CVS examination

Cardiovascular Physical Examination
• Introduction
• Ask name
• Explain procedure
• Consent
• Privacy
• Comfort
• Clarification
• WASH HANDSSSS
• Equipment (stethoscope, pen-torch, sphygmomanometer, 2 rulers)
• Exposure
o Until the waist
o Take off socks (to palpate pulses)
• Positioning - Lie patient down at 450 supine
• - If female patient, cover breasts with towel or loose garment
• General Inspection
• Stand back/ at the foot of the bed to observe:
o Is the patient in pain?
o Does patient look well/ unwell – fatigue?
o Cyanoses, pallor, anemia
o Muscle wasting/ Malnourishment ( Cachexia)
o Breathing – dyspnea, tachypnea
o Obesity
o Jaundice (congestion of liver)
o IV line, asthma inhaler
o Congenital :
 Turner’s Syndrome (for females only) – webbed neck (coarctation of the aorta)
 Down Syndrome – Physical appearance (congenital heart defect)
 Marfan’s Syndrome – Tall, Long hands, Pectum excavatum /pigeon chest, high arched palate (aortic regurgitation)

• Hands – stand on the right side of patient
o Tremors = hyperthyroidism
o Clubbing – right angle/ fingernails together
o Peripheral cyanosis
o Splinter hemorrhage – fingernail (indicative of infective endocarditis)
o Osler’s Node – tender pulp of finger/ hypothenar (indicative of infective endocarditis)
o Janeway Lesion – non tender middle palm (indicative of infective endocarditis)
o Tar = smoking, needle marks= diabetes
o Capillary refills – indicating good or poor circulation (<5secs)
o Xanthomata (thickening of tendons)
o Scars: Carpal tunnel – hyperthyroidism/ diabetes
• Radial pulse:
o Regular pulse: 30secs x2, irregular >1min
o Arterial pulse: Vessel (hardened)
Volume (full/low)
Rate
Pulse (pounding, rising)
Rhythm – regularly regular (sinus rhythm)
Regularly irregular (AV block)
Irregularly irregular (AF)
Sinus arrhythmia = changes with respiration
o Radio-Radial delay
o Radio-femoral delay (Coarctation of aorta)
o Collapsing pulse
o Brachial pulse

• Blood Pressure

• Face
o Hair- dry= hyperthyroidism
o Malar flush – rosy cheek and bluish tinge
o Eyes – Pallor, Jaundice, anemia, xanthelasmata
o Pupils - corneal arcus = dyslipidemia

• Mouth
o Lips – bluish/cyanosis
o Tongue (under) – Bluish/Cyanosis
o Palate – High arched (Marfan’s Syndrome)
o Teeth and gums
 Swelling, redness, bleeding
 any Infection may cause infective endocarditis
o Chemosis – press forward inner canctus
o Buccal Mucosa – Swelling, petechiae (minute bleeding under skin) that may
indicate infective endocarditis.


• Neck
o Carotid pulse: rate, rhythm and volume
o Goiter/ Thyroidectomy
o JVP
 Can usually see vein btwn 2 heads of sternoclaidomastoid, pathology : until pinna of ear
 Ask patient to turn head to the left
 Observe pulsations above the clavicle
 Put a ruler on the sternal angle (zero point) and another ruler on the maximum height of pulsation – measurement more than 3cm indicates high pressure in the right side of the heart
eg. Sign of right ventricular failure, volume overload or some types of pericardial disease.
o Characteristics of JVP: compressible, blood fills from above, hepatojugular reflex, has 2 waves
o Locate the carotid pulse – character

• Praecoridum
o Inspect
 Scars – pacemaker, median sternotomy, lateral thoracotomy
 Shape of chest wall: barrel chest, kyphosis, pectus perinatum, pectus excavatum
 deformity
 Swelling
 Apex beat – site (mid-clavicular 5th intercostal space)
 Abnormal pulsation – might indicate hypertrophy/enlargement

o Palpation WASH HANDS if you haven’t
 Apex beat – position and character (mid-clavicular 5th intercostal space) can be felt better by lying on left side
 Thrills – palpable murmur due to turbulent flow (4 areas)
• Over the apex
• Left sternal edge (tricuspid, pulmonary) right is aortic
• Over the base of the heart/upper part of the chest
 Left parasternal heave – hand on left side of chest, if impulse is felt,
indicates right ventricular enlargement/ severe
left arterial enlargement.
• Palpable P2 – click sound (pulmonary hypertension)
• Pectus Ductus Arteriosus – doesn’t become a ligament. Feel a thrill below left clavicle


o Auscultation
 Check for heart sounds and mumurs
 Mitral area – Bell first then diaphragm (3rd heart sound can only be heard using the bell, 4th with the diaphragm) expiration
 Tricuspid area (5th left intercostal space -left sternal edge) on inspiration
 Base of the heart ( 2nd left intercostal space) – pulmonary, on inspiration
 Base of the heart (2nd right intercostal space) – aortic, on expiration; move further up to the carotid
 Carotid bruits- (can also be done in the neck section) Ask patient to inhale and hold breath. Swishing sounds of turbulent blood flow, indicative of carotid artery stenosis.
 If any murmurs heard or suspected, position patient left laterally to bring the heart closer as to hear better.
 Hole in heart: VSD/ASD can be heard in left sternal border.
 Systolic murmur – when holding carotid pulse and murmur at the same beat.
 Sit upright:
• Inhale and hold breath. Auscultate pulmonary area. During inspiration, right murmurs at pulmonary and tricuspid valves are heard best.
• Expiration, but hold nostrils and close mouth. During expiration, left murmurs at aortic and mitral valves are heard best.

*1st heart sound – closure of mitral and tricuspid valve “lub”
2nd heart sound – closure of the aortic and pulmonary valves “dub”

• Back
o Scars
o Deformity
o Sacral edema – Any pitting after approx 30 secs of pressure?
o Pleural effusion – listen at the intercostal spaces: crepitus if there’s fluid. Left ventricular failure
• Abdomen- lying down with one pillow only
o Palpate liver & spleen – press in when during expiration; can only be felt if they’re enlarged.
o Ascites- (excess fluid in the peritoneal cavity) percuss
o Femoral Arteries – palpate and auscultate

• Legs
o Inspection
 Clubbing
 Oedema
 Xanthomata – Achilles tendon
 Cyanoses – Toes
 Trophic changes – Changes from interruption in nerve supply
 Loss of hair – indicative of ischemic occlusion – depending on hairiness
 Varicose veins - DVT
 Ulceration

o Palpation
 Cold limbs
 Calf tenderness
 Oedema– apply pressure at medial tibia for approx 30 seconds, observe any pitting
 Peripheral pulses: Dorsalis pedis, posterior & anterior tibialis, popliteal
o Others
 Fundascopy – eyes: to check for infective endocarditis – presence of Roth’s spot
 Temperature Chart
 Urine analysis
o Conclusion
 Thank patient and ask patient to dress up.
 Summarize and present findings.