Cardiovascular examination

From Ganfyd

General Inspection

• Breathless ?
• On oxygen ?
• On telemetry
• Infusions
• Midline sternotomy scar of previous CABG
• Legs show SVG grafts

Anaemia

Conjunctival pallor and pale skin creases are sometimes used as signs of anaemia, but this is not always a reliable sign.

Cyanosis

Requires greater than 5g/dl deoxygenated haemoglobin and therefore is not visible in severely anaemic patients.

• Peripheral cyanosis
• Central cyanosis

Xanthelasmata

Hand

• Finger clubbing
• Splinter haemorrhages

Pulse

Rate

• Normal pulse 60 - 100 bpm
• Abnormal
  • Rate < 60 bpm - Bradycardia - Complete heart block, Beta Blockers, Hypothyroidism
  • Rate >100 bpm - Tachycardia

Rhythm

• Normal - Regular
  • Regularly irregular - 3:1 or higher degrees of heart block
  • Iregularly irregular - Atrial fibrillation, frequent ectopic beats

Volume

• Normal
  • Low volume - low output states, shock, peripheral vascular disease
  • Plateau - Aortic stenosis
  • Hyperdynamic - exercise, thyrotoxicosis, fever
  • Collapsing/Waterhammer - Aortic incompetence

Blood pressure

How to take the blood pressure

Interpretation

Jugular venous pressure

• a wave
• x descent
• c wave
• v wave
• y descent

Praecordium

You must keep a finger on the pulse at all times to time murmurs, heaves and thrills. Any event synchronous with the pulse is systolic and asynchronous diastolic.

Inspection

• Pectus excavatum
• Midline sternotomy scar
• Thoracotomy scar under left nipple
• Pacemaker in either right or left position
• defibrillation burns
• GTN patches

Palpation

• the apex beat (normally 5th intercostal space in the mid clavicular line)
• thrills (palpable murmurs) over the apex and at the left sternal edge

Be careful with your words at this stage of the examination: patients do not appreciate the announcement that you are going to "feel for thrills."

Percussion

Auscultation

Heart sounds

• First heart sound

Closure of mitral and tricuspid valves.

• Second heart sound

• Third heart sound

• Fourth heart sound

• Ejection clicks

• Midsystolic clicks

• Opening snaps

• Tumour plops

Murmurs

Systolic

• Aortic stenosis
• Aortic sclerosis
• HOCM
• Mitral incompetence
• Ventricular septal defect

Diastolic

• Mitral stenosis
• Aortic incompetence
• Atrial myxoma

Lung bases

Fine inspiratory crepitiations suggests pulmonary oedema

Abdomen

Smooth tender hepatomegaly suggests right heart failure, or may be unrelated to the heart!

Ankles

Pitting oedema will suggest possible right heart failure