Cardiovascularexam:

Generalinformation:• Chest,possiblythighs(femoralpulse),kneesandfeetexposed.• Examinefromthepatient’srightside• Liepatientonthebedwithitinclinedto45°• Washhandsbeforeandaftertheexamination• Sternalangle=secondintercostal,justbelow=secondintercostalspace.• Alwaysaskifthepatientisinanypain.• Cleanthediaphragmandbellofthestereoscopebeforeuse

• Heartvalveauscultationsites:AllPatientsTakeMedsàaortic,pulmonary,tricuspid,mitral• Heartvalvesequenceinheart:TrypullingMyaortaà Tricuspid,pulmonary,mitral(bicuspid),

aorta

• Pulses:- Carotid:nexttothelaryngealprominence(Adamsapple)–lateral- Brachial:cubitalfossa,medialtothebicepstendon- Radial:nexttotheradialstyloidprocess- Femoral:midpointoftheinguinalligament,slightlyinferiortoit.- Popliteal:behindtheknee–flexkneeslightly- Posteriortibial:behindthemedialmalleolusoftheankle- Dorsalispedis:lateraltoextensorhalluceslongus

Introduction:HimynameisKyleBennett,I’mafirstyearmedicalstudentatMonashUniversity.I’mheretogiveyouacardiacexaminationtoday;thiswillinvolveremovingyourshirt,inspectingyourheartandpulses,andalsolookingatyourmouth,hands,legsandfeet.Thiswilltakearound8minutesandallfindingswillremainconfidentialbetweenyouandI.IfyouneedmetostopatanytimeorwantsomethingIsayclarified,pleasesaysoandI’llstopstraightaway.Isitokayifwecontinue?Examination:

Inspection(general,peripheries,local)–palpation–percussion–auscultationInspection:

IngeneralDon’tblowcock,fuckprettychicksGeneral:

• Dyspnoea• BMI–healthy,overweight,obese• Cachexia(rapidweightlossormuscleloss)• Fatigue• Painordistress• Congenitalabnormality:Turner’s(verythickneck,short)orMarfan’s(slendermantype

appearance,verylongandthinlimbs)

Peripheral:CCCJTOTES

• Hands:- Peripheralcyanosis:bluishtingeinthehandsàwithcentralcyanosis=lungproblem(PE),

withoutcentralcyanosis=peripheralvasculardisease/stenosis

- Capillaryrefill:squeezethefingertipsandrelease,thecolourshouldreturninlessthan2secondsàdehydration,peripheralvasculardisease

- Clubbing:softtissueincreaseinthefingertip,reducingangleofthenailàcongenitalcyanoticheartdisease(lowlevelsofoxygeninblood),chronichypoxia,congenitalcardiacabnormality

- Splinterhaemorrhages:redlinesinthenails,whichareverticlebloodclots;whereflecksofbacteriabreakawayfromtheheartwithclotsandcausecapillariesinthenailstobreakàendocarditis

- Temperature

- Osler’snodes:painful,red,raisedimmunologicallesionsonthepalmsorfingersàinfectiveendocarditis

- Janewaylesions:painlesserythematousorhaemorrhagiclesionsonthepalmsàinfectiveendocarditis

- Palmarerythema:rednessofthepalmsàpolycythemia(toomanyRBC)

- Tendonxanthomata:nodulesonthetendonsinthepalmàhypercholesterolemia

• Pulses:- Radialpulse:

rate(30seconds,bpm),rhythm(irregular,regular),- Radio-radialdelay:feelbothradialpulsesatonce,theyshouldpulsesimultaneouslyif

notàaneurysm,stenosis/atherosclerosisinoneside,aorticdissection(emergency)- Radio-femoraldelay:feelradialandfemoralpulsesimultaneously,ifdelayàaortic

coarctationi.e.narrowedaorta

• Bloodpressure

• Head:TARMACJXP

- Jaundice:yellowdiscolouration,especiallyinthewhiteoftheeyeàHepaticcongestion,

hepaticstenosis,excessivehaemolysis,congestiveheartfailure(notenoughbloodtoliver)

- Anaemia:conjunctivaandskinforpallor

- Malarflush:rosycheckswithabluishtinge,maybeinabutterflypatternàPulmonaryHTduetomitralstenosis(lackofCO2inbloodcausesvasodilationincheeks)

- Xanthelasma:yellowcholesteroldepositsaroundtheeyes,moretheedgesàhypercholesterolemia

- ArgyllRobertsonpupil:pupilaccommodatesbutdoesn’treactàsyphilis

- Arcussenilis:aringofgreyaroundtheirisàhypercholesterolemia

- Mouthandtongueforcentralcyanosis:bluenessinthelipsandtongueàlackofperfusionà anaemia,lungproblems

- Teethàdentalhygienei.e.evidenceofplaqueordecayàinfectiveendocarditisduetothebacteriacolonisingtheteethgettingintothebloodstream

- Palate:ahigharchedpalateisindicativeofMarfan’ssyndrome

• Neck:- Palpatebothcarotids(strong/weak,regular/irregular,collapsing)àweak=cardiac

failure,collapsing=aorticregurgitation

- Brutisovercarotid(patientneedstoholdbreath),willheararushingsoundinstenosis

- JVP:internaljugulardeeptotheSCMmusclebutcanbeseenbetweentheheadsofthemuscle(betweenthemanubriumandjustlateraltoclaviclehead)whentheheadisrotatedtooneside(left).o Thehighestlevelofthepulsationswillthenbedeterminedandifitisgreaterthan

3cmitisraised.o TheJVPcanbedistinguishedfromthecarotidpulseby:itisnotpalpable,itflickers

twiceandmovesinpositionwhentheheadismoved.o Theabdominojugularreflexisthenperformed,wherethemiddleoftheabdomenis

compressedandtheJVPshouldrise,andthenfallbacktonormalwithinafewseconds.Ifitdoesnotfall,itisindicativeofrightheartfailure,astherightheartcannotcompensateforthehighervenousreturn

o Awave=atrialcontraction=spikeinpressureo Cwave=tricuspidclosingandcarotidpulse(backpressureformclosureandalso

carotidpulsepressure)o Xwave=thefillingoftheatriumwithtricuspidclosedo Vwave=theatriumisalmostfullandthereforeflowisreduced(tricuspidstill

closedo Thetricuspidopensandbloodflowsintotheventricle

Local:

• Locateapexbeat–visible?(Commonlynotvisible)• Visiblepulsationsàindicateabnormalities• Scars/rashes• Chestwalldeformity• Pacemarkerpresent• Breathingrateandpattern• Sacraloedema

Palpation:

• Apexbeatàlateraland/orinferiororpresenceofthrills=cardiomegalyorpleuraldeformity

• Leftparasternalborder:- Heaveorimpulse:heelofhandjustleftofthesternum;nothingshouldbefelt,oraslight

inwardmovement.Aheavewillmovethehandoffthechestwallàrightventricularhypertrophyorsevereleftventricularhypertrophy(pushingrightatriumacrossandanterior)

- Thrill:apalpablevibrationsometimesaccompanyingaloudmurmuràturbulentbloodflowfelt

• Fourvalvesites:shouldbefeltforthrills- Aortic:rightsecondintercostalspace- Pulmonary:leftsecondintercostalspace- Tricuspid:leftparasternalfifthintercostalspace- Mitral:leftmidclavicularfifthintercostalspace

Percussion:Auscultation:

MRASS:MitralRegur=early,AorticStenosis=lateinSystolicARMSD:AorticRegur=early,MitralStenosis=lateinDiastolic

AllPatientTakeMeds

• Aortic:rightsternalborder,2ndintercostalspace• Pulmonary:leftsternalborder,2ndintercostalspace• Tricuspid:leftsternalborder,5thintercostalspace• Mitral:midclavicularline,5thintercostalspace

1. Listenoverthe4heartvalves:allwiththediaphragm,andthemitralwiththebellalso2. Positioning:

- Rollpatientontotheirleftsidetobringthemitralcloser- Sitthepatientforwardtoheartheaorticandpulmonarybetter

3. Bloodflow:- Inspirationtoheartherightheartsoundsbetter(tricuspidandpulmonaryàlower

pressureinchest,morebloodreturns)- Expirationtoheartheleftheartbetter(aorticandmitralàsqueezesbloodfrom

pulmonarybedintorightheart)Heartmurmurs:Itisimportanttorememberthattheheartsoundsareinfactthevalvesshutting,thusthefirstheartsoundheartisthemitralandtricuspidclosing,andthesecondistheaorticandpulmonaryclosing.ItisthusimportanttounderstandthatbetweenS1andS2istheventriclescontractingandbloodejectionfromtheventriclesinsystole,andthesecondheartsoundmeansthatsystoleisfinishedandthattheheartisnowfillingagain,thusbetweenS2andS1isdiastole.

Lowerlimb:PPHCTOX

(fuckedoxduetobrokenleg)• Pulses:

- Femoral- Popliteal- Posteriortibial- Dorsalispedis

• Palpatedistalshaftoftibiaforoedema(heartfailure)• Clubbingofthetoes• Xanthomataonachillies• Pallor• Absenceofhair• Temperature• Capillaryreturn