Cardiovascular examination

General examination regarding CVS

Anaemia-Angina

Clubbing with cyanosis-Right to left shunt

Hyperlipidaemia-

                 

• Xanthroleshma
• Archus cornea-Creamy yellow discoloration at the boundary of iris due to cholesterol precipitation

Splinter hemorrhage-(SBE)-Small linear hemorrhage under nail

Ostler’s nodes-Painful erythematous swelling in finger pulp(SBE)

Arterial pulsation examination

Radial pulse(Mnemonics - RRV_CCT)

Check Rate , Rhythm , Volume , Condition of vessel wall , Character ,Tension of vessels ,radio radial delay , radio femoral delay(Coarctation of aorta)

Volume and character better by carotid pulse

Brachial pulse-Medial to biceps at antecubital fossa

Carotid pulse-Angle of jaw just anterior to sternocleidomastoid muscle

Popliteal-Popliteal fossa

Posterior tibial-2cm below and behind the medial malleolus between  flexor digitorum and flexor hallucis longus

Dorsalis pedis-Just lateral to extensor hallucis longus in 1^st inter metatarsal space most proximally

Pulse rate-

          Bardycardia(Heart rate below 60 beats/min) 
          Sinus bradycardia: When SA node produces impulse <60 beats/min

          Tachycardia(Heart rate >100beats/min) 
          Sinus tachycardia: When SA node produces impulse 100 beats/min

Examination of Blood pressure

JVP examination-

Measured at 45 degree lying

Opposite sided face to relax neck muscle

Observe along medial border of sternocleidomastoid muscle

If not found , then do abdomino jugular reflux to confirm highest limit of pulse

Measure from sternal angle which is normally 4cm indicating 6mmHg pressure of right atrium. In Kussmaul’s sign there is paradoxical rise in JVP in inspiration indicating constrictive pericarditis due to less accommodation of increased venous return during inspiration---

·         a wave peak: Right  Atrial contraction(Giant in tricuspid stenosis , absent in atrial fibrillation)

·         x descent: Tricuspid ring descent/fall in g atrial pressure during ventricular systole(Rapid descent in Constrictive pericarditis)

·         c wave peak: Tricuspid closure

·         v wave peak: Atrial filling/ventricular contraction(Giant in tricuspid regurgitation)

·         y descent: Opening of tricuspid(Rapid descent in Pericardial effusion)

Raised JVP: Congestive cardiac failure , tricuspid regurgitation ,constrictive pericarditis , pericardial temponade , superior  venacaval obstruction

[Pulse & Blood pressure for left heart , and JVP  & leg edema for right heart]

Precordium examination

Area of heart that lies on the anterior chest wall is precordium

Inspection

Patients sits at 45 degree sitting position and check for-

1.Shape of the chest/precordium

2.Visible cardiac impulse ,bulging/TOF/children mainly

3.Engorged vein-Sup venacaval obstruction(Downward direction) ,inferior venacaval obstruction(Upward direction)

4.Scar marks-Parasternal for open heart surgery ,mitral area for mitral commissurotomy

Palpation

1.Loacte apex and measure from left sternal edge along midclavicular line(Minorly check for any swelling/tenderness)

If not found/obese person make left lateral position to confirm(Normal , Thrusting in right ventricular hypertrophy , Tapping in Mitral stenosis , Thrilling in VSD)

2.Check for thrill(Palpable murmur on chest wall) by flat of the fingers at apex(mitral area) , 3^rd/4^th space(tricuspid area) , aortic and pulmonary area , below the clavicle(PDA) ,above tricuspid area(VSD)

3.Left parasternal heave( Systolic thrust in right ventricular hypertrophy) by heel of the hand with fingertips  right angle to sternum

4.Pulmonary component of 2^nd heart sound(Palpable P2) at left 2^nd space with finger tips(Use index , middle , ring finger tips)

Percussion

1.Locate apex and upper border liver dullness and join  the line which is inferior border of heart

2.Draw clinical base of heart ; Right and Lelft 2^nd space 1.25cm from each sternal edge ,on  left space along upper border of 3^rd rib and on right space along lower border of 2^nd rib

3.Mark multiple point along right and left margin of heart where dullness is found by percussing from shoulders ,lateral chest wall ,and join the point to indicate the borders/margin of heart

Auscultation

1.Locate apex and place at apex with the diaphragm

2.On left lateral position then with diaphragm at apex(Mitral regurgitation) and bell at apex(Mitral stenosis) in breath holding expiration (Maneuver for Mitral stenosis)and radiation to axilla( maneuver for Mitral regurtitation)

3.Return to 45 degree angle

4.Auscult at  tricuspid , pulmonary , aortic area with diaphragm

5.Sit and Lean a bit forward and auscultate with diaphragm at lower left parasternal edge(Think Tricuspid area but never say it) with breath holding expiration(Maneuver for Aortic regurgitation), breath hold inspiration same area nearly above(Tricuspid regurgitation) and at pulmonary & aortic area in breath holding expiration

6.Over carotid arteries by diaphragm and radiation in neck

During auscultation of CVS always check coincidation with carotid artery with thumb and during thrill palpation do only if murmur found