CVS Examination

Approach

  • Wash hands
  • Rapport
  • Positioning
    • 45 deg
  • Exposure to waist

Surroundings

General appearance

  • Dyspnoea, cachexia
  • Dysmorphic features
    • Marfan’s
      • AR,
    • Turner’s
      • PS,
    • Down syndrome
      • AVSD
  • Rheumatological disorders, e.g.
    • ankylosing spondylitis
      • (aortic regurgitation)

Ask for vitals

Hands

  • Quinke sign
    • (AR)
  • Clubbing
    • causes
      • cardiovascular
        • infective endocarditis
        • cyanotic congenital heart disease
      • respiratory
        • carcinoma  
        • pulmonary fibrosis
        • chronic suppurative conditions
          • cystic fibrosis
          • bronchiectasis
          • abscess, empyema
        • asbestosis, mesothelioma
      • GIT
        • inflammatory bowel disease
        • coeliac disease
      • pregnancy
  • Tar
  • Signs of infective endocarditis—
    • splinter haemorrhages
      • Other causes
        • trauma
        • vasculitis
          • RA
          • PAN
        • sepsis
        • haematological malignancy
    • Oslers nodes
    • Janeway lesions ( palms)
  • Radial pulses
    • Rate / rythm / character
      • —right and left
      • [Collapsing pulse]
        • (AR, hyperdynamic, PDA)
      • [pulses alternans]
        • (severe LVF)
    • Delay
      • [Radiofemoral delay]
        • (coarctation)
      • [ radio radio delay]
        • (subclavian artery stenosis)
        • (atherosclerosis)
        • (aneurysm)
  • Peripheral cyanosis
  • Palmar pallor
  • Palmar erythema
    • ( chronic liver disease, thyrotoxicosis, pregnancy, rheumatoid arthritis, polycythaemia, leukaemia)
  • Xanthomata

Blood pressure

  • Pulsus paradoxus (>10mmHg drop on inspiration)
    • causes
      • constrictive pericarditis
      • pericardial effusion
      • severe asthma
  • postural drop
    • ( hypovolaemia, drugs, Addison’s, hypopituatary, autonomic neuropathy, idiopathic
  • Narrow PP
    • AS
  • Wide PP
    • AR

Face

  • Syndromes
    • Malar flush
      • (mitral stenosis, pulmonary stenosis, SLE)
    • SLE
  • Eyes
    • Sclerae—
      • pallor
      • jaundice
        • (liver congestion, haemolysis from prosthetic valve)
    • Pupils—Argyll Robertson (tertiary syphilis)
      • (aortic regurgitation)
    • Xanthelasmata
  • Mouth
    • Cyanosis
    • Palate (high arched—Marfan’s)
    • Dentition (endocarditis risk)

Neck

  • Jugular venous pressure
    • JVP Height
      • (right ventricular failure)
      • (volume overload)
      • (pericardial disease)
      • (TR, TS)
    • Wavesform
      • [cannon a]
        • (CHB)
      • [Giant a waves]
        •  (TS, PS, pulm HT)
      • [Large v (atrial filling & ventr systole)]
        • (TR)
    • Abdominal-jugular reflex (sustained JVP innovation for the duration of pressure)
      • (decreased compliance)
    • Kussmaul sign ( elevation on inspiration due to decreased right ventricular filling)
  • Carotids
    • Pulse character
      • [small vol, slow rising]
        • (AS)
      • [collapsing]
        • (AR, PDA, hyperdynamic)
      • [jerky]
        • (HOCM)
      • [bisferience] (slow rise + collapse)
        • (AS + AR)
    • Bruit
      • carotid
      • thyroid
      • (AS)

Praecordium

  • Inspect
    • Scars—whole chest, back
      • Pacemakers
      • midline
        • (CABG, valve replacement)
      • [thoracotomy]
        • (transplant, mitral valvotomy)
    • Deformity
      • [Pectus excavatum]
        • (Marfan)
    • Apex beat
      • position
      • character
        • [heaving]
          • (pressure loaded = AS, HT)
        • [thrusting]
          • (volume loaded = MR)
        • [dyskinetic]
          • LV dys Fx ? post MI
        • [double]
          • (HOCM)
        • [tapping]
          • (MS)
        • [Sustained]
          • (AS)
    • Abnormal pulsations
  • Palpate
    • Apex beat
      • [displaced, thrusting, diffuse]
        • [ severe MR, cardiomyopathy]
      • [heaving, hyperdynamic]
        • (AS, HT)
      • [ double impulse]
        • (HOCM)
      • Dextrocardia?
    • Heave
      • RVH
    • Thrills
      • [palpable P2]
        • ( pulm HT)
    • Abnormal impulses
    • Note: beware of dextrocardia
  • Auscultate
    • Heart sounds
      • S1
        • [loud]
          • (MS, tachycardia, short AV conduction)
        • [soft]
          • (MR, 1st HB, LBBB)
        • [split]
          • (RBBB)
      • S2
        • Splitting of S2:
          • Increased: inspiration & RV emptying
            (1) (RBBB, PS, VSD, MR)
          • Fixed:
            (1) (ASD)
          • Reversed:
            (1) delayed depolarization LV
            (a) LBBB
            (2) delayed LV emptying
            (a) AS, coarc
            (3) LV early filling
            (a) large PDA
        • [Loud]
          • (HT, congenital AS, pulm HT)
        • [Soft S2]
          • (Calcified AV, AR)
      • S3:
        • Mid-diastolic gallop rhythm. Rapid diastolic filling. Maybe normal in children/young adults.
          • Louder LSE
            (1) (RVF, constrictive pericarditis)
          • apex
            (1) (LVF, AR, MR)
      • S4:
        • Late diastolic gallop rhythm. ↓Ventricular compliance.
          • LV S4
            (1) (AS, MR, HT, IHD, elderly),
          • RV S4
            (1) (pulm HT, PS)
      • Opening snap:
        • MV in MS soon after S2 in diastole before murmur
      • Systolic ejection click:
        • Early systole in congenital AS or PS before murmur
      • Non-ejection systolic clicks:
        • MVP, ASD, Ebstein’s anomaly
    • Murmurs
      • Precordium
      • Neck
      • Loudness – soft versus loud
    • Prosthetic valve sounds

Position patient

  • Left lateral position
  • Sitting forwards (forced expiratory apnoea)
  • NB: Palpate for thrills again after positioning
  • Dynamic auscultation
    • Respiratory phases
      • R side murmurs louder on inspiration, L on expiration.
    • Held deep expiration
      • enhances AR murmur & pericardial rub
    • Valsalva
      • murmurs of HOCM louder & MVP longer
    • Isometric exercise
      • most murmurs louder except AS & HOCM
    • Squatting
      • AS & MR louder
  • Carotids

Back (sitting forwards)

  • Scars, deformity
  • Sacral oedema
  • Pleural effusion (percuss)
  • Left ventricular failure (auscultate)

Abdomen (lying flat—1 pillow only)

  • Bruising
    •  LMWI
  • Palpate
    • liver (pulsatile etc.),
    • spleen,
    • aorta
  • Percuss for ascites (right heart failure)
  • Femoral arteries—palpate, auscultate

Legs

  • Peripheral pulses
  • Peripheral vascular disease
    • Cyanosis, cold limbs, trophic changes, ulceration
  • Oedema
    • Pitting
      • Bilateral
        • Cardiac
          • CCF, pericarditis
        • Renal
          • Nephrotic
        • Hepatic
          • Hypoalb
      • Unilateral
        • Venous obstruction / DVT, tumor
  • Xanthomata
  • Calf
    • tenderness
    • swelling

Other

  • Temperature chart (endocarditis)
  • Fundi
    • [Roth spots]
      • (endocarditis)
    • HT
    • DM
  • Urine analysis (infective endocarditis)
  • Postural BP
  • ECG
  • CXR
  • Echo

Wash hands

if you hear nothing

  • MS
    • roll to left, exhale
  • second heart sounds
    • fixed splitting = ASD
  • pulm HT
    • RV heave, loud S2
  • pericarditis
    • recheck JVP
  • TR
    • recheck JVP
    • check liver
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