What is the first stage of any examination?
I- Introduce
I- Identify
I- Informed consent
Wash hands
Adjust bed 45
Expose body
What are you looking for on inspection in a cardio exam?
- Cyanosis → a bluish discolouration of the skin due to poor circulation (e.g. peripheral vasoconstriction secondary to hypovolaemia) or inadequate oxygenation of the blood (e.g.
right-to-left cardiac shunting). - Shortness of breath → may indicate underlying cardiovascular (e.g. congestive heart failure,
pericarditis) or respiratory disease (e.g. pneumonia, pulmonary embolism). - Pallor → a pale colour of the skin that can suggest underlying anaemia (e.g. haemorrhage,
chronic disease) or poor perfusion (e.g. congestive cardiac failure). It should be noted that a
healthy individual may have a pale complexion that mimics pallor, however, pathological
causes should be ruled out. - Malar flush → plum-red discolouration of the cheeks associated with mitral stenosis.
- Oedema → typically presents with swelling of the limbs (e.g. pedal oedema) or abdomen
(i.e. ascites). There are many causes of oedema, but in the context of a cardiovascular
examination OSCE station, congestive heart failure is the most likely culprit.
What equipment should you check for in a cardiology examination?
Medical equipment → note any oxygen delivery devices, ECG leads, medications (e.g. glyceryl trinitrate spray), catheters (note volume/colour of urine) and intravenous access.
- Mobility aids → items such as wheelchairs and walking aids give an indication of the
patient’s current mobility status.
- Pillows → patients with congestive heart failure typically suffer from orthopnoea,
preventing them from being able to lie flat. As a result, they often use multiple pillows to
prop themselves up.
- Vital signs → charts on which vital signs are recorded will give an indication of the patient’s
current clinical status and how their physiological parameters have changed over time.
Fluid balance → fluid balance charts will give an indication of the patient’s current fluid
status which may be relevant if a patient appears fluid overloaded or dehydrated.
- Prescriptions → prescribing charts or personal prescriptions can provide useful information
about the patient’s recent medications.
What are you looking for when inspecting the hands in a cardio exam?
Colour → pallor suggests poor peripheral perfusion (e.g. congestive heart failure) and
cyanosis may indicate underlying hypoxaemia.
- Tar staining → caused by smoking, a significant risk factor for cardiovascular disease (e.g.
coronary artery disease, hypertension).
- Xanthomata → raised yellow cholesterol-rich deposits that are often noted on the palm,
tendons of the wrist and elbow. Xanthomata are associated with hyperlipidaemia (typically
familial hypercholesterolaemia), another important risk factor for cardiovascular disease
(e.g. coronary artery disease, hypertension).
- Arachnodactyly (‘spider fingers’) → fingers and toes are abnormally long and slender, in
comparison to the palm of the hand and arch of the foot. Arachnodactyly is a feature of
Marfan’s syndrome, which is associated with mitral/aortic valve prolapse and aortic
dissection.
Finger clubbing
To assess for finger clubbing:
- Ask the patient to place the nails of their index fingers back to back.
- In a healthy individual, you should be able to observe a small diamond-shaped window
(known as Schamroth’s window)
- When finger clubbing develops, this window is lost
.
Signs in the hands associated with endocarditis
- Splinter haemorrhages → a longitudinal, red-brown haemorrhage under a nail that looks
like a wood splinter. Causes include local trauma, infective endocarditis, sepsis, vasculitis
and psoriatic nail disease.
- Janeway lesions → non-tender, haemorrhagic lesions that occur on the thenar and
hypothenar eminences of the palms (and soles).
- Osler’s nodes → red-purple, slightly raised, tender lumps, often with a pale centre, typically
found on the fingers or toes
What are you palpating the hands for in a cardio exam?
What can it signify?
Temperature
- Place dorsal aspect of hands on patients, should be symmetrically warm.
- Cold –> poor peripheral perfusion –> CCF, ACS
- Cold and sweaty –> ACS
CRT
- Apply five seconds of pressure to the distal phalanx of one of a patient’s fingers and then release.
- Normal <2 seconds
- > 2 seconds –> poor peripheral perfusion, hypovolemia, CCF
How long should you palpate the radial pulse to determine rate and rhythm?
- Can be 15 seconds x4 or 30 seconds x2
- When irregular –> 60 seconds
What can cause a bpm <60?
-Athletic individuals, AV block, medications, sick sinus syndrome
What can cause >100 bpm?
-Anxiety, SVT, hypovolaemia, hyperthyroidism
After palpation of the radial pulse for rate and rhythm what further pulses and areas should you palpate before examination of the face?
Radio-radial delay
-Palpate both, should be in sync.
Collapsing pulse - ASK ANY SHOULDER PAIN
-Palpate brachial w R arm, radial w L arm –> raise patients arm above head
Brachial pulse
Blood pressure
- Both arms
- Lying and standing
Carotid pulse
-Auscultate first - ask patient to take deep breath.
No bruit (could be radiating aortic stenosis murmur), then palpate.
-Risk of reflex bradycardia, patient should be in safe position.
Raised JVP
What are the causes of radio radial delay?
-Aortic coarction, dissection, sub clavian artery stenosis.
What are the causes of collapsing pulse?
-Normal physiological states e.g. fever, pregnancy Cardiac lesions e.g. aortic regurgitation, patent ductus arteriosus
High output states e.g. anaemia, arteriovenous fistula, thyrotoxicosis
What are the potential types of brachial pulse
- Normal
- Slow rising –> aortic stenosis
- Bounding –> aortic regurgitation and CO2 retention
- Thready –> intravascular hypovolaemia e.g sepsis.
What do differences in BP between arms represent?
Narrow pulse pressure
- <25 mmHg difference between systolic and diastolic. -Causes –> aortic stenosis, congestive heart failure and cardiac tamponade.
Wide pulse pressure
- > 100 mmHg of difference between systolic and diastolic.
- Causes –> aortic regurgitation and aortic dissection.
Difference between arms
- 20 mmHg difference between each arm is abnormal and may suggest aortic dissection.
How should you measure JVP?
What are the causes of a raised JVP?
- Assessing the vertical distance between the sternal angle and the top of the pulsation point of the IJV (in healthy individuals.
- This should be no greater than 3 cm.
- Raised JVP –> venous hypertension
-Right-sided heart failure –> commonly caused by left-sided heart failure. Pulmonary hypertension is another cause of right-sided heart failure, often due to COPD or ILD.
Tricuspid regurgitation –> causes include infective endocarditis and rheumatic heart disease.
Constrictive pericarditis –> often idiopathic, but rheumatoid arthritis and tuberculosis are also possible underlying causes.
Why is JVP and indicator of central venous pressure?
- The internal jugular vein (IJV) connects to the right atrium without any intervening valves, resulting in a continuous column of blood.
- The presence of this continuous column of blood means that changes in right atrial pressure are reflected in the IJV (e.g. raised right atrial pressure results in distension of the IJV).
What is the hepatojugular reflux?
- Involves the application of pressure to the liver whilst observing for a sustained rise in JVP.
- To be able to perform the test, there should be at least a 3cm distance from the upper margin of the baseline JVP to the angle of the mandible:
- In healthy individuals, this rise should last no longer than 1-2 cardiac cycles (it should then fall).
- If the rise in JVP is sustained and equal to or greater than 4cm this is deemed a positive result.
- +ve then right ventricle unable to accommodate increased venous return
What are you looking for on inspection of the eyes in a cardio exam?
Conjunctival pallor –> suggestive of underlying anaemia. Ask the patient to gently pull down their lower eyelid to allow you to inspect the conjunctiva.
Corneal arcus –> a hazy white, grey or blue opaque ring located in the peripheral cornea, typically occurring in patients over the age of 60. In older patients, the condition is considered benign, however, its presence in patients under the age of 50 suggests underlying hypercholesterolaemia.
Xanthelasma –> yellow, raised cholesterol-rich deposits around the eyes associated with hypercholesterolaemia.
Kayser-Fleischer rings –> dark rings that encircle the iris associated with Wilson’s disease. The disease involves abnormal copper processing by the liver, resulting in accumulation and deposition in various tissues (including the heart where it can cause cardiomyopathy).
What are you looking for on inspection of the mouth on a cardio exam?
Central cyanosis –> bluish discolouration of the lips and/or the tongue associated with hypoxaemia (e.g. a right to left cardiac shunt)
Angular stomatitis –> a common inflammatory condition affecting the corners of the mouth. It has a wide range of causes including iron deficiency.
High arched palate –> a feature of Marfan syndrome which is associated with mitral/aortic valve prolapse and aortic dissection.
Dental hygiene –> poor dental hygiene is a risk factor for infective endocarditis.
What are you looking for on close inspection of the chest?
- Scars suggestive of previous thoracic surgery
- Pectus excavatum –> a caved-in or sunken appearance of the chest.
- Pectus carniatum –> protrusion of the sternum and ribs.
- Visible pulsations –> a forceful apex beat may be visible secondary to underlying ventricular hypertrophy.
What are the types of scar?
Median sternotomy scar –> located in the midline of the thorax. This surgical approach is used for cardiac valve replacement and coronary artery bypass grafts (CABG).
Anterolateral thoracotomy scar –> located between the lateral border of the sternum and the mid-axillary line at the 4th or 5th intercostal space. This surgical approach is used for minimally invasive cardiac valve surgery.
Infraclavicular scar –> located in the infraclavicular region (on either side). This surgical approach is used for pacemaker insertion.
Left mid-axillary scar –> this surgical approach is used for the insertion of a subcutaneous implantable cardioverter-defibrillator (ICD).
What is the process of palpation of the chest in a cardio examination?
Apex beat
- 5th intercostal space, mid clavicular line.
- The displacement –> ventricular hypertrophy
Heaves
- Precordial impulse that can be felt
- Heel of hand parallel to left sternal edge, heaves present then heel of hand move upwards w each beat.
- RVH
Thrills
- A palpable murmur
- Palpable vibration turbulent blood flow
- Go through each heart valve
- Horizontal over chest wall, flats of fingers and palms over area to be assessed.
Explain the auscultation process
- Ask patient to lift breast when relevant
1. Palpate the carotid pulse to determine the first heart sound.
2. Auscultate ‘upwards’ through the valve areas using the diaphragm of the stethoscope whilst continuing to palpate the carotid pulse:
3. Repeat auscultation across the four valves with the bell of the stethoscope.
Where do you auscultate each of the valves?
- Mitral valve –> 5th intercostal space in the midclavicular line.
- Tricuspid valve –> 4th or 5th intercostal space at the lower left sternal edge.
- Pulmonary valve –> 2nd intercostal space at the left sternal edge.
- Aortic valve –> 2nd intercostal space at the right sternal edge.
What are the accentuation manoevures?
- Auscultate the carotid arteries using the diaphragm of the stethoscope whilst the patient holds their breath to listen for radiation of an ejection systolic murmur caused by aortic stenosis.
- Sit the patient forwards and auscultate over the aortic area with the diaphragm of the stethoscope during expiration to listen for an early diastolic murmur caused by aortic regurgitation.
- Roll the patient onto their left side and listen over the mitral area with the diaphragm of the stethoscope during expiration to listen for a pansystolic murmur caused by mitral regurgitation. Continue to auscultate into the axilla to identify radiation of this murmur.
- With the patient still on their left side, listen again over the mitral area using the bell of the stethoscope during expiration for a mid-diastolic murmur caused by mitral stenosis.
