OSCE revision: Cardiovascular examination

Introduction

 

Introduction

•  Introduce yourself. Elicit name, age and occupation. Establish rapport.

Consent

•  Explain the examination to the patient and seek consent.

Position

•  Sit the patient at a 45 degree angle and expose the patient appropriately.

 

 

Inspection



 

General

• Stand and look at the patient from the edge of the bed. Observe for abnormal breathing, scars, added sounds or a pacemaker.
• Breathing at rest: Comfortable, dyspnoeic, cough
• Presence of scars: Midline sternotomy (CABG, valve replacement), Lateral thoracotomy (mitral valvotomy)
• Malar flush: Dusky pink discolouration of cheeks (mitral stenosis)
• Added sounds: Audible heart valves

Hands

• Feel the hands.
• Temperature: Warm and well perfused/poor perfusion
• Peripheral cyanosis: Blue nail beds
• Clubbing: Endocarditis, cyanotic congenital heart disease
• Endocarditis (SBE): Osler nodes and Janeway lesions, Splinter haemorrhages
• Nicotine stains: Peripheral vascular disease

Pulse

• Feel the radial pulse medial to the radius with three fingers. Assess the rate, rhythm, volume and character of the pulse.
• Rate
• Count for 15 seconds and multiply by 4
• Normal: 60-100 bpm
• Tachycardia: >100 bpm
• Bradycardia: <60 bpm
• Rhythm
• Establish the quality of the rhythm
• Regular: Sinus arrhythmia
• Regularly irregular: 2nd degree heart block
• Irregularly irregular: AF or multiple ectopics
• Volume
• Establish the volume of the pulse
• Low volume: Low cardiac output, heart failure, aortic stenosis
• Large volume: Thyrotoxicosis, CO2 retention, aortic regurgitatio
• Character
• The carotid pulse is palpable in the neck and provides more accurate information of volume and character than the radial pulse
• Normal pulse
• Slow rising pulse (aortic stenosis)
• Collapsing pulse (aortic regurgitation, patent ductus arteriosus)
• Bisferien pulse (double peaks, both stenosis and regurgitation
• Delay
• Radio-radial delay (Aortic arch aneurysm
• Radio-femoral delay (Co-arctation of the aorta)

Arms

• Blood pressure

Face

• Eyes for anaemia
• Around eyes for hyperlipidaemia (xanthelesmata, corneal arcus)
• Central cyanosis tongue
• Dental hygiene (SBE)
• High arched palate (Marfan's)

Carotid pulse

• Never palpate both simultaneously

JVP

• No more than 3cm above sternal angle
• Causes of raised JVP -  PQRST
• P - Pericardial effusion/ Pulmonary embolism/ Pericardial constriction
• Q - Quantity of fluid increased (iatrogenic fluid overload)
• R - Right heart failure or congestive heart failure
• S - Superior vena caval obstruction
• T - Tricuspid regurgitation/ Tricuspid stenosis/ Tamponade (cardiac)
• Apply firm pressure over the abdomen for about 15 seconds and look for a rise of about 2cm in JVP (hepatojugular reflex
• A persistent rise in JVP over 15 seconds of compression is a positive hepatojugular reflux sign (right ventricular failure)

Palpation

 

Apex beat

• Palpate the apex beat by feeling the furthest pulsating point of the heart
• It is normally located in the 5th intercostal space mid-clavicular line
• Note
• Character of apex beat
• Whether it is displaced (Left ventricular hypertrophy)
• Character
• Tapping - Mitral stenosis
• Thrusting - Aortic stenosis
• Heaving - Mitral regurgitation or aortic regurgitation
• Diffuse - Left ventricular failure, dilated cardiomyopathy
   

 

Heaves and thrills

• Feel for the presence of thrills (palpable murmurs - AS, VSD) by using the flat of the hand to palpate over the precordium.
• Use the flat of the hand to palpate over the left sternal edge, feeling for a parasternal heave (right ventricular hypertrophy)

 

Auscultation

Listen

• Auscultate over the four areas of the heart with a stethoscope listening for heart sounds, additional sounds (extra heart sounds, clicks or snaps), murmurs, or pericardial rubs
• Time the murmurs with carotid pulse to establish if its systolic or diastolic

 

Murmurs

• Note
• Timing
• Systolic
• Ejection (AS,PS,ASD)
• Pansystolic (MR,TR,VSD)
• Diastolic
• Early diastolic (AR,PR)
• Mid diastolic (MS, TS)
• Continuous
• Patient ductus arteriosus (PDA)
• Intensity
• Grade 1-3 - Thrill absent
• Grade 4-6 - Thrill present
• Site
• Aortic, Pulmonary, Tricuspid, Mitral (Right to left)
• Character
• Note if the murmur is rumbling (MS), blowing (MR), or harsh (AS) in character
• Assess if it is a crescendo-decrescendo, decrescendo, or crescendo or plateau type of murmur
• Pitch
• Assess the pitch of the murmur. High-pitch murmurs are best heard with the diaphragm (AS) while low pitch murmurs are best heard with the bell
• Radiation
• Check if the murmur radites to the carotids (AS), axilla (MR), left sternal edge (AR) or back (PDA)
• Effect of respiration
• Right sided murmurs heard with the greatest intensity on inspiration
• Left sided murmurs heard with the greatest intensity on expiration
• Position
• Note
• If heard best in supine
• Leaning forward with breath held in exhalation (AR)
• Or in left lateral position (MR)

 

Manoeuvre

• The Valsalva manoeuvre (exert downward pressure on the patient's abdomen as they exert outward pressure) increases the intensity of hypertrophic cardiomyopthy and mitral valve prolapse while softening aortic stenosis
• Squatting increases the intensity of aortic stenosis but softens hypertrophic cardiomyopathy

Lung bases

• Keep the patient leaning forwards and auscultate the lung bases listening for crepitations and pleural effusion (left ventricular failure)

Additional points

 

Oedema

• Sacral oedema by applying firm pressure on lower back and for pedal oedema by pressing down over the ankle
• Pitting
• Heart failure, nephrotic syndrome, cirrhosis, malnutrition, severe anaemia
• Non-pitting
• Lymphatic obstruction, deep vein thrombosis, myxoedema

Pulses

• Palpate the peripheral pulses (femoral, popliteal, post tibial, dorsalis pedis)
 

Request

• BP
• ECG tracing
• CXR
• Dipstick
• Fundoscopy (hypertension)
• Oxygen sats and temperature chart