInfective endocarditis
Peripheral cyanosis and PerfusionEndocarditis is suggested by
Splinter haemorrhagesOsler's nodes = tender lumps in pulp of fingertipsJaneway lesions = red macules on wrist and hand
Nicotine stains - peripheral vascular disease
Radial pulse - for rate and rhythm
Irregularly irregular = atrial fibrillation (or multiple ectopics)Regularly irregular = 2nd degree heart blockWater hammer pulse (= Collapsing)
strong radial pulse that taps hand on lifting of armindicates wide pulse pressure of aortic regurgitation
Bounding pulseCO2 retentionLiver failureSepsis
Small volume thready pulse = shockRadio-radial delay - suggests coarctation or dissectionArterio-venous fistulae - buzzing - for dialysis
Carotid pulse - for character
NormalSmall volume - in low output states eg heart failure, shock, mitral stenosisSmall Volume And Slow Rising pulse = aortic stenosisCollapsing (rapid up and rapid down) in aortic regurgitation (also AV fistula or hyperdynamiccicrulation)Bisferiens = collapsing and slow rising occurring in mixed aortic diseasePulsus alternans - LVFJerky - hypertrophic cardiomyopathyPulsus Paradoxus - pulse weakens in inspiration - indicates tamponade or constrictive pericarditis
Cardiovascular Examination http://www.zen104556.zen.co.uk/Medicine/Medicine/ClinExamn/GenC...
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Face
Malar flush = mitral stenosis (also present in mixed mitral disease)? Jaundice - poss. prosthetic valve causing mild haemolysis
Eyes
Argyll-Robertson pupilpupil constricted, does not react to light but does to accomodation"the prostitute's pupil accomodates but does not react"think of syphilitic aortic regurgitation & poss. aneurysm
Xanthelasmata or corneal arcus = hyperlipidaemia
Mouth
CyanosisHigh arched palate of Marfan's -> aortic regurgitationMucosal petechiae -> infective endocarditis
JVP
Inspection of precordium
ScarsDeformityPulsationPacemaker boxes
Palpation
ThrillsHeaves
parasternal heave of RVHapex beat may be
tapping (quick and light) - mitral stenosisthrusting (diffuse and long) - mitral regurgitationheaving (sharp and firm) - LVH & aortic stenosis
Apex beat should be 5th intercostal space mid-clavicular line
Auscultation
Remember to roll into left lateral position and to sit forwardsRemember to listen on inspiration and on held expiration
Chest
Listen at lung bases for fine inspiratory creps of pulmonary oedema (LVF)
Sacral oedema
Abdomen
Hepatomegaly - RVF
Cardiovascular Examination http://www.zen104556.zen.co.uk/Medicine/Medicine/ClinExamn/GenC...
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Pulsatile hepatomegaly - tricuspid regurgitationSplenomegaly - endocarditisPulsatile mass (not liver) - abdominal aneurysmFemoral arteries, radio-femoral delay (coarctation of aorta) and femoral bruitsAlso can listen for renal bruits
Peripherally
Peripheral pulsesPitting oedemaPeripheral vascular disease - cold feet, gangreneVaricose veins
Finally
BLOOD PRESSUREnarrow pulse pressure indicates aortic stenosiswide pulse pressure indicates aortic regurgitationdrop of > 10mm Hg in inspiration indicates pulsus paradoxus and either tamponade orconstrictive pericarditis
Fundihypertensive change
grade I copper wiring of arteriesgrade II arteriovenous nippinggrade III flame or blot haemorrhages, cotton wool exudatesgrade IV papilloedema
Roth' spots = retinal vasculitis indicative of endocarditisUrine - haematuria may indicate endocarditisTemperature chart - endocarditis
The Signs of Different Conditions
Aortic Stenosis (Uncomplicated)
Observation - more likely to be maleHands - nilRadial pulse
normalAF (irregularly irregular)
Carotid pulse - slow rising pulseFace - nilJVP - normalThrills
aortic areas2nd R intercostal space (classical aortic area)4th L intercostal space/sternal edge whch is along the line of LV ejectionover apex (along line of LV ejection)
Apexnormal position 5th intercostal space in mid-clavicular lineheaving character due to LVH
Auscultation1st HS normalEjection systolic click may precede murmurEjection systolic murmur
Cardiovascular Examination http://www.zen104556.zen.co.uk/Medicine/Medicine/ClinExamn/GenC...
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loudest sitting forwardloudest in expirationradiates to carotids and apex
2nd HSmay be soft or absentparadoxical splitting may occur during expiration such that P2 occurs before A2 butA2 may not be audible anyway
No diastolic murmurs4th HS may be present just before 1st HS
Peripherally nil of noteBlood pressure
narrow pulse pressure eg 120/80 or 110/80
Mitral Regurgitation (Uncomplicated)
Observation - nilHands
look for signs of endocarditis ie splinter haemorrhages (transilluminate them), Osler's nodes,Janeway lesions
Radial pulse - may find AFFace - normal in uncomplicated mitral regurgitation (but malar flush of mitral stenosis if mixedmitral disease)Carotid
usually normal characterin severe disease may get a small volume jerky pulse due to shortened ejection volume andtime
JVPusually normalraised if subsequent pulmonary hypertension
Thrill possible in mitral areaHeaves
in severe regurgitation may develop a parasternal heave due to left atrium enlargementmay also have RV Heave if pulmonary hypertension has developed
Apexdisplaced laterally and downthrusting
Auscultation1st HS - soft or normalPan-systolic murmur
loudest at apex in left lateral positionradiates to the axillamay obscure aortic component of 2nd HS
2nd HS may be obscured (but if there is pulmonary hypertension it could be loud and late)3rd HS often present
Cardiovascular Examination http://www.zen104556.zen.co.uk/Medicine/Medicine/ClinExamn/GenC...
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