Cardiovascular Examination

3rd Year Examination Lectures

Dr G. Aidoo-Micah

Clinical Teaching Fellow

Overview

• WIPER (wash hands, introduce self, permission, expose, re-position patient)

• End of bed assessment

• Peripheral examination

• Precordium – Inspection

– Palpation

– Percussion

– Auscultation

• Conclude, thanks and summary

End-of bedogram

• Well/unwell?

• Comfortable/in pain/anxious?

• What’s around the bed?

– O2/IV access/GTN spray/drip

• ECG monitoring

• Scars

• Obvious syndromes (IE, Marfan’s)

• Listen for clicking of valve replacement

Peripeheral examination

• Hands – temperature, peripheral cyanosis, tar staining, palmar erythema, tremor, CRT <2

seconds.

Osler’s nodes/Janeway lesions

Splinter haemorrhages

Stigmata of bacterial endocarditis

Palpate pulses

• Radial pulse

• Comment on RATE and RHYTHMN.

– Regular

– Regularly irregular

– Irregularly irregular

• Collapsing pulse

• (offer to perform radial-radial delay and radio-femoral delay)

Arm + Eyes

• Take the blood pressure, offer brachial pulse

• Eyes corneal arcus, conjunctival pallor,

xanthelasma.

Face + mouth

• Red cheeks (malar flush)

• Pallor

• Mouth blue lips, central cyanosis, high arched palate, dental hygiene.

Neck

Palpate the carotid pulse. CHARACTER

• Bounding • Collapsing • Slow rising

JVP

OSCE Tip: How do you distinguish between a carotid pulse and a JVP? Answer: JVP moves down with inspiration, rises with pressure on the right abdomen (liver: hepatojugular reflux – explain the procedure first!) and is impalpable.

Chest

• Inspect CLOSER • Median sternotomy

• Thoracotomy (left)

• Deformity

• Pacemakers/defibrillation

• Palpation

• Apex beat

• Heaves and thrills

Chest

• Auscultation

– 4 areas (aortic, pulmonary, tricuspid, mitral)

• Look up mnemonics

• What positions?

Murmur manoeuvres

• Listen in axilla with bell – get patient to roll on to left side.

• Sit forward breath in/out HOLD + listen

• Listen in carotids.

• While patient sat forward listen to base of lungs.

AS AR MS MR

Systolic/diastolic? Ejection Systolic Early Diastolic Mid Diastolic Pan Systolic

Loudest at..? R 2nd ICS LLSE L 5th ICS L 5th ICS

Manouver Listen at carotid Listen at LLSE leaning forward in end expiration

Listen with the bell

Roll to left lateral

Radiation? Carotids LLSE - Axilla

Effect on apex? Heaving, Undisplaced

Displaced, Hyperdynamic

Tapping Hyperdynamic

Effect on pulse? Slow rising Collapsing None None

Effect on BP? Narrowed Widened None None

Legs

• Looking for scars?

• Pedal oedema.

To complete my examination…

• Peripheral vascular examination

• Urine dip (blood)

• ECG

• Fundoscopy

• Order echo if they have murmur

• See the obs chart and review the notes.

Resources

Special thanks to Dr Jacob Schofield

http://geekymedics.com/category/osce/cardio/