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Cardiovascular Exam: SHOW THAT YOU ARE LOOKING

WIPPPPE: Wash hands, Introduce, Permission, Patient Particulars, Pain, Position, Exposure 1. Knock Door 2. Say candidate number 3. INTRODUCE self: Good morning/afternoon Sir/Mdm (? Shake hands to assess tone, coordination, power), my name is Sarah Tai, Im a year 3 medical student. Id like to examine your heart. Would that be okay? (PERMISSION) So in this exam, Ill be looking at your hands, face, chest and listening to your heart. Is that okay? thank you. May I confirm your name please? And your date of birth?, and how old does that make you? (PARTICULARS) Do you mind taking off your shirt and rolling up your pants for me please? (MAKE SURE HAVE BLANKET!) you may use the blanket to cover yourself after youve undressed. (EXPOSURE) and please have your arms by your side and legs uncrossed. Im going to wash my hands, please tell me when youre ready. (WASH HANDS) Are you in any discomfort at all? If yes, note, CARE when examining area. Esp shoulder collapsing pulse; chest (palpation), legs (pitting edema) now Im just going to POSITION the bed at a 45o angle (POSITION BED) 1. GENERAL INSPECTION of SURROUNDINGS: this might look a bit weird, but Im just going to stand in front of the bed and look at you. (remove blanket) - Medication: (pills (statins, antihypertensives antiarrhythmics, GTN), insulin, inhalers (salbutamol) GTN spray - Equipment (walking aids, wheelchair, sputum bowl, TEDS, spectacles, magnifying glass, hearing aids - Connected to patient (ECG, O2, iv cannula(see if connected to patient and what solution is it connected to), urine catheter (see if connected to patient and colour of urine), insulin pump, continuous glucose monitoring, dialysis, central line - Consumption: Cigarettes, alcohol, types of food (fatty, high carbo) and drinks (caffeine) - Signs: NBM, consultant name, scheduled for surgery

2. GENERAL INSPECTION of PATIENT: - Age: young/old - habitus: Obese/ Cachectic - Distress: pain/ distress? Breathing? (respiratory distress, strenuous effort in breathing, tachypnea, deep and labored, fast and shallow) Clutching chest pains?

- Oriented? - Fever: sweating? Shivering? - Pallor (anemia)? Cyanosed? - MALAR FLUSH (mitral stenosis, SLE) - Bruises - SCARS: midline sternotomy (CABG) if found, check legs for saphenous venous graft; Thorocotomy (R side for mitral or aortic valve replacement); Pacemaker (under L clavicle); chest drains (2nd I.c.s. midaxillary line) - Posture: Chest (pectus carinatum, pectus excavatum, barrel chested (COPD), kyphosis scoliosis, patient leaning forward and proppring themselves up and using accessory muscles to breathe) (THEN GO STAND AT PATIENTS RIGHT) 3. HANDS - Clubbing: Shamroths window test: DEMONSTRATE at their eye level, facing them while standing on the RIGHT of their bed, while giving instructions: Sir/Mdm, can you stick out your index finger and put your fingernails facing each other like this for me please? (cardiac causes of clubbing: atrial myxoma, subacute bacterial endocarditis, congenital cyanotic disease) - now can I see both your hands please? 1. Check DORSUM and while looking test CAPILLARY REFILL: a. capillary refill (hydration status): press for 5 sec, should refill in < 2 sec (compare with other fingers) b. Colour: - peripheral cyanosis, - nicotine stains, - peripheral anemia c. nails: - streak haemorrhages (for subacute bacterial endocarditis), - koilonychias (IDA): spoon nails - Leuconychia (Liver disease) - Pitting and ridging nails (Psoriasis) - Quincke's sign is pulsation of the capillary nail bed (with the very wide pulse pressure of aortic regurgitation). d. Fingers: - oslers nodes (pulps of fingers: raised, painful, red: subacute bacterial endocarditis) - Arachnodactyly aka achromachia: abnormally long, slender fingers (Marfans syndrome Aortic dissection radioradial delay)

e. palms: SHOW by really feeling palms rub fingers against patients palms! - janeway lesions: painless, non-raised (macular), ecchymotic (bruise-like) subacute bacterial endocarditis - Palm creases: pallor (anemia); hyperpigmented (addisons) compare with skin colour. Normal for palm creases to be darker in dark skinned people. - palmar erythema:liver disease (portal hypertension, hyperthyroidism, pregnant women, dermatoses (e.g. eczema, psoriasis) - Dupuytrens contracture: alcoholism liver disease (CARE! Diff from ulnar clawed hand where also ring and little finger most commonly affected!) Feels fibrosed - Cold/ warm hands (cold and cyanosed: congestive heart failure; warm and cyanosed: sepsis)

2. WRISTS - RADIAL PULSE (peripheral pulse): medial to radial styloid, lateral to FCR tendon, press against radial styloid: Test at heart lvl! (raise patients wrist to their heart level) - Rate: report EXACT rate and then describe (normal/ tachycardia/ bradycardia): in bpm (WATCH! 15 sec x 4); but if bradycardia or irregular rhythm: take 1 whole min! (take on one hand, R hand, ONLY first!) - Rhythm: regular (sinus)/ regularly irregular (e.g. 1st degree AV block, 2nd degree AV block, Atrial flutter)/ irregularly irregular (Atrial fibrillation) - Radio-radial delay: now use BOTH hands (feel other hand first to find pulse, then press back for R hand to feel both together and compare): for radioradial delay, must have an OBVIOUS differenceif not sure, prob not. coarctation, of aorta, aortic dissection) TAKE RESPIRATORY RATE AT SAME TIME - Collapsing pulse: first ask patient may I know if there is any PAIN in your shoulders at all? Wrap palm firmly but not hard enough to feel pulse, over wrist. With right hand over wrist and left hand feeling brachial pulse, lift arm (water hammer pulse aortic regurg.)

3. Arms: - AV fistula (lower arm, near wrist): current/post haemodialysis - tendon xanthoma(ta):wrist tendons and ELBOW (behind olecranon): hypercholesterolemia: pathognomic in young (familial hypercholesterolemia) but can be normal in old. - BLOOD PRESSURE: I would now like to take the patients blood pressure say to examiner - bruising: liver disease (decreased clotting factors) - scratch marks: jaundice - track marks: iv drug users

4. FACE now Ill just have a closer look at your eyes) just look straight ahead for me please? (look over patient first for upper sclera, then around eyes for xanthelasma, then inside eyes for jaundice and corneal arcus) and then conjunctiva pallor (now can you look up again for me while I gently pull down your lower eyelids). And lastly: lid lag: now I want you to follow my finger with your eyes while keeping your head straight facing me up and down. - at the same time check for MALAR FLUSH -EYES: - xanthelasma (hypercholesterolemia) on skin around eyes - corneal arcus: around iris (blue): hypercholesterolemia - Jaundice: yellow sclera (sclera icterus): RHF/ valve prosthesis - hyperthyroidism: (also AF? High output HF?) - Exophthalmos:: see upper sclera (normally not visible) GRAVES disease (patient look like hes staring at you) do only if suspect hyperthyroidism - Lid-lag: now I want you to follow my finger with your eyes while keeping your head straight facing me: lid cannot close fast enough, see upper white sclera. Thyrotoxicosis (not just graves) do only if suspect hyperthyroidism - Conjunctiva pallor: now can you look up again for me while I gently pull down your lower eyelids)

- CHEEKS: - Malar flush: mitral stenonis, thyrotoxicosis, pregnancy, SLE - EAR: earlobes normally smooth. But if CREASED = increased risk of coronary artery disease & MI (but not predictive in native American Indians and Asians) - MOUTH: now can you open your mouth wide? (demonstrate) and stick out tongue, and now use your tongue to touch the roof of your mouth) - BREATH IN: check breath!!! - marfans syndrome: high-arched palate (also have arachnodactyly (thumb and 2nd finger easily wrap around wrist), radioradial delay if have aortic dissection, long arm span > height, pectus excavatum, tall) - angular stomatitis aka angular chelitis: at edges of mouth: IDA and open your mouth for me please? - Dentition (risk factor for bacterial endocarditis) -stick out tongue - General hydration: hairy tongue, dry mouth - IDA: pale and smooth tongue

- Vit B12 and folate deficiency: Beefy and red tongue - central cyanosis (under tongue) lift up tongue - breath: - alcohol - ketones (DKA, T1DM or severe stage T2DM): pear drops - hepatic fetor (sweet faecal smell): liver failure. 3. NECK Sir/Mdm, can you please turn your head over to the LEFT and just relax your neck against the pillow (GET A PILLOW to support head) - Inspect: JVP (patient 45o!), look for JVP supraclavicular, or maybe higher if raised (sometimes at ear). Measure by the highest border vertical distance to sternal angle: normal = 3cm raised i.e. 8cm of blood. Distinguish from carotids: (1) seen, but not palpable (2) double wave form (a &v) (3)if occlude at supraclavicular area, jugular vein fills up and flushes away when pressure is released (4) height decreases with inspiration, increases with expiration. - observe by BENDING DOWN and looking up along sternocleidomastoid! (JVP should be - HEPATOJUGULAR REFLEX: PERFORM IT if cannot find JVP! Im just going to press down gently on your tummy while you are in this position. Just relax for me, keep your tummy nice and soft.

- Goitre: feel anterior part of neck (if suspect hyperthyroidism/ hypo): smooth/ nodular? Symmetrical enlargement? Im just going to feel your neck a bit from behind youjust relax your chin against my handsCan you swallow for me please? while touching enlargement : if move when swallow = thyroid gland. - lymph nodes: not really in cardio - CAROTID PULSE (Central pulse): VOLUME and CHARACTER, Bruitsnow Im just going to feel the side of your neck for your carotid pulse 1. palpate: c4 lvl of laryngeal prominence of thyroid cartilage; medial border of sternocleidomastoid, in anterior triangle of neck. Press down slowly and deeply till feel pulse, then release slight pressure to feel contours of pulse. CHARACTER: a) Slow-rising (anacrotic): aortic stenosis, LV outflow obstruction b) thready/ low volume: MI (cardiogenic), sepsis, hypovolemic ..(usually fast pulse tachycardia) c) collapsing/ water hammer: aortic regurgication (wide pulse pressure) d) hyperdynamic (and usually tachycardic) cardiac output high and peripheral resistance is low: (in CO2 retention) : emotion, heat, exercise, pregnancy, anxiety, fever, anemia, thyrotoxicosis, COPD

e) normal = dicrotic

4. CHEST (MOST IMPT!): spend most time here! INSPECT, PALPATE, (PERCUSS), AUSCULTATE! a) INSPECT: really show that looking - scars (dun forget lateral sides!) - at the same time, PALPATE just below left clavicle and in left axilla for PACEMAKER b) PALPATE Im just going to feel for your heart beat - apex beat LOCATION: use palm of right hand to find it (PMI: point of maximal impulse). then localize with finger then CHECK BACKcount ribs back (5-4-3-2-sternal angle)..CHECK FOR ANY LATERAL AND INFERIOR DISPLACEMENT (LV hypertrophy): should be 5th ics, slightly medial to L mid-clavicular line. (just medial to nipple): (if cannot feel, MANUOVRE!: get patient to lie your body slightly on his left Sir could you lie your body slightly on your left side please? and remain there for auscultation later! - REMEMBER where you palpate it for later! Auscultation - might not be able to locate apical beat in pericardial effusion - HEAVES: use heel of hand: will lift your heel up 1) at apex (LV hypertrophy) 2) at L Lower Parasternal edge (RV hypertrophy) - THRILLS (feel through BONES of chest wall): vibration buzzing feeling: use pulp of fingers: COUNT before putting fingers so know where to feel! 1) at pulmonary area: 2nd R ics. (pulmonary valve stenosis) 2) at aortic area: 2nd L ics. (aortic valve stenosis: strongest murmur usually can only feel this)

c) AUSCULTATE now Im going to listen to your heart, while feeling the side of your neck, would you mind turning over to your left side please? if the patient not already in that position * bell for higher frequency, diaphragm for low frequency sounds - Apex: use BELL, listen for : and TIME WITH CAROTID PULSE! (systolic/ diastolic) and where is loudest! i) HEART SOUNDS (normal = lub-dub, dub longer than lub.; EXTRA HEART SOUNDS: S3 (Kentucky, early diastolic, left heart failure); S4 (Tennesse, prediastolic murmur; LV hypertrophy/ stiff) ii) MURMURS: 1) MITRAL area

- mitral stenosis diastolic murmur, loud S1, (soft sound) opening snap in diastole (after S2), middiastolic mumur, presystolic accentuation, leading back to loud S1) . Other sides of MS is MALAR FLUSH - or Mitral Regurgitation PAN systolic murmur wind through trees) if cant hear, now can you take a deep breath in, and OUT all the way, and hold RMB intensity: 1) louder on inspiration or expiration? 2) louder where? to compare with tricuspid area later.

2) auscultate for radiation to LEFT AXILLA (mitral regurg) 3) Can you please sit forward now while changing bell to DIAPHRAGM - TRICUSPID area: auscultate at Left 2nd-5th ics (COUNT!) and breath out all the way and breath IN all the way and hold: if murmur louder on expiration than inspiration, and louder than mitral area = tricuspid valve problem. - Also hear AORTIC REGURGITATION (louder on expiration, collapsing pulse and corrigans sign (bounding pulse at carotids may be visible), wide pulse pressure (BP measurement) high SBP low DBP; LV hypertrophy (Displaced apex beat, apex heave) and HEAD-NODDING with heart beat. : - patient REMAIN leaning forward

(to differentiate b/w mitral and tricuspid: (only do when hear murmur) 1) Mitral louder on EXPIRATION, tricuspid louder on inspiration 2) Mitral louder in mitral area (apex); tricuspid louder in tricuspid area (2nd to 5th left ics) 3) and tricuspid stenosis no presystolic accentuation (unlike mitral stenosis)

4) PULMONARY: (use diaphragm) auscultate at left 2nd Ics for PULMONARY STENOSIS (ejection systolic murmur): Dogbarking now breath out all the way, and breathe IN all the way, and hold - less common than aortic stenosis (sounds the same) - but louder on INSPIRATION, louder in pulmonic area

5) AORTIC STENOSIS: (use diaphragm) ausculate at right 2nd ics, Dog-barking now breath in all the way, and breathe OUT all the way, and hold like pulmonary stenosis a pre-ejection systolic murmur, but i) more common than pulmonary stenosis ii) louder on EXPIRATION iii) louder in aortic area. radiate to CAROTIDS (auscultated already while examining neck): listen for carotid bruits: ..now Im just going to listen to it for a bit..can you take a deep breath in, and HOLD use BELL. a) carotid artery stenosis (turbulent blood flow) b) murmur radiating from aortic stenosis valve.

6. LUNGS - now Im going to listen to your lungs, do you mind leaning a bit more forward for me please? - listen to lung bases 1) decreased lung sounds: pleural effusion 2) crackles (more on inspiration): pulmonary edema (caused by LHF) 3) Wheeze (more on expiration): pulmonary edema: continuous, high pitched, hissing sounds 4) Pleural rubs (creaking or brushing sounds produced when the pleural surfaces are inflammed or roughened and rub against each other. discontinuous or continuous sounds. both inspiratory and expiratory phases): pericarditis, pleuritis, pleural effusion.

7) SACRAL EDEMA (where the butt cracks start) now Im just going to check your lower back for edema 8) LEGS and finally your legs for any pitting edema..is there any pain at all in your legs?: start from ankles and move up if +ve sign. Assess the height of edema! - INSPECT again for saphenous vein grafts and possible diabetic foot. (SHOW)

To conclude: 1) Thank patient (I have finished my examination, thank you very much 2) Do you need any help getting dressed? 3) WASH HANDS 4) Present findings: Present findings: - on INSPECTION, patient appears (well, not in any distress); surroundings? SCARS, pacemaker? peripheral stigmata of subacute bacterial endocarditis? Peripheral or central cyanosis? Peripheral stigmata of anemia? Peripheral signs of hypercholesterolemia? Hydration status (capillary refill, furry tongue) peripheral stigmata of liver disease? MALAR FLUSH? Signs of hyperthyroidism/ graves?

- PULSE: Peripheral: HR (report absolute value and give description) and rhythm (regular/ regularly irregular/ irregularly irregular), Collapsing pulse? Respiratory rate is : value. Regular? Shallow and fast?/ deep and labored? - BLOOD PRESSURE: report and describe - Central pulse: normal volume? Character normal/ slow-rising/ thready/ bounding/ hyperdynamic? - JVP: how many cm rise normal? Raised? - on chest palpation: - APEX beat: displaced? - any heaves/ thrills? - on Ausculation: - carotid bruit (carotid artery stenosis) - extra heart sounds? Or no heart sounds (pericardial effusion)Becks triad for cardiac tamponade (hypotension, raised JVP and distant or muffled heart sounds) - Murmur? (systolic/ diastolic? Or other special features e.g. pan-systolic for MR; loud S1, MDM and PSA for mitral stenosis? Loudest where? Louder on inspiration or expiration? (RILE) Radiation to axilla (for mitral regug) or carotids (aortic stenosis) - Lung bases (crackles/ decreased breathe sounds/ wheeze/ pleural rub) - sacral edema? Ankle edema? Diabetic foot?

5) Assessment of patient: ? To further assessment, I would? CXR, ECG, feel for peripheral pulses, FBC (LFT, U&E for renal), respiratory examination? Fundoscopy for roths spots (bacterial endocarditis), diabetic retinopathy and hypertensive retinopathy, urine dipstick (proteinuria for kidney disease; glucosuria for DM, ketonuria for T1DM, lying and standing BP (postural hypotension), echocardiography (for valve disease), pulse oximetry (for O2 saturation), check for hepatomegaly, ascites and loss of peripheral pulses if detect RV hypertrophy, raised JVP, RHF, edema (pulmonary, sacral, ankle) or signs of liver disease e.g. leuconychia, jaundice, palmar erythema, dupuytrens contracture,

Other tests: - Roths spots with fundoscope (if ? subacute bacterial endocarditis) - echocardiography (for valve defects: audible/palpable murmurs; mitral stenosis (malar flush), collapsing pulse (aortic regurg); extra heart sounds, coractation of aorta (associated with aortic stenosis)/ aortic dissection (marfans syndrome -arachnodactyly (radioradial delay)

Notes: Jaundice (liver failure due to RHF/ hemolysis from valve replacements)

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