Cardiovascular Examination Josh Exley

Walk into the station.. Take your time to listen to examiner’s instructions and read the sheet 5 seconds to think about what you are going to do

Introduction Name and role Explain the examination What you will be doing Exposed chest – Chaperone? Empathy Gain consent Wash hands

intro spiel ‘Hello, my name is ______ and I am a second year medical student at the University of Liverpool.’ ‘I have been asked today to perform what is called a cardiovascular examination’ ‘This will involve me looking at your hands, face and neck, as well as having a look, feel and listen to your chest. There are a few parts to the examination, so I will explain more as I go along.’

intro spiel ‘This examination will require you getting undressed from the waist up. Would you like a chaperone for this?’ ‘If you are uncomfortable at any point, please let me know.’ ‘Does this sound okay?’

Introduction Be yourself Keep short and succinct Wash hands whilst speaking Practice, practice, practice

General inspection Make sure you do this! Comment as you go along… Bedside – oxygen, fluids, medication Patient at 45 degrees, chest exposed Appearance – well at rest, in pain, breathless

Hands Inspection - things relevant to the cardiovascular system Cyanosis, Osler’s nodes/Janeway lesions, Nicotine staining Nail signs – Clubbing, Koilonychia, Splinter haemorrhages Feel Warm, well perfused Capillary refill (<2 seconds) Radial pulse – rate & rhythm (check for 30 seconds) (Radio-radial delay, collapsing pulse)

Normal findings ‘In the hands, there are no obvious signs of cardiovascular disease, such as peripheral cyanosis, koilonychia or splinter haemorrhages’ ‘The hands are warm and well perfused, with a capillary refill time of less than 2 seconds’ ‘The radial pulse was regular at a rate of approximately 70 beats per minute’ ‘I would also like to measure the blood pressure in both arms’

Face & Neck Malar flush (Mitral stenosis) Eyes – xanthelasma, corneal arcus, conjunctival palor Mouth – central cyanosis, poor dentition JVP Patient turns head slightly to the right – neck muscles relaxed Characteristic ‘double waveform’ pulsation Measure from sternal angle, should be <3-4cm Carotid Pulse – character & volume (normal, thready, bounding)

Normal findings ‘No evidence of malar flushing, xanthelasma or conjunctival pallor’ ‘In the mouth, dentition is good with no evidence of central cyanosis’ ‘A double waveform pulsation was observed approximately 3cm above the sternal angle, indicating a normal JVP’ OR ‘I was unable to assess the JVP’ The carotid pulse was of normal volume and character

Chest Inspection Scars, chest deformity, visible heave Palpation Apex beat – start in armpit with fingers between ribs Normal = 5th intercostal space, midclavicular line Make a big deal of counting rib spaces to examiner Heaves & thrills Heave = hypertrophy Thrill = palpable murmur

Pectus excavatum, pectus carinatum

Chest Ausculatation (whilst feeling carotid pulse) Aortic – right sternal edge, 2nd ICS Pulmonary – left sternal edge, 2nd ICS Tricuspid – Left sternal edge, 4th ICS Mitral – Apex Lung bases, carotids and abdomen for bruits

A P T M

Normal findings ‘On inspection, there are no obvious scars, chest wall deformity or visible heave.’ ‘The apex beat was palpated in the 5th intercostal space, midclavicular line. There were no palpable heaves or thrills.’ ’On auscultation, there was a normal first and second heart sound in all 4 valvular areas with no additional sounds or murmurs detected.’ ‘The lung bases were clear and no carotid or abdominal bruits were detected’

Finishing up Time at the end Palpate for sacral and ankle oedema Thank the patient, help them to get dressed Wash hands ‘I am going to report my findings now to the examiner, if this is okay?’

Presenting findings Be systematic and concise 1-2 sentences about each part of the exam If you are going to mention a sign, know what the sign means!