Cardiovascular Examination

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

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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


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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


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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


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Cardiovascular Examination