Cardiovascular Examination
Published on Nov 18, 2015
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PRESENTATION OUTLINE
What’s the purpose?
●This examination aims to pick up on any cardiovascular pathology that may be causing a pt.’s symptoms e.g.,chest pain, breathlessness, heart failure, extreme fatigue, pallor.
Photo by Matthias Rhomberg
Step One
Wash your hands, introduce yourself to the pt. and clarify their identity by asking their name and D.O.B. Explain that you are going to examine them and obtain consent.
●You should have the pt. sit in bed at a 45 degree angle.
Photo by OUCHcharley
Step 2
●Begin by observing the pt. from the end of the bed. You should note whether the pt. looks comfortable sitting up in the bed?
●Are they cyanotic, flushed, pale, or short of breath?
●Is the pt.’s respiratory rate normal?
Cyanosis- appearance of a blue or purple coloration of the skin or mucous membranes due to the tissues near the skin surface having low oxygen saturation.
Photo by various brennemans
Step 3
●Inspect the pt.’s hands. Initially note how warm they feel as this gives an indication of how well perfuse they are.
●Particular signs which you should be looking for are nail clubbing, splinter hemorrhages, palmar erythema, janeway lesions, osler’s nodes and nicotine staining.
Photo by Camera Eye Photography
Definitions of previous terms
●Palmar erythema- reddening of the palms
●Janeway lesions- non-tender, small erythematous or hemorrhagic macular or nodular lesions on the palms or soles only a few millimeters in diameter that are indicative of infective endocarditis.
●Osler’s nodes- painful, red lesions found on the hands and feet
Photo by John-Morgan
Step 4
●Take the radial pulse. This is not a suitable pulse for describing the character of the pulsation, but can be used to assess the rate and rhythm.
●Check for a collapsing pulse- a sign of aortic incompetence.
●Locate the radial pulse and place your palm over it, then raise the pt.’s arm above their head. A collapsing pulse will present as a knocking on your palm.
Step 5
●Examine the extensor aspect of the elbow for any evidence of xanthomata
Xanthomata- deposition of yellowish cholesterol-rich material in tendons or other body parts
Photo by buhny
Step 7
●Move up to the pt.’s face. Look in his/her eyes for any signs of jaundice, particularly in the sclera beneath the upper eyelid.
●Look for xanthelasma ( yellowish deposit of fat underneath the skin usually on or around the eyelids.)
●Check the color of the pt.’s tongue for any cyanosis.
Photo by Foxtongue
Step 8
●Move to the pt.’s neck to assess their jugular venous pressure. Ask them to turn their head to look away from you. Look across the neck between the two heads of the sternocleidomastoid muscle (anterior portion of the neck) for a pulsation.
Photo by vitualis
Step 8 cont.
●If you do see a pulsation, you need to determine whether it is the JVP.
●If it is, then the pulsation is non-palpable, obliterable by compressing distal to it.
●Pulsation will be exaggerated by performing the hepatojugular reflex.
●Warn the pt. that it may cause some discomfort, press down on the liver.
●This will cause the JVP to rise further.
●If you decide the pulsation is due to the JVP, note its’ vertical height.
Photo by perpetualplum
Step 9
●Move to the pt.’s chest. Inspect the area, looking for any obvious pulsations, abnormalities, or scars. Check the axillae as well.
●Palpation of the precordium (chest) starts by trying to locate the apex beat. Use your entire hand and gradually become more specific until it is felt under one finger and describe its’ location anatomically.
●The normal location is in the 5th intercostal space in the mid-clavicular line. However, it is not uncommon to not feel the apex beat at all.
Step 10
●Now palpate for any heaves or thrills. A thrill is a palpable murmur whereas a heave is a sign of left ventricular hypertrophy.
●Left ventricular hypertrophy- thickening of the muscle of the left ventricle of the heart
●A thrill feels like a vibration and a heave feels like an abnormally large beating of the heart.
●Feel for these all over the chest.
Photo by Kris Kesiak Photography
Step 11
●Listen to the pt.’s heart using the diaphragm of your stethoscope, for all 4 valves of the heart.
●Mitral valve- where the apex beat was felt
●Tricuspid valve- on the left edge of the sternum in the 4th intercostal space
●Pulmonary valve- left edge of the sternum in the 2nd intercostal space
●Aortic valve- right edge of the sternum in the 2nd intercostal space
Step 11 cont.
●Listen and note how many heart sounds you can hear with the diaphragm
●Are there any extra to the normal 2 sounds?
●Are there any murmurs?
●Are the heart sounds normal in character?
●Can you hear any rub?
Photo by archer10 (Dennis)
Abnormal
●If you hear any abnormal sounds, you should describe them by when they occur and the type of sound they are producing.
●Feeling the radial pulse at the same time can give a good indication as to when the sound occurs, as the pulse occurs at systole.
●If you suspect a murmur, check if it radiates.
●Mitral murmurs radiate to the left axilla whereas the aortic murmur often radiates to the left carotid artery. Listen over here for any carotid bruits.
Step 12
●Ask the pt. to sit forward and breathe in and out and hold out, while listening over the aortic area with the diaphragm.
●This checks for aortic incompetence which is the leaking of the aortic valve that causes blood to flow in the reverse during ventricular diastole, from the aorta into the left ventricle.
Photo by EUSKALANATO
Step 13
●To check for mitral stenosis, have the pt. lay down on their left side, ask them to breathe in and out and hold it out and listen over the apex and axilla with the bell of the stethoscope.
Step 14
●Finally assess for edema. While the pt.’s sits forward, feel the sacrum for edema and assess the ankles.
Photo by hopeandmegan
If any abnormalities found, arrange for an 12 lead EKG and a echocardiogram.
Photo by Rennett Stowe
