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Cardiovascular Examination
Procedure and what to be looking for at each stage
Observation
Clubbing
Cyanotic congential heart disease
Infective endocarditis
Peripheral cyanosis and Perfusion
Endocarditis is suggested by
Splinter haemorrhages
Osler's nodes = tender lumps in pulp of fingertips
Janeway lesions = red macules on wrist and hand
Nicotine stains - peripheral vascular disease
Radial pulse - for rate and rhythm
Normal
Small volume - in low output states eg heart failure, shock, mitral stenosis
Small Volume And Slow Rising pulse = aortic stenosis
Collapsing (rapid up and rapid down) in aortic regurgitation (also AV fistula or hyperdynamic
cicrulation)
Bisferiens = collapsing and slow rising occurring in mixed aortic disease
Pulsus alternans - LVF
Jerky - hypertrophic cardiomyopathy
Pulsus Paradoxus - pulse weakens in inspiration - indicates tamponade or constrictive pericarditis
11/1/2015 6:57 PM
Cardiovascular Examination
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Face
Argyll-Robertson pupil
pupil constricted, does not react to light but does to accomodation
"the prostitute's pupil accomodates but does not react"
think of syphilitic aortic regurgitation & poss. aneurysm
Xanthelasmata or corneal arcus = hyperlipidaemia
Mouth
Cyanosis
High arched palate of Marfan's -> aortic regurgitation
Mucosal petechiae -> infective endocarditis
JVP
Inspection of precordium
Scars
Deformity
Pulsation
Pacemaker boxes
Palpation
Thrills
Heaves
parasternal heave of RVH
apex beat may be
tapping (quick and light) - mitral stenosis
thrusting (diffuse and long) - mitral regurgitation
heaving (sharp and firm) - LVH & aortic stenosis
Apex beat should be 5th intercostal space mid-clavicular line
Auscultation
Listen at lung bases for fine inspiratory creps of pulmonary oedema (LVF)
Sacral oedema
Abdomen
Hepatomegaly - RVF
11/1/2015 6:57 PM
Cardiovascular Examination
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Peripheral pulses
Pitting oedema
Peripheral vascular disease - cold feet, gangrene
Varicose veins
Finally
BLOOD PRESSURE
narrow pulse pressure indicates aortic stenosis
wide pulse pressure indicates aortic regurgitation
drop of > 10mm Hg in inspiration indicates pulsus paradoxus and either tamponade or
constrictive pericarditis
Fundi
hypertensive change
grade I copper wiring of arteries
grade II arteriovenous nipping
grade III flame or blot haemorrhages, cotton wool exudates
grade IV papilloedema
Roth' spots = retinal vasculitis indicative of endocarditis
Urine - haematuria may indicate endocarditis
Temperature chart - endocarditis
11/1/2015 6:57 PM
Cardiovascular Examination
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Observation - nil
Hands
look for signs of endocarditis ie splinter haemorrhages (transilluminate them), Osler's nodes,
Janeway lesions
Radial pulse - may find AF
Face - normal in uncomplicated mitral regurgitation (but malar flush of mitral stenosis if mixed
mitral disease)
Carotid
usually normal character
in severe disease may get a small volume jerky pulse due to shortened ejection volume and
time
JVP
usually normal
raised if subsequent pulmonary hypertension
Thrill possible in mitral area
Heaves
in severe regurgitation may develop a parasternal heave due to left atrium enlargement
may also have RV Heave if pulmonary hypertension has developed
Apex
displaced laterally and down
thrusting
Auscultation
1st HS - soft or normal
Pan-systolic murmur
loudest at apex in left lateral position
radiates to the axilla
may obscure aortic component of 2nd HS
2nd HS may be obscured (but if there is pulmonary hypertension it could be loud and late)
3rd HS often present
11/1/2015 6:57 PM