Cardiovascular

Examination
 History
 Chest pain
 Dyspnoea
 Palpatations
 Oedema
 Syncope or presyncope
 Chest pain
• Site and radiation
• Character
• Severity
• Frequency
• Duration
• Aggravating factors
• Relieving factors
• Associated features
 Dyspnoea
• Onset
• Severity
• Related to effort
• Orthopnoea
• Paroxysmal nocturnal dyspnoea
 Other symptoms
• Cough
• Haemoptysis
• Tiredness
• Nausea and vomiting
• Bowel upset
• Oliguria
• Visual loss
 Other aspects of history
• Past medical history
• Drug history
• Family history
• Social history
• Occupational history
 Physical examination
• Look around
• Hands, pulse, BP
• Face & Neck
• Chest examination
• Other bits
 Look around
 Initial impression
– Distress
– Breathlessness
– Audible cough
 O2
 TPR
 Hands
• Perfusion
• Peripheral cyanosis
• Finger clubbing
• Tar stains
• Splinter haemorrhages
• Xanthomata
 Pulse and BP
 Radial pulse
– rate
– rhythm
– volume and character
 Central pulse
 BP
– consider BP in both arms
 Face
• Malar flush
• Xanthelasma
• Corneal arcus
• Central cyanosis
• Anaemia
• Teeth – endocarditis
 JVP
• JVP = right atrial pressure
• Falls during inspiration
• High in fluid overload e.g. right heart failure
• Fixed in SVCO
• Low in dehydration and fluid depletion
 45o – supine
 Inspect from side
 Internal jugular
– Sternomastoid
 Height
 Waveforms
 The Heart
• Inspection
• Palpation
• (Percussion)
• Auscultation
 Inspection
• Skeletal abnormalities
• Scars
• Pulsations
• Pacemaker
• Respiratory rate
 Palpation
• Apex beat
• Abnormal pulsations
• Thrills
• Parasternal heave
 Apex beat
• Furthest point downwards and outwards
• Normally 5th interspace in mid-clavicular line
• Right hand placed on left chest wall
• Middle finger over approx site
• Once located count down the rib spaces
• Displacement suggests cardiac enlargement
• May be impalpable
 Auscultation
• Diaphragm – high pitched sounds
• Bell – low pitched sounds

• Heart sounds
• Added sounds
 Heart sounds
• 1st & 2nd heart sounds usually audible at
apex
• “lub-dup”
• Time with carotid pulse
• Systole occurs between the heart sounds
 Listening
 Entire praecordium
– Apex (mitral)
– Lower left sternal edge (tricuspid)
– Upper left sternal edge (pulmonary)
– Upper right sternal edge (aortic)
 Identify S1 and S2
 Identify any murmurs
Listening
 Listening
 Note features of murmurs
 (Carotids and axilla)
 Roll to the left (MS)
 Sit forward (AR)
 First heart sound
• Mitral valve closure (end of atrial systole)
• Tricuspid valve usually quiet
• “lub” in lub-dup
• Immediately precedes apical pulse
• Immediately precedes carotid wave pulse
• Apex with bell or diaphragm
 Second heart sound
• Closure of aortic and pulmonary valves at
end of ventricular systole
• “dup” in lub-dup
• Immediately follows apical impulse
• Immediately follows carotid wave pulse
• Upper left sternal edge with diaphragm
 Third heart sound
• Normal in young healthy
• Impaired LV function
• Raised end diastolic pressure
• Low pitched at apex – bell
• “gallop” or “triple” rhythm when
tachycardic
 Fourth heart sound
• Accompanies and is due to atrial systole
• Only heard in sinus rhythm
• Loud in left atrial hypertrophy i.e. IHD,
hypertension
• Low pitched at apex – bell
• Triple or gallop rhythm
 Heart sounds
• Rate

• Rhythm
Sinus arrhythmia
Ectopic beats – premature
Intermittent heart block – dropped beats
Atrial fibrillation
 Murmurs
• Turbulent flow across valves
• Leaking or narrowed valve
• Timing
• Intensity

Grade 1 – very quiet

...
Grade 6 – audible without stethoscope
 Systolic murmurs
• Heard between 1st & 2nd heart sounds
• Pan-systolic
• Ejection systolic
 Pan systolic murmurs
• Start with S1
• Mid systolic accentuation
• Extend through systole & continue to S2
• Mitral regurgitation – apex, low pitched
• Triscuspid regurg- left sternal edge to apex
• VSD – rough, tearing with thrill
 Ejection systolic murmurs
• Turbulent flow across narrowed valve
• Onset after SI - distinct and separate
• Intensity increases towards mid systole
• Aortic stenosis – aortic area (carotid)
• Pulmonary stenosis – pulmonary area
 Diastolic murmurs
• Heard between 2nd & 1st heart sounds
• Aortic regurgitation
• Mitral stenosis

• Pericardial friction rub

 Other findings
• Carotid bruits
• Pitting oedema (ankles & sacrum)
• Chest auscultation
• Abdominal examination
• Peripheral pulses
• Urinalysis