Introduction
Wash hands
Introduce yourself
Confirm patient details – name / DOB
Explain the examination
Gain consent
Position the patient at 45° with their chest exposed
Chaperone??
Ask if the patient currently has any pain
General inspection
Bedside – treatments or adjuncts? – GTN spray / O2 / medication / mobility aids
Obesity/Cachexia
Check the patient is comfortable at rest
Malar flush – plum red discolouration of cheeks – may suggest mitral stenosis
Inspect chest - scars or visible pulsations? (remember to look underneath arms for thoracotomy scars and for small scars from minimally invasive surgery)
Inspect legs - scars from saphenous vein harvest for CAGB / peripheral oedema / missing limbs or toes
Hands
Hands out with palms facing downwards
Splinter haemorrhages – reddish/brown streaks on the nail bed – bacterial endocarditis
Finger clubbing - infective endocarditis and cyanotic congenital heart disease
Koilonychia –Iron Deficiency Anaemia
Hands out with palms facing upwards
Colour – dusky bluish discolouration (cyanosis) suggests hypoxia
Temperature – cool peripheries may suggest poor cardiac output/hypovolaemia
Sweaty/Clammy– can be associated with acute coronary syndrome
Janeway lesions – non-tender maculopapular erythematous palm pulp lesions – bacterial endocarditis
Osler’s nodes – tender red nodules on finger pulps/thenar eminence – infective endocarditis
Tar staining – smoker – risk factor for cardiovascular disease
Xanthomata – raised yellow lesions – often noted on tendons of the wrist – caused by hyperlipidaemia
Capillary refill time – normal is <2 seconds – if prolonged may suggest hypovolaemia
Pulses
Radial pulse – assess rate and rhythm
Radio-radial delay: A delay may suggest aortic coarctation
Brachial pulse – assess volume and character, state of vessel wall (arteriosclerosis)
Collapsing pulse – associated with aortic regurgitation
First, ensure the patient has no shoulder pain
Palpate the radial pulse with your hand wrapped around the wrist
Raise the arm above the head briskly
Feel for a tapping impulse through the muscle bulk of the arm as blood empties from the arm very quickly in diastole, resulting in the palpable sensation
This is a water hammer pulse and can occur in normal physiological states (fever/pregnancy), or in cardiac lesions (e.g. AR/PDA) or high output states (e.g. anaemia/AV fistula/thyrotoxicosis)
Blood pressure:
Measure blood pressure and note any abnormalities – e.g. hypertension/ hypotension
Narrow pulse pressure is associated with aortic stenosis
Wide pulse pressure is associated with aortic regurgitation
Carotid pulse:
Assess character and volume – e.g. slow rising character in aortic stenosis
It’s often advised to auscultate the carotid artery for a bruit before palpating, as theoretically palpation may dislodge a plaque which could lead to a stroke
However, if you perform carotid auscultation at this point, remember that the ‘bruit’ may actually be a radiating murmur!
Jugular venous pressure (JVP)
Raised JVP may indicate – fluid overload / right ventricular failure / tricuspid regurgitation
Hepato-jugular reflux:
Apply pressure to the liver and observe the JVP for a rise
In healthy individuals, this 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 a positive result
A positive hepatojugular reflux sign is suggestive of right-sided heart failure and/or tricuspid regurgitation
Face
Conjunctival pallor – anaemia– ask the patient to pull down on eyelids
Corneal arcus – yellowish/grey ring surrounding the iris – hypercholesterolaemia
Xanthelasma – yellow raised lesions around the eyes – hypercholesterolaemia
Malar flush - plum red discolouration of cheeks – may suggest mitral stenosis
Central cyanosis – bluish discolouration of the lips and/or the tongue
Angular stomatitis – inflammation of the corners of the mouth – iron deficiency
High arched palate – suggestive of Marfan syndrome– ↑ risk of aortic aneurysm/dissection
Dental hygiene – important if considering sources for infective endocarditis
Hydration
Inspection of the chest
Scars/Rashes – shingles causes chest pain
Chest wall deformities – pectus excavatum / pectus carinatum
Visible pulsations (forceful apex beat may be visible) – hypertension/ventricular hypertrophy
Palpation
Apex beat:
Lateral displacement suggests cardiomegaly
Impalpable: Obesity, emphysema, pericardial effusion
Heaves:
A parasternal heave is a hypertrophic ventricular wall thrusting against inside the chest wall
Parasternal heaves are present in patients with right ventricular hypertrophy
Place the heel of your hand parallel to the left sternal edge (fingers vertical) to palpate for heaves
Thrills:
A thrill is a palpable vibration caused by turbulent blood flow through a heart valve (the thrill is a palpable murmur)
You should assess for a thrill across each of the heart valves in turn
Auscultation
Auscultate the four valves
Palpate the carotid pulse to determine the first heart sound.
Auscultate all valve areas using the bell and diaphragm of the stethoscope:
Mitral valve – 5th intercostal space – midclavicular line (apex beat)
Tricuspid valve – 4th or 5th intercostal space – lower left sternal edge
Pulmonary valve – 2nd intercostal space – left sternal edge
Aortic valve – 2nd intercostal space – right sternal edge
Auscultate the carotid arteries with the patient holding their breath to check for radiation of an aortic stenosis murmur (this is known as an accentuation manoeuvre).
Sit the patient forwards and auscultate over the aortic area during expiration to listen for the murmur of aortic regurgitation (this is known as an accentuation manoeuvre).
Roll the patient onto their left side and listen over the mitral area with the bell during expiration for mitral murmurs (regurgitation/stenosis).
Conclusion
Auscultate lung bases:
Crackles may suggest pulmonary oedema (e.g. secondary to left ventricular failure)
Consider chronic lung diseases if the patient has no other signs of fluid overload (e.g. pulmonary fibrosis)
Sacral oedema/pedal oedema – may indicate right ventricular failure
Abdominal Palpitation, aortic bruits
Thank the patient
Wash hands
Summarise findings
Suggest further assessments and investigations
Record a 12-lead ECG – arrhythmias / myocardial ischaemia
Dipstick urine – proteinuria / haematuria – hypertension
Murmurs:
Caused by turbulent blood flow in the heart due to valve dysfunction or heart defects occurring at specific points of the cardiac cycle
Characteristics:
Site
Radiation
Characteristics
Timing
Effect of respiration
Effect of position
Right sided murmur (pulmonary/tricuspid) will increase during held inspiration
Left sided murmurs increase during held exhalation
Bruit
Audible (turbulent) blood flow in arteries associated with distortion of vessel walls
Peripheral Vascular Assessment
State of peripheral tissues: Colour (normal/pale), Temperature, Viability
Venous Circulation: Varicose veins, Ulcers
Leg Pulses: femoral, popliteal, tibialis posterior, dorsalis pedis
Questions:
Describe the murmurs heard in: Mitral stenosis/regurgitation and Aortic stenosis/regurgitation
What are splinter haemorrhages?
Give 2 cardiac causes of clubbing
Give 3 reasons for an irregularly irregular pulse
What is a collapsing pulse? In what condition does it occur?
What is radio femoral delay? In what condition does it occur?
What is a malar flush? In what condition does it occur?
Give 2 clinical signs of hyperlipidaemia?
Give 2 causes of raised jugular venous pressure (JVP)
What causes S1 and S2?
Is S3 always pathological? Explain your answer
What is congestive cardiac failure?
Give 3 signs of right sided heart failure
Give 3 signs of left signed heart failure
What is a bruit? Where can you listen for them?
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