Cardiovascular Examination

The cardiovascular examination (CVS) is the examination of patient's heart and circulatory system. The CVS exam does not simply focus on the chest but is also a systemic clinical examination of the patient. It is one of the core aspects of any OSCE exam. In the real world any patient that is admitted into the hospital needs to have a cardiovascular exam completed. Often patients with chest pain, shortness of breath or palpitations will need specific focus on their cardiovascular system due to the nature of their presenting complaint.

Wash hands

Wash your hands using the Ayliffe technique

Introduce yourself

Introduce yourself and give your name and grade

“Hi, my name is John Smith and I am a 4th year medical student”

Check patient details

Clarify patients identity by confirming name and asking for their DOB

Describe examination

Explain what examination you are performing and what it involves

“I have been asked to perform a Cardiovascular examination on you today. This involves having a look at your hands and face,  having a feel of your chest and a listen to your heart”

Gain verbal consent

“Would this be ok with you?”

Offer a chaperone

Ask if they would like a chaperone

“The exam involves you having to remove your upper garment. Would you like a chaperone for the exam?”

Positioning patient at 45 degrees

Initially lie the patient at 45 degrees and expose them from waist up

End of bed inspection

Inspect the patient from the end of the bed and look for the following:

  • Patient ‐ Note any tachypnoea, cachexia, oedema
  • Adjuncts ‐ Any supplemental O2 (%), IV lines, infusions, catheter
  • Paraphernalia ‐ GTN spray, cigarettes, walking aid

Inspect the hands

Inspect the hands and check for stigmata of cardiovascular disease.

  • Skin
    • Tar staining (smoker)
    • Janeway lesions ‐ Micro‐abscess, painless (pathognomonic of subacute infective endocarditis)
    • Osler nodes ‐ Inflammatory complex, painful (10‐25% of SIE)
    • Xanthomata ‐ Cholesterol deposits in tendons of hand and elbows (hypercholesterolaemia)
    • Scar ‐ Radial scar from angiography
  •  Temperature
    • Cold hands ‐ Poor cardiac output, Raynauds, PVD
  •   Nails
    • Clubbing (Cyanotic heart disease ‐ Fallot’s tetralogy, transposition of great arteries, Eisenmenger's, chronic endocarditis)
    • Splinter haemorrhage (subacute bacterial endocarditis)
    • Koilonychia (iron deficiency)

Check pulse and respiratory rate

Check the patient's pulse and resp rate. Time for 15 seconds and multiply by 4.

  •  Character
    • Irregular (AF, ectopics, respiratory sinus arrhythmia)
    • Pulsus paradoxus ‐ decrease in amplitude of pulse/BP during inspiration (cardiac tamponade, constrictive pericarditis)
    • Pulsus alternans ‐ alternating weak and strong beats (LV dysfunction)
    • Collapsing pulse ‐ tapping (Aortic regurgitation)
  • Delay
    • Radio‐radial ‐ coarctation aorta (pre left subclavian), dissection
    • Radio‐femoral ‐ coarctation aorta (post left subclavian)

Inspect the face and neck

Next, inspect their eyes, mouth for the following.

  •  Eyes
    • Xanthelasma ‐ yellow deposits around skin of eyes (hypercholesterolaemia)
    • Corneal arcus ‐ white, grey, blue ring around edge of  cornea (hypercholesterolaemia, unilateral ?decreased blood flow to eye)
    • Pale conjunctiva (anaemia)
  • Skin
    • Malar flush ‐ flushing of cheeks (mitral regurgitation)
  •  Mouth
    • Cyanosis
    • Glossitis ‐ large tongue (iron deficiency)
    • Angular cheilitis ‐ cuts to edge of lips (iron deficiency)

Inspect the neck for the JVP

There are seven features of a JVP than distinguish it from other vessels.

  • Complex waveform
  • Non palpable
  • Collapsible
  • Predominantly down going
  • Changes on inspiration (normal to go down)
  • Changes with positioning 
  • Hepatojugular reflex

Raised (sign of fluid overload)

Kusmauls sign ‐ JVP rises on inspiration (cardiac tamponade, constrictive pericarditis)

Canon waves ‐ large a wave (complete heart block)

General Inspection

Inspect the chest  again more closely and look for the following:

Scar

  • Central sternotomy (CABG, valve replacement, cardiac surgery)
  • infraclavicular (PPM, defibrillator, reveal device)

PPM boxes

Palpation of the chest

Palpate the chest wall, feeling for the following.

NB ‐ warn patient that you will be feeling under the left breast to feel for the apex beat

Heave ‐ hypertrophy

Thrill ‐ palpable murmur

Apex beat ‐ Normally 5th IC space mid‐clavicular line

Listen to the heart sounds

listen to the following four areas of the chest for the heart sounds.

  Mitral region (apex beat / 5th IC space)

  •  Murmur
    • Stenosis (Mid‐diastolic)
    • Regurgitation (pan‐systolic)
  • Manoeuvres
    • Lie on left side
    • Expiration ‐ enhances left sided heart sounds
    • Bell of stethoscope ‐ high pitched MS murmur
    • Axilla radiation ‐ mitral regurgitation

Tricuspid region (4th IC space left sternal edge)

  • Murmur
    • Stenosis (Mid diastolic murmur)
    • Regurgitation (pan‐systolic)
  • Manoeuvres
    • Inspiration ‐ enhances murmur
    • Liver ‐ pulsates with heart beat and murmur can be heard in severe TR

Pulmonary region (2nd IC space left sternal edge)

  • Murmur
    • Stenosis (early systolic)
    • Regurgitation (early diastolic)
  • Manoeuvres
    • Inspiration ‐ enhances murmur

Aortic region (2nd IC space right sternal edge)

  • Murmur
    • Stenosis (ejection systolic, crescendo‐decrescendo)
    • Regurgitation (early diastolic)
  •  Manoeuvres
    • Expiration ‐ enhances murmur
    • Listen to carotid ‐ aortic stenosis
    • Sit forward (listen 4th IC space left sternal edge) ‐ Aortic regurgitation

Examine the back

Inspect the back and check for the following.

  •  Sacral oedema (fluid overload and heart failure)
  •  Listen to base of lungs (fluid overload and heart failure)

Conduct a brief vascular exam

  • Aorta
    • Palpate ‐ Pulsatile/expansile (aneurysm)
    • Listen
      • Aortic bruis   
      • Renal bruis (renal artery stenosis)
  • Femoral (inguinal line)
    • Palpate
    • Check for femoral femoral delay
  • Popliteal
  • Posterior tibialis
  • Dorsalis pedis

Check for peripheral oedema

Check for peripheral oedema. Note if it is pitting and to what level it extends.

Thank patient

Let the patient know you have finished examining them and thank them for their time. Be courteous and offer them help to get redressed.

“That’s the end of the exam. Thank you for your time. Would you like any help getting dressed?”

State other exams for completion

Turn to the examiner and state what else you would do to complete the exam.

“To complete the examination I would check the patients BP. I would also also perform fundoscopy of the eyes.”

State what tests you would perform

Explain to the examiner what tests and investigations you would perform

  •  ECG
  •  Urine dip ‐ Proteinuria
  •  Bloods tests
    • FBC ‐ anaemia/infection
    • U&E ‐ renal function (if on ACEi/diuretic) 
    • LFT ‐ ALP if severe overload, dysfunction if on amiodarone
    • Lipid profile ‐ hypercholesteralaemia
    • Blood cultures ‐ 3x from different place and time (IE)
    • BNP ‐ if heart failure
  •  CXR
    • Cardiomegaly ‐ HTN disease, HF, cardiomyopathy
    • Fluid overload ‐ increased vascular marking, effusions, fluid in fissure, curly B line