Summary of CVS exam

CVS physical Examination

Slightly detailed - referred to Mcleods’, OHCEPS (Oxford Handbook of Clinical Examination), Practical Skills), and Talley’s.

I made it very easy to understand for the ease of sem3 juniors. I shall make a more practical one for myself later. This page is solely for understanding of fundamental CVS physical examinations.

Flow of events

1.       GIEP

2.       Wash Hands

3.       General inspection

4.       Examination of hands

a.       Palmar

b.      Dorsum

c.       nails

5.       Examination of arms

a.       Pulses

b.      Blood Pressure

6.       Examination of face

a.       Eyes

b.      Mouth

7.       Examination of neck

a.       General inspection

b.      JVP

8.       Examination of chest

a.       Mediastinal shift

                                                               i.      Apex location and charactor

                                                             ii.      Tracheal shift

b.      Parasternal heave

c.       Thrills

d.      Auscultation of chest

9.       Thank patient, leave.

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GIEP

Refer to THIS

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Washing of hands

·         Be quick, but wash properly.

·         During exam, aim for 10 seconds including wiping your hands.

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General inspection

·         Who is he? How old is he?

·         What is is position?

o   Important in CVS - patient may have orthopnea - increased respiratory distress then lying down. This is why the bed is in 45 deg in CVS physical examinations. If flat, patient may feel uncomfortable.

·         Is he alive?

o   Hopefully, your SPs will be alive.

·         Alertness

·         Consciousness

·         Responsiveness

·         Any evidence of obvious pain?

o   If the patient is in pain, suggestive of MI - what are you doing!? Call the Dr!

·         Any signs of respiratory distress?

o   How can one know if the patient is in respiratory distress? - looking at the usage of extra-pulmonary muscles - which are

§  Scalene

§  Sternocleidomastoid

§  Flaring of nasal alae

·         patient may look cachectic:

o   that is, there may be severe loss of weight and muscle wasting.

o   This is commonly caused by malignant disease, but severe cardiac failure may also have this effect (cardiac cachexia).

o   It probably results from a combination of anorexia (due to congestive enlargement of the liver), impaired intestinal absorption (due to congested intestinal veins) and increased levels of inflammatory cytokines such as TNF-α.

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Examination of hands

·         Note temperature.

o   May be cold in…

§  Congestive Heart Failure

§  Hypothyroidism

§  Hypothermia

o   May be warm in…

§  Hyperthyroidism (important due to cardiac involvement of thyrotoxicosis)

·         Dorsum

o   Note any scars.

§  Some IV drug users MAY use their hand veins for IV access.

o   Note the joints

§  There may be tendon xantomata - accumulation of lipids benath skin.

·         Often seen at tendons of wrist.

·         Palmar

o   Janeway lesions

§  On the palms - they are NON-TENDER macular-papular erythematous lesions

§  Sign of Bacterial Infective Endocarditis

§  Rare.

o   Osler’s nodes

§  TENDER (meaning painful) red, nodules on finger pulps or thenar eminence

§  Late manifestation of infective endocarditis

§  Rare. Usually treatment done before development.

o   Discolouration at palmer creases

§  Pallor

§  Jaundice

§  Caroteinemia

·         If you eat too much carrots / mangoes. It looks like jaundice, but this one doesn’t affect sclera.

·         Nails

o   Note if there is any clubbing

§  3 methods to assess for clubbing

·         Bring finger to eye-level and look at it from lateral aspect

o   should the nail bed angle be flat, there is clubbing

·         bring 2 fingernails of opposite hand and same finger together.

o   If diamond shape observed in between, NO clubbing.

·         Try to fluctuate nail from nailbed

o   by holding the finger using 2 hands - use all your fingers to hold the patient’s finger but free both your index finger. - move the nail side to side using the free finger

§  cardiac causes for Clubbing are…

·         Infective Endocarditis

·         Cyanotic Congenital Heart Disease

o   Note any discoloration

§  Bluish discolouration - due to poor peripheral blood flow

·         Confirm by carrying out capillary refill - press on the fingernails for at least 15 seconds - if the nails regain colour within 2 seconds, it is normal. More than that suggests poor perephiral blood flow.

§  Splinter haemorrhage

·         Red longitudinal discolouration on nails

·         May be due to manual work

·         May be due to infective endocarditis

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Examination of Arm

·         Feel for the radial pulse

o   First things first, comment where you will find the radial pulse

§  Lateral to the tendon of flexor carpi radialis.

o   Comment on…

§  Character

·         Normal

·         Other things you can comment are…

o   Slow-rising

§  Aortic stenosis

o   Collapsing pulse / water-hammer pulse

§  Aortic regurgitation

o   Pulsus paradoxus - radial pulse diminish / disappear upon inspiration 
suggests cardiac tamponade

§  Pulse rate

·         Measure for at least 30 seconds & multiply by 2.

·         Better still, measure for one full minute.

·         Report in Beats per minute.

·         Normal is 60-100 bpm.

o   Below that - bradycardia

§  Physiological (atheletes, sleepy, etc)

§  Hypothyroidism

§  Medication by B-blockers, digoxin, amiodarone etc

§  Heart block

§  MI

§  Etc etc…

o   Above that - tachycardia

§  Hyperthyroidism

§  Anxiety

§  Fever

§  Pregnancy

§  anemia

§  medication by B-agonist (salbutamol etc)

§  hypovolemic shock

§  pulmonary embolism

§  etc etc…

§  Rhythm

·         3 possible reportings

o   Normal - “regularly regular”

o   Irregularly irregular - reserved only for atrial fibrillation

o   Regularly irregular - Supraventricular arrhythmias, ventricular arrhythmias.

§  Volume

·         Normal

·         High / bounding

o   Aortic regurgitation

·         Pulsus alternans

o   Alternating high and low volume

o   Due to severe left-sided heart failure

§  Radial-radial delay

·         Due to aortic coarctation

§  Radio-femoral delay

·         Due to aortic coarctation as well

·         But different regions as the above -go read only if interested ; )

·         Feel for the brachial pulse

o   Medial to the tendon of biceps brachii

·         Take blood pressure

o   Refer HERE.

o   If sphygmomanometer not available, say you would do so if given the chance.

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Examination of the face

·         Eyes

o   Look into the eyes

§  Note any corneal arcus

·         Yellow ring observed overlying iris.

·         Deposition of fat on the eye

§  Look at the conjunctiva

·         By pulling the eyelid down and asking the patient to look up

·         Look for Pallor.

§  Look at the sclera

·         by pulling the eyelid up and asking the patient to look down

·         look for any discolouration - jaundice in particular.

·         Mouth

o   Oral hygene

§  Tooth caries may predispose to infective endocarditis - especially steph viridians sp. (slow-progression IE)

o   High-arch palate

§  Suggesting marfan syndrome (associated with AR, Aortic aneurism and dissection)

o   Tongue

§  Central cyanosis

§  Hydration status

o   Underneath the tongue

§  Cyanosis

§  Jaundice

§  pallor

·         Cheeks

o   Check for mitral facies

§  Rosy cheeks - suggestive of mitral stenosis… or make-up!

·         Neck

o   Inspection

§  Scars

§  Swellings

§  discolouration

o   Examine Jugular Venous Pulse (JVP)

§  Report where you would expect to find the JVP

·         In between 2 heads of Sternocleidomastoid

§  Measure the height of the JVP a-wave

·         Normal is less than 3cm above sternal angle. (8cm from heart)

§  Report the height of JVP

·         JVP is 2cm above sternal angle, hence 7 cm from the right atrium… something like that.

§  Perform hepatojugular reflux to see a nonappreciable JVP / confirm it is a JVP

·         Press hand firmly onto the liver, while looking at the neck pulsation.

·         JVP should rise approx. 2cm, but carotid will not.

Difference between Carotid pulse and JVP

JVP	Carotid pulse
2 peaks (in sinus rhythm)	1 peak
Impalpable	Palpable
Easily obliterated / occluded	Hard to obliterate
Moves with respiration	Little movement with respiration
Rises with Hepatujugular reflux	Doesn’t change position with HJR

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Examination of the chest

·         Inspection

o   Scars

o   Gross deformities

§  Pectus carinatum

§  Pectus cavenatum

o   Pacemaker / implantable defib

o   Visible pulsations

§  Make sure you go level with the chest to see this.

·         Palpation

o   Prepare  patient for palpation

§  Warm hands

§  Warn patient

§  Ask for any pain on the area

o   Palpation for apex beat

§  Place palm on left chest

§  Palpate for the most inferior and lateral area where the pulsation can be felt

§  Locate the apex

·         By leaving one finger on the apex beat, and with another hand…

·         Start from sternal notch

·         Sterna angle - corresponding to 2^nd rib

·         Count intercoastal spaces downwards, and measure the distance from mid-clavicular line / mid-axillary line. Depends on the closest reference lines. (use a ruler)

§  Report on the location and character

·         Location usually at midclavicular line, left 5^th intercoastal space

·         Character- comment if there is any…

o   Tapping (mitral stenosis)

o   Thrusting (LVH, aortic stenosis, HOCM)

• thrusting displaced apex beat is caused by volume overload: an active large stroke volume ventricle eg aortic or mitral regurgitation or left to right shunts.
• sustained apex beat is caused by pressure overload eg aortic stenosis, gross hypertension.
• tapping apex beat - mitral stenosis.
• diffuse pulsation asynchronous with apex beat - left ventricular aneurysm.
• double or triple impulse may occur in hypertrophic obstructive myopathy.
• an impalpable apex beat - obesity, overinflated chest, pericardial effusion. Also consider dextrocardia.

o   Palpation for thrills

§  Comment on the 4 areas that you would feel for thrills (palpable murmurs)

·         Mitral

o   Same area as apex beat (differs for each patient)

·         Tricuspid

o   Left 4^th/5^th ICS, parasternal edge

·         Aortic

o   RIGHT 2^nd ICS, parasternal edge

·         Pulmonic

o   LEFT 2^nd ICS, parasternal edge.

§  Report.

o   Parasternal heave

§  Ask patient to breath in, out, then hold.

§  Using the lateral aspect of the hand, feel for any heaves on left parasternal edge (looks like katare-chopping the person using your hands)

§  Report.

·         Auscultation

o   The 4 areas (same with the thrills palpation area)

o   Findings

§  1^st heart sound

§  2^nd heart sound

§  Any extra heart sounds?

§  Any murmurs?

§  Any pericardial rub?

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Thank patient - leave after washing your hands.

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