Before
starting
- Introduce
yourself to the patient.
- Confirm
his name and date of birth.
- Explain
the examination and obtain his consent.
- Position
him at 45 degrees, and ask him to remove his top(s).
- Ensure
that he is comfortable.
- Wash
your hands.
The examination (IPPA)
General inspection
- From
the end of the couch, observe the patient’s general appearance (age, state
of health, nutritional status, and any other obvious signs). Is he
breathless or cyanosed? Is he coughing? Does he have the malar flush of
mitral stenosis?
- Observe
the patient’s surroundings, looking in particular for items such as a
nitrate spray, an oxygen mask, ECG electrodes, and IV lines and infusions.
- Inspect
the chest for any scars and the precordium for any abnormal pulsation. A
median sternotomy scar could indicate coronary artery bypass grafting
(CABG), valve repair or replace- ment, or the repair of a congenital
defect. A left submammary scar most likely indicates repair or replacement
of the mitral valve. Do not miss a pacemaker if it is there!
Inspection and examination of the hands
- Take
both hands noting:
- – temperature: feel with the back of your hand
- – colour, in particular the blue of peripheral cyanosis and
the orange of nicotine stains
- – nail bed capillary refill time: press the nail for 5
seconds; it should refill within 2 seconds
- – any presence of clubbing (endocarditis, cyanotic
congenital heart disease)
- – any presence of Osler nodes and Janeway lesions (subacute
infective endocarditis)
- – any presence of splinter haemorrhages (subacute infective
endocarditis)
- – any presence of koilonychia or ‘spoon nails’ (iron
deficiency)
- Determine
the rate, rhythm, volume, and character of the radial pulse. A regularly
irregular rhythm suggests second degree heart block, whereas an
irregularly irregular rhythm suggests atrial fibrillation or multiple
ectopics.
- Raise
the patient’s arm above his head to assess for a collapsing/water hammer
pulse (aortic regurgitation). Ask the patient whether he has any shoulder
pain first.
- Simultaneously
take the pulse in both arms to exclude radio-radial delay (aortic arch
aneurysm). Indicate that you would also exclude radio-femoral delay
(coarctation of the aorta).
- As you
move up the arm, look for bruising, which may indicate that the patient is
on an anti- coagulant, and for evidence of intravenous drug use, which is
a risk factor for acute infective endocarditis.
- Indicate
that you would like to record the blood pressure (see Station 12).
A wide pulse pressure is typically seen in aortic regurgitation; a narrow
pulse pressure in aortic stenosis.
Clinical Skills for OSCEs
Station 13
Cardiovascular examination
|
Inspection and examination of the head and neck
- Inspect
the eyes, looking for peri-orbital xanthelasma and corneal arcus, both of
which indicate hyperlipidaemia.
- Gently
retract an eyelid and ask the patient to look up. Inspect the conjunctivus
for pallor, which is indicative of anaemia.
- Ask the
patient to open his mouth, and look for signs of central cyanosis,
dehydration, poor dental hygiene (subacute bacterial endocarditis), and a
high arched palate (Marfan’s syndrome).
- Palpate
the carotid artery and assess its volume and character. A slow-rising pulse
is suggestive of aortic stenosis, a collapsing pulse of aortic
regurgitation. Never palpate both carotid arteries
simultaneously.
- Assess
the jugular venous pressure (see Figure 6) and, if possible, the
jugular venous pulse form:
ask the patient to turn his head slightly to one
side, and look at the internal vein medial to the clavicular head of
sternocleidomastoid. Assuming that the patient is reclining at 45 degrees, the
vertical height of the jugular distension from the angle of Louis (sternal angle)
should be no greater than 4 cm: if it is greater than 4 cm, this suggests right
heart failure, fluid overload, or tricuspid valve disease.
Palpation of the heart
Ask the patient if he has any chest pain.
- Determine
the location and character of the apex beat. It is normally located in the
fifth inter- costal space at the midclavicular line. The apex may be:
- – impalpable: obesity, dextrocardia, situs inversus...
- – displaced, suggesting volume overload (mitral or aortic
regurgitation)
- – heaving, suggesting pressure overload and left ventricular
hypertrophy (aortic stenosis)
- – ‘tapping’, suggesting mitral stenosis
- Place
the flat of your hands over either side of the sternum and feel for any
heaves and thrills.
Heaves result from right ventricular hypertrophy (cor
pulmonale) and thrills from transmitted murmurs.
29
Height of jugular
venous distention 4 cm
Angle of Louis (sternal angle)
45°
Figure 6. Assessing the jugular venous pressure.
Cardiovascular and respiratory medicine
Station 13
Cardiovascular examination
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30
Auscultation points
C C Mid-clavicular line
AP
T
M
M
Ax
Auscultation of the heart
- Listen
for heart sounds, additional sounds, murmurs, and pericardial rub. Using
the stetho- scope’s diaphragm, listen in the:
- – aortic area
right second intercostal space near the sternum
- – pulmonary area
left second intercostal space near the sternum
- – tricuspid area
left third, fourth, and fifth intercostal spaces
near the sternum
- – mitral area (use the stethoscope’s bell)
left fifth intercostal space in the mid-clavicular
line
- Manoeuvres
and points to remember:
- – ask the patient to bend forward and to hold his
breath at end-expiration. Using the stetho- scope’s diaphragm, listen at
the left sternal edge in the fourth intercostal space for the mid-
diastolic murmur of aortic regurgitation
- – ask the patient to turn onto his left side and to
hold his breath at end-expiration. Using the stethoscope’s bell,
listen in the mitral area for the mid-diastolic murmur of mitral stenosis
- – listen over the carotid arteries for any bruits and the
radiation of the murmur of aortic
stenosis
- – listen in the left axilla for the radiation of the murmur
of mitral regurgitation
For any murmur, determine its location and
radiation, and its duration (early, mid, late, ‘pan’ or throughout) and timing
(diastolic, systolic) in relation to the cardiac cycle. This is best done by
palpating the carotid or brachial artery to determine the start of systole.
Grade the murmur on a scale of I to VI according to its intensity (see Table
4). Common conditions associated with murmurs are listed in Table 5.
Figure 7. Auscultation points.
Clinical Skills for OSCEs
Station 13
Cardiovascular examination
|
31
Table 4. Grading murmurs
|
|
I
|
Barely audible murmur
|
II
|
Soft and localised
murmur
|
III
|
Murmur of moderate
intensity that is immediately audible
|
IV
|
Murmur of loud intensity
with a palpable thrill
|
V
|
As above, murmur audible
with only stethoscope rim on chest wall
|
VI
|
As above, murmur audible
even as stethoscope is lifted from chest wall
|
Table 5. Common conditions associated with
murmurs
|
|
Aortic stenosis
|
Slow-rising pulse,
heaving cardiac apex, ejection/early-systolic murmur best heard in the aortic
area and radiating to the carotids and cardiac apex
|
Mitral regurgitation
|
Displaced thrusting
cardiac apex, pan-systolic murmur best heard in the mitral area and radiating
to the axilla, patient may be in atrial fibrillation
|
Aortic regurgitation
|
Collapsing pulse,
thrusting cardiac apex, diastolic murmur best heard at the lower left sternal
edge
|
Mitral valve prolapse
|
Mid-systolic click,
late-systolic murmur best heard in the mitral area
|
RILE: Right-sided
murmurs are heard loudest on Inspiration whereas Left-sided murmurs are heard
loudest on Expiration
|
Chest examination
• Percuss and auscultate the chest, especially at the bases of the
lungs. Heart failure can cause pulmonary oedema and pleural effusions.
Abdominal examination
- Palpate
the abdomen to exclude ascites and/or hepatomegaly.
- Check
for the presence of an aortic aneurysm.
- Ballot
the kidneys and listen for any renal artery bruits.
Examination of the ankles and legs
- Inspect
the legs for scars that might be indicative of vein harvesting for a CABG.
- Palpate
for the ‘pitting’ oedema of cardiac failure: check for pain and then press
for 5 seconds on the patient’s legs. If oedema is present, assess how far
it extends. In some cases, it may
extend all the way up to the sacrum or even the
torso (‘anasarca’).
- Assess
the temperature of the feet, and check the posterior tibial and dorsalis
pedis pulses in
both feet.
Cardiovascular and respiratory medicine
Station 13
Cardiovascular examination
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32
After the examination
- Indicate
that you would look at the observation chart, dipstick the urine, examine
the retina with an ophthalmoscope (for hypertensive changes and the Roth’s
spots of subacute infective endocarditis), and, if appropriate, order some
key investigations, e.g. FBC, ECG, CXR, echocar- diogram.
- Cover
the patient up and ensure that he is comfortable.
- Thank
the patient.
- Summarise
your findings and offer a differential diagnosis.