Comprehensive Examination of Cadiovascular System

7/31/2019 Comprehensive Examination of Cadiovascular System

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Introduction

at the start

Wash your hands, introduce yourself, obtain consent.

Patient position:

Always make sure the patient is comfortable. Sit the

patient up at 45o. Obtain adequate exposure - thepatient should be exposed up to the waist. For femalepatients, bras should ideally be removed, or else it can bevery difficult to palpate or auscultate at the apex.


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From the end of the bed:

- Look at the patient: oxygen masks / signs ofrespiratory distress / pain / cyanosis / lines / scars (eg.pacemaker), etc.

- Look around the bed: medication (eg. GTN sprays) /fluids / walking aids / cigarette packets, etc.


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Peripheral signs

Hands:

- Tremor: Can be caused by thyrotoxicosis - can cause Atrial Fibrillationand congestive heart failure (CHG).

- Clubbing: Causes - congenital (cyanotic) heart disease, sub-acuteinfective endocarditis.

- Tar staining: Smokers. - Nail bed capillary pulsation: 'Quinke's sign' of Aortic Regurgitation. - Splinter haemorrhage: Endocarditis, acute glomerulonephritis. - Osler nodes: Small and painful red-brown subcutaneous papules on

the pulps of the fingers or toes (infective endocarditis). - Jane way lesions: Small and non-tender erythematous/haemorrhagic

macules on the palms/soles of feet(infective endocarditis). - Arachnodactyly: Long slender hand and fingers - Marfan's syndrome. - Xanthomata: Yellowish macular deposits found on the tendons with

hypercholesterolaemia. - Koilonychia: Spoon-shaped nails caused by iron deficiency anaemia

(which can cause heart failure).


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Pulse

General tips

- Note the following: rate / rhythm / character /symmetry (between left & right side).

- Always palpate: Radial and carotid pulses.- Consider

palpating: Other relevant pulses (brachial, abdominalaorta, femoral, popliteal, posterior tibial and dorsalispedis). The brachial pulse should certainly be used ifasked to measure the Blood Pressure. It may also be

worth routinely palpating for radio-femoral delay (asign of coarctation of the aorta).


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What to do:

. 1. Palpate the radial pulses of both arms at the same time. Initiallycount the rate (ideally you should do this for 30seconds). Also be feelingfor radio-radial differences/delay (a feature of aortic dissection).

2. Note the following features of the pulse:

Rate: Tachycardia (>100bpm) can be caused by anxiety, pain, congestivecardiac failure, pulmonary emboli, hyperthyroidism, anaemia,fever/sepsis, medications (eg. beta-agonists such as Salbutamol), etc.Bradycardia (


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Pulse count. Character: A collapsing pulse (also known as a 'water-hammer' pulse)

is jerky, with a full expansion phase followed by a sudden collapse uponraising the arm to above heart level (seen mainly with AorticRegurgitation, however other cause scan include a Patent Ductus

Arteriosus, thyrotoxicosis, A-V fistulae, pregnancy, Paget's disease andanaemia). An anecdotic (slow rising) pulse is seen in Aortic Stenosis.Pulses alternant (regular rate, alternating amplitude that varies frombeat-to-beat) is seen in Left Ventricular Failure. Pulses bisferiens (2strong systolic peaks separated by a mid-systolic 'dip') is seen in aortic

valve disease and hypertrophic cardiomyopathy. A diacrotic pulse (twosystolic and diastolic peaks) is seen in septic, hypovolaemic and

cardiogenic shock. Pulsus paradoxus is seen in severe asthma, cardiactamponade and massive Pulmonary Emboli. The pulse pressure normalfalls with inspiration, however when this is exaggerated(>10mmHgdifference) then this is deemed pulsus paradoxus.


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Pulse count. 3. Mention to the examiner at this point, that you would ideally like to measure the

Blood Pressure. If they want to you to do this, then they will hand you asphygmomanometer. If they wish you to carry on with your examination, they willusually tell you what the blood pressure is. Don't ignore what they say - it could give

you a clue as to the diagnosis! A narrow pulse pressure (pulse pressure=systolic-

diastolic)is a feature of aortic stenosis. A widened pulse pressure is a feature ofaortic regurgitation.

4. If you wish to feel for radio-femoral delay (seen in coarctation of the aorta), thendo so at this stage. Remember to explain to the patient what you are doing before

you just reach for their groin!

5. Palpate the carotid pulse before you examine the face, or else you may forget later.Never palpate both sides at once - inducing a spot of syncope in your older patientsis not something you ideally want to do in an exam. Note the same features of thispulse. Some of the signs may be easier to determine in this pulse, as compared tothe radial pulse.


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Face General features:

- Anxious / apprehensive looking faces: pain, anxiety, respiratory distress (could be a sign of aMyocardial Infarction or angina-related chest pain, Pulmonary Embolus, Pulmonary oedema / heartfailure, and various cardiac arrhythmias, including AF, supraventricular tachycardia and ventriculartachycardia.

- Colour: Many conditions can lead to a change in the normal colour of the skin, particularlynoticeable at the face. These include: Malar flush: Red areas on the upper cheeks - seen in MitralStenosis and similar to the butterfly rash of Systemic Lupus Erythematosus. Polycythemia: causes adark reddish appearance to the skin. It is important, as it can be a cause of thrombotic events, infarctsandhypertension. Haemochromatosis: also known as 'bronze diabetes' due to the deposition of iron(can lead to cardiomyopathy). Addison's disease: dark buccal pigmentation (can be a cause ofhypotension). Carcinoid syndrome: Release of 5-HT leads to flushing and hypotension.

- Shape: Classical 'moon-face' of Cushing's disease (a cause of hypertension).

- Skin texture: Coarse & dry 'toad face' of hypothyroidism (can cause bradycardia).

- Central cyanosis: A bluish tongue suggests either a right to left intra-cardiac shunts or lung disease.

- Head shape: Paget's disease: features a large head (can lead to high-output failure). Marfan'ssyndrome (long narrow face - associated with aortic regurgitation). Williams syndrome (small elf-like

forehead, turned up nose, low set ears - associated with Aortic Stenosis). Noonan's syndrome (widelyset eyes, web neck - associated with Pulmonary Stenosis.


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Eyes: - Roth spots: Retinal haemorrhages (white/pale centres), usually seen on

fundoscopy. Caused by microemboli (bacterial endocarditis). Roth's spots may

be observed in leukaemia, sub-acute bacterial endocarditis, ischemic eventsassociated with elevated venous pressure and systemic vascular conditions withcapillary fragility.

- Xanthelasma: Yellowish macules on the eyelids (similar to tendonxanthomata) seen in hypercholesterolaemia.

- Eyelid (periorbital) oedema: Seen in hypothyroidism, nephrotic syndrome,

etc. - Exophthalmos: Along with other signs such as eyelid retraction, is a feature of

(hyper)thyroid eye disease (which causes AF and can lead to a high-outputheart failure).

- Corneal arcus senilis: A grey-ish ring around the outer cornea. Whilst

relatively common in the elderly, in young people it can indicateshypercholesterolaemia.

- Blue sclera: Seen in Marfan's and Ehlers-Danlos syndromes (is associatedwith Aortic Regurgitation, as well as Mitral Valve Prolapse, and Atrial SeptalDefects.) Lens subluxation is another feature of Marfan's.

- Argyll Robertson Pupil: The 'prostitute's pupil' - accommodates, but does not

react (to light). Seen in neurosyphilis (which can cause Aortic Regurgitation).


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JVP/CAROTID WAVEFRONT

How to perform:

- Get the patient to turn their head away from you and hold it still. You should then look 'along' the skin(i.e.. with your line of sight almost in line with the neck surface). Look for the internal jugular (the lessobvious waveform) rather than the external (easily seen, superficial).The JVP can be differentiated fromthe carotid pulse by a number of features (see below). A quick test is to confirm if it can be occluded bypressure - the carotid pulse cannot be, whilst the JVP is occluded by this manoeuvre.

- Remember that the JVP will be affected by the patient's position. It is usually described as theequivalent of a column of fluid - i.e.. how far the 'column' of the JVP rises above the manubriosternalangle.- To 'accentuate' the JVP, you can gently press down on the abdomen (hepato-jugular reflux - raises intra-abdominal pressure and enhances venous return). Make sure the patient has no abdominal pain beforeyou do this.

Waveform:

- A-wave: Atrial contraction (systole).- C: Tricuspid valve closure. Start of ventricular systole. Coincides with palpable carotid pulse and first

heart sound.

- - X-descent: Ventricular systole.- - V: End of ventricular systole and start of atrial filling (with closed tricuspid valve).- - Y-descent: Tricuspid valve opens.


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JVP COUNT.

JVP vs Carotid waveform:

FEATURES JVP CAROTID PULSE

WAVES 3 1

ABDOMINALPRESSURE RAISED NO EFFECT

FINGER PRESSUREObliterates waveform NO EFFECT

RESPIRATIONDecreases on inspiration(Kussmaul's sign is a paradoxicalrise in JVP)

NO EFFECT

POSITIONDEPENDANT?

Yes - lower with sitting up moreNO EFFECT


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Inspection

Look for:

As before, look carefully, ensuring you do not missany scars (eg. median sternotomy / smaller

thoracic scars from valve repairs). Also, lookfor anysigns of a pacemaker. These are normally found inthe 'upper-outer' quadrant of the pectoral area.These are usually small and thin box likestructures

just deep to the skin. Also look for abnormalities ofthe chest wall (eg. pectus excavatum in Marfan's).


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Palpation

Feel for:

- Apex beat: This is defined as the most inferior and lateral site at which thepulse can be palpated. It is located at the 5th left intercostal space, in the mid-clavicular line, and is the 'most forceful' palpable pulsationof the heart. Lateraldeviation suggests left ventricular enlargement. If you cannot feel it then tryagain (dextrocardia is a classic exam trick and it can be very embarrassing tosay you felt the apex when it was actually way over the other side...). Animpalpable apex can be caused by 'DOPES': Death, Obesity, Pericarditis,Emphysema/COPD, Situs inversus. Normal apex beats are brief outwardimpulse. There are many confusing wordsused to describe abnormal apex beats- do not try and understand or remember these. Just remember: 'tapping' inMitral Stenosis and 'hyperdynamic' in Aortic Stenosis.

- Parasternal heave: Use the lateral edge of your palm. Palpate either side of thesternal border. Palpable upwards movements are suggestive of RightVentricular Hypertrophy, although they can also be felt in patients with thinchest walls.

- Thrills: Palpable murmurs. Again, using the lateral edge/palm of your hands,

feel at the upper chest (just below the clavicles).


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Auscultation

Listen for:

- Listen at the 4 main areas: Aortic (2nd right intercostal space),Tricuspid (lower left sternal edge), Pulmonary (2nd left intercostalspace) and Mitral (apex beat). Always start at the apex. A good way toremember the order, is the mnemonic 'At The Post Mortem' (Aortic,

Tricuspid, Pulmonary, Mitral), going diagnonally up-and-down thechest. Always palpate a 'central' pulse (the carotid, or alternatively thesubclavian - can be easier to palpate and is found just above the medialborder of the clavicle), at the same time. This will help you to time anymurmurs.

- Heart sounds: 1st sound = mitral and tricuspid closure, 2nd sound =aortic and pulmonary closure. Listen at the apex for extra heart sounds:

3rd sound = immediately after the 2nd sound - like 'ken-tucky' (normalin young patients, suggests over-rapid ventricular filling with a failureof the ventricle to relax, eg. in heart failure, thyrotoxicosis), 4th sound= immediately before the 1st sound - like 'tenne-ssee' (alwaysabnormal, cause by a stiff ventricle, found in left ventricularhypertrophy, hypertrophic cardiomyopathy, acute infarction, etc.)


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AUSCULTATION COUNT.- Murmurs:At the apex, use the bell and then the diaphragm. The bell

will be useful for low frequency diastolic murmurs. Get the patient to lean

on their left side (left lateral position) whilst auscultating at the apex.This will accentuate the mid-diastolic murmur of mitral stenosis.Remember to listen in the axilla for radiation of mitral murmurs.- Listen at the carotids, for both, bruits and radiation of aortic areamurmurs. Tell the patient to hold their breath so breath sounds do not

impede what you can hear. Ejection systolic murmurs heard at the aorticarea but that do not radiate to the carotids may be cause by aortic(calcific) sclerosis rather than stenosis.- Get the patient to lean forwards, whilst holding your stethoscope at thelower left sternal edge. Get the patient to take a deep breath in, breath allthe way out, then hold it there. Listen during held expiration for the earlydiastolic murmur of aortic regurgitation.

- See the 'murmurs' notes for more information on cardiac murmurs.

- Finally, listen at the lung bases (posteriorly) for signs of pulmonary

oedema (left sided heart failure).


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To complete your examinationAlso examine:

- Feel the pre-tibial area for pedal pitting oedema (sign of right heart failure).- Palpate the peripheral pulses for abnormalities (eg. aneurysms). Start fromthe abdominal aorta, then palpate bilaterally at the femorals, popliteal,posterior tibial and dorsalis pedis). You can usually skip this step inexaminations unless specifically asked - saying to the examiner that'tocomplete my examination, I would like to palpate the peripheral pulses' isusually enough.

- Also mention that you would like to palpate the abdomen for signs of rightheart failure ('smooth' hepatomegaly and hepatic pulsatility).

Finally:

- Ask for the following investigations to complete your examination:Temperature (raised in endocarditis), Urine Dipstick (blood in hypertension

or endocarditis, glucose in diabetes), Blood Pressure (if not already done so),Chest X-ray(approximate heart size, rib notching in coarctation of the aorta),and a cardiac echo scan (especially if a murmur was heard or there was anyevidence of heart failure).


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Presenting your findings

Example presentation:

On examination, Mrs Jones appeared mildly short of breath at rest.She was on 5L of Oxygen through nasal prongs. She had tar stainingon her hands, and there was a packet of cigarettes by the side of thebed, suggesting that Mrs Jones is a smoker. Her pulse was slowrising, and her blood pressure was 96/70, demonstrating a narrowpulse pressure. There were no other peripheral stigmata ofcardiovascular disease. On palpation, her apex beat was present andhyperdynamic in character. On auscultation, both heart soundswere present, however the second heart sound was quiet. There wasan ejection-systolic murmur that was loudest at the 2nd right

intercostal space, and that radiated to the carotids. There were nosigns of heart failure. In summary, these findings are consistentwith a diagnosis of aortic stenosis.

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Comprehensive Examination of Cadiovascular System