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Clinical Skills 6: CVS Physical Examination - Coggle Diagram
Clinical Skills 6: CVS Physical Examination
Golden Rules for Students before conducting an examination
Introduce yourself to the Patient: Name and role
Explain the examination
What you'll be doing
Exposed chest - Offer a Chaperone ?
Empathy
Gain informed consent
Wash hands
Example:
Hello my name is , I am a 2nd year MBChB student at the University of Cape.
I have been asked today to perform what is called a cardiovascular examination
This will involve me looking at your hands, face and neck, as well as having a look, feel and listen to you chest. There are a few parts to the examination, so I will explain more as I go
This examination will require you to get underdressed from the waist upwards. Would you like a chaperone for this ?
If you are uncomfortable at any point, please let me know
Does this sound okay ?
Wash hands
General Inspection
After the Introduction ALWAYS follow with a general examination
Make sure you do this ! Comment as you go along...
Check around the bedside - Oxygen, Fluids, Medication, If the patient is connected to any Cardiac Monitors
Patient must lie at 45 degree, with chest exposed
Appearance - Well at rest, Pain, Shortness of breath, Anxious
General Examination of the Patient
During the general examination, look particularly for the following:
Assess for Pallor on the Conjunctive of the eye
By pulling down the lower eye lids and asking patient to look up
Assess for Central Cyanosis
By looking at the patient's Mouth and Tongue are Blue
Clubbing
By asking the patient to connect index fingers, and if Schamroth's triangle disappears or remains visible
Oedema
Pitting Oedema by gently pressing over the Tibia for 10 seconds with thumb
Ankle Oedema
Inspecting the Face
When inspecting the face, look at the:
Eyes for
Xanthelasma is a sign for Hyperlipidaemia
It is characterized by the yellow cholesterol deposit around the eyes
Corneal arcus is a sign for Hyperlipoproteinemia with elevated serum Cholesterol.
It is common in older adults, caused by aging
Sclera for
Conjunctiva Pallor is a sign for Anaemia
Jaundice
Haemorrhages
Rashes for
Malar Rash is a sign for Mitral stenosis/ Pulmonary Stenosis (Vasodilation due to Chronic Hypoxia)
Mouth for
Inspect oral cavity for Cyanosis and Pallor
Assess for Infections and Dental caries which may predispose Bacterial endocarditis
Central Cyanosis is a sign for decreased oxygen attached to red blood cells in bloodstream
Assessing the Neck
Outline how to Asses the Neck
When assessing the neck we will asses for 2 things:
Locating and Assessing the Carotid Pulse
Determining ate Jugular Venous Pulse (JVP)
Outline how to Locate and Assess the Carotid Pulse
Carotid Pulse can be located at at the Borders of the Sternocleidomastoid muscle lateral to the Thyroid Cartilage
Carotid pulse can be assessed at one side at a time, individual must place to palmer surface of 2nd and 3rd fingers at the point of pulsation
Bilateral Carotid Pulse landmarks
NB !!! Never check the Carotid arteries together, check one at a time
Pressing too firmly may cause the Patient to faint
Why do we assess the Carotid Pulse
Carotid Pulse should be palpated for Contour and Timing in relation to the Cardiac Impulse
Abnormalities in the Carotid Pulse Contour reflect underlying cardiac abnormalities such as Aortic Stenosis
BUT generally appreciated ONLY after detecting an abnormal Cardiac impulse or Murmur
The Carotid Pulse may be Increased in Frequency and may be Intense in normal patients with higher Stroke Volume secondary to Aortic Regurgitation, Hyperthyroidism, Fever, Anaemia or Atriovenous Fistula
Auscultate the Carotid Pulse
Outline how to Auscultate the Carotid Pulse
Prior to palpating the Carotid artery, you NEED to Auscultate the vessel to rule out the presence of a Bruit (an abnormal sound heard through a stethoscope, Murmur)
The presence of a bruit suggests underlying Carotid Stenosis, thus making palpation of the vessels potentially dangerous due to the risk of dislodging a Carotid plaque and causing an Ischaemic Stroke
Place the Bell of the Stethoscope between he Larynx and the Anterior border of the Sternocleidomastoid muscle over the Carotid Pulse
Ask the Patient to take a deep breath with their mouth closed and then hold it while listening
BE aware that at this point in the examination, the presence of a Carotid Bruit may in fact be a radiating Cardiac murmur , Aortic stenosis
Palpate the Carotid Pulse
Outline how to palpate the Carotid Pulse
If no bruit were identified, proceed to Carotid pulse palpation
Ensure that the patient is positioned safely on the bed as there is a risk of inducing Reflex Bradycardia when palpating the Carotid artery, Potentially causing a Syncopal episode
Gently place your fingers between the Larynx and the Anterior Border of the Sternocleidomastoid muscle to locate the Carotid Pulse
PLEASE DO NOT palpate/occlude BOTH carotid arteries simultaneously as this may cause the patient to faint
What do we assess for when Palpating the Carotid Pulse ?
When palpating the Carotid Pulse we assess for:
Character (Slowly-rising or Thready)
Volume of the Pulse
Determining the Jugular Venous Pulse (JVP)
Define the Jugular Venous Pulse
Jugular Venous Pulse is the oscillating top of the vertical column of blood in the Right Internal Jugular Vein (IJV) that reflects the pressure changes in the Right Atrium in the Cardiac Cycle
Why do we assess the Jugular Venous Pulse (JVP) ?
JVP is useful in the differentiation of different forms of Heart and Lung disease.
What equipment do we need to perform this examination ?
Ruler
Penlight torch
Outline the method of examination of the Jugular Venous Pulse (JVP)
Patient preparation
Patient positioning
Practical aspects and considerations
Landmarks
Technique
Patient Preparation
Patient Positioning
Patient must be in a reclining position with the head elevated at 45 degrees
The patient should lie comfortably during the examination
Clothing should be removed from the Neck and Upper thorax
Neck should NOT be sharply flexed
Landmarks
The JVP is approximately 2 cm in the normal situation
JVP usually best appreciated behind the Clavicles with the patient lying at 45 degrees
It is sensible to look first for the Jugular Venous Pulsations in this position.
Look behind the Clavicles
Be prepared to look on BOTH sides
Practical aspects and considerations
You may NOT see the Jugular Venous Pulsations if the:
Jugular Venous Pulse is somewhat low
In this case the Pulsations are hidden behind the Clavicles and will ONLY become visible if you lower the head of the bed.
Jugular Venous Pulse is very high
In this case the pulsations will in fact lie within the Skull, BUT may become visible if the patient sits upright.
Technique
Look on BOTH sides for the Jugular Venous Pulse and turn the patient's head towards and away from you so you can look obliquely across the neck
It is easier to view the Jugular Venous Pulsation in profile, across the neck
Unlike in arterial pulsations, Venous pulsations are low pressure and are easily occluded by laying a finger across the base of the neck
Thus preventing the transmission of pressure waves up the Jugular Vein
The Level of Venous Pressure
Outline how to determine the Level of Venous Pressure
Using a cm ruler, measure the Vertical Distance between the Angle of Louis (Manubriosternal Joint) and the Highest level of the Jugular Vein Pulsation
Measure from the Sternal angle
The Normal JVP (Jugular Venous Pulse) is no more than 3 cm from the Sternal Angle
If the patient's head is lower than 45 degrees, it will ELEVATE the JVP
If the patient's head is above the 45 degrees, it will REDUCE the JVP
For this examination it is preferred to use the Right Internal Jugular Vein as it is in direct line with the Superior Vena Cava
Internal Jugular vein is located from the Angle of Mandible to between the 2 heads of the Sternocleidomastoid muscle
As yourself is there a pulsation ? Is there a double wave ? If yes, then it is a JVP. If there is a single wave then it is most likely the Carotid
List why we prefer to use the Internal Jugular vein (IJV) ?
IJV has a direct course to the Right Atrium
IJV is anatomically closer to the Right Atrium
IJV has NO VALVES (Valves in the External Jugular vein prevent transmission of Right Atrial pressure)
Vasoconstriction secondary to Hypotension ( in Congestive Cardiac failure) can make EJV small and barely visible
Outline why do we prefer the Right Internal Jugular Vein
Right Jugular veins extend in an almost direct line to the Superior Vena cava, thus favoring transmission of Hemodynamic changes from the Right Atrium
The innominate vein is NOT in a straight line and may kinked or compressed between the Aortic Arch and Sternum, by a dilated Aorta or by an aneurysm
Distinguish between the Internal Jugular vein Pulsations from the Carotid Artery Pulsations
Internal Jugular Vein Pulsations
More lateral
Wavy, abundant
Decrease with Inspiration
Increase in Supine Position
Increases with abdominal pressure
Double Peaks
Obliterated with pressure
Better Visible
Better viewed from foot end of the bed
Carotid Artery Pulsations
Medial
Forceful, Brisk
No Change
No Change
No Change
Cannot be obliterated
Better palpated
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Locating the Pulses
Outline where do to find the Radial Pulse
Carefully palpate, localizes and assess the Radial pulse.
Use the Left Hand to support the patient's forearm; his wrist must be fully extended to stretch the artery.
Lay the palps of the fingers of the left hand within the Radial Border of the Forearm and identify the pulse
See how the Left Hand supports the patient's forearm with their wrist fully extended to stretch the artery
Assessing the Pulse
Outline assessing the Pulse
Make sure to describe all the following properties of the pulse before continuing:
Rate: Count pulsations for 30 seconds and double to give Beats per minute
Rhythm: Rhythm refers to pattern of the beats palpated
Is the rhythm Regular or Irregular
If it is Irregular, is it Chaotic or is there a Rhythm to the Irregularity
If Irregular count for one full minute
Volume: Volume refers to the volume of blood pushed against the wall of the artery during Ventricular contraction.
In order to assess the Volume and the Character of the Pulse, it is best to palpate an artery larger then the Radial artery such as the Brachial Pulse
Character: Character indicates variation in the blood flow with each pulse
Is the time between the beats Constant and Regular
Locating the Brachial Pulse
Outline where to find to find the Brachial Pulse
Brachial artery runs in the Antecubital fossa, about one third of the way across from the Medial Side of the Supinated Forearm
Use the Left hand to support the patient's arm and ensure that the elbow is fully extended
CORRECT PLACEMENT OF FINGERS: Move the pads of your three fingers medial (about 2 cm) from the Tendon and about 2-3 cm above the Antecubital fossa
Assess the Brachial Pulse
Outline what do we Assess in the Brachial Pulse
In the brachial Pulse we assess the following
Rhythm
Volume and Character
Brachial pulse is the most convenient to asses for volume and character.
Character indicates variations in the blood flow with each pulse.
The the pulse:
Weak or Thready (Lacks fullness)
Full and bounding (Volume higher than normal)
Imperceptible (Cannot be felt or heard)
Waveform of Pulse
Outline the types of Waveforms of Pulses
Normal
Slow Rising Wave with a Plateau
Sign of moderate or severe Aortic stenosis
Collapsing Pulse
Pulse pressure is greater than Diastolic Pressure
Sign of Aortic Incompetence, Elderly Arteriosclerotic patient or Gross Anaemia
Bisferiens Pulse
2 pulses with a lowered Amplitude, in place of 1 pulse
Sign of Aortic Stenosis with severe incompetence
Pulsus Paradoxus
Pulse is weaker or disappears on Inspiration
Sign of Contractive pericarditis, Tamponade, Status asthmaticus
Special Pulse Examination and Technique: Comparing Pulses
List the types of Pulses we Compare and Assess at the same time
Radio-Radial Delay
Radio-Femoral delay
Collapsing Pulse
How to Assess the Radio-Radial Delay
Evaluate both Radial Pulses to determine any delay or discrepancy
Delay of Left Radial confirmed with Right artery indicates Coarctation of the Aorta Proximal to Left Subclavian Artery
How to Assess the Radio-Femoral Delay
In Radio-Femoral delay you assess both the Left radial Pulse and the Left Femoral pulse
Delay may indicate Coarctation of the Aorta
How to Assess the Collapsing Pulse (Waterhammer)
Ask if any shoulder pain
Hold arm straight down whilst supporting the elbow
Palpate radial pulse with flat finger
Raise the arm upwards fast to accentuate the fast run off using gravity
In collapsing pulse the first few beats will be BOUNDING and FOPRCEFUL
Then it collapses due to Ventricular run off
Collapsing pulse is due to Aortic Regurgitation
Outline the Mechanism of a Collapsing Pulse
In Aortic Regurgitation, during Diastole:
The Left Ventricle receives a normal Pulmonary venous return PLUS some ejected blood into the Aorta
Resulting in a large Stroke Volume that is vigorously rejected
Then there is a rapidly rising Carotid pulse which then collapses as blood runs back
Taking a blood Pressure
Outline how to take a blood pressure
Step 1 - Choose the right equipment:
What you will need:
A quality stethoscope
An appropriately sized blood pressure cuff
A blood pressure measurement instrument such as an aneroid sphygmomanometer.
Step 2 - Prepare the patient
Make sure the patient is relaxed by allowing 5 minutes to relax before the first reading.
The patient should sit upright with their upper arm positioned so it is level with their heart.
Remove excess clothing that might interfere with the BP cuff or constrict blood flow in the arm. Be sure you and the patient refrain from talking during the reading.
Step 3 - Choose and apply the BP cuff properly
Most measurement errors occur by not taking the time to choose the proper cuff size.
Wrap the cuff around the patient's arm and use the INDEX line to determine if the patient's arm circumference falls within the RANGE area.
Otherwise, choose the appropriate smaller or larger cuff.
Secure the BP cuff ± 2cm above the antecubital fossa.
Step 4 – Palpate the brachial artery
With the arm fully extended, feel for the pulsation of the brachial artery.
Failure to fully extend the arm will result in difficulty both in locating the artery and in auscultating Korotkoff sounds.
In most people, the pulse can be felt at the medial aspect of the antecubital fossa, where the artery comes closest to the skin
Step 5 - Use palpation to estimate the Palpated Systolic blood pressure
While palpating the brachial pulse, inflate the cuff until the pulse disappears.
Release the pressure until the pulse returns and note the reading on the sphygmomanometer at this point. This is your Palpated systolic blood pressure.
Step 6 - Position the stethoscope
On the same arm that you placed the BP cuff, palpate the arm at the antecubital fossa (crease of the arm) to locate the strongest pulse sounds and place the stethoscope over the brachial artery at this location.
Step 7 - Inflate the cuff to 30 mmHg above the palpated systolic pressure
You should strive to inflate the cuff to 30 mmHg above the palpated systolic pressure—no more and no less.
This avoids both under- and over-inflating the cuff.
Begin pumping the cuff bulb as you listen to the pulse sounds.
When the BP cuff has inflated enough to stop blood flow you should hear no sounds through the stethoscope.
If this value is unknown, you can inflate the cuff to 160 - 180 mmHg. (If pulse sounds are heard right away, inflate to a higher pressure.)
Step 8 - Slowly Deflate the BP cuff
Release the valve partially at 2-3 mmHg per second so that the pressure is slowly released. Anything faster may likely result in an inaccurate measurement.
Step 9 - Listen for the Systolic Reading
The first occurrence of rhythmic sounds heard as blood begins to flow through the artery is the patient's systolic pressure.
This may resemble a tapping noise at first.
Step 10 - Listen for the Diastolic Reading
Continue to listen as the BP cuff pressure drops and the sounds fade.
Note the gauge reading when the rhythmic sounds stop. This will be the diastolic reading.
Step 11 - Thank the patient, disinfect your hands and record your reading
If blood pressure reading is abnormal it will need to be rechecked. To check the pressure again for accuracy, wait about five minutes between readings.
Pericardium Examination
This section covers the 3-Staged Assessment
Inspection
Palpation
Auscultation
Inspection
You need to look at the chest wall anterior and posterior. This will require that you undress your patient.
Look at the shape of the chest, also their work of breathing, are there any scars, bruising or pacemaker sites, can you see any visible pulsations?
Does your patient appear pale and/or central cyanosed?
When looking at the movement of the chest you need to check symmetry and pulling in of the chest.
Think about the underlying structure within the chest, look for any strong outward thrust of the chest wall that occurs during systole, this is called a Heave.
Label the images
This is a skeletal deformity called pectus Carinatum
This is a skeletal deformity called Pectus Excavatum
This is a scar from a previous surgery
Chest Palpation
List the Areas of the hand used in Chest Palpation
There are certain areas of the hand that are used to Palpate for different cardiac Abnormalities or Clinical Signs
2nd and 3rd finger is used for localized Pulsations
Palmar knuckles are used for Thrills
'wrist' end of the hand is used for Heaves or Lifts
The Apex Beat
The apex allows some assessment of the size of the ventricle.
Normally felt in the midclavicular line usually in the 5th intercostal space in healthy individuals.
Palpate the apex beat with your fingers (placed horizontally across the chest).
Lateral displacement suggests cardiomegaly.
Palpation of the apex
Outline how to palpate the Apex Beat
It is important to note that the apical beat can be difficult to locate in an obese patient or a patient with a thick chest wall.
Asking the patient to roll slightly over onto their left side or lean forward can move the heart slightly anteriorly making it easier to feel.
The technique is to place the flat of the hand over the left chest wall and attempt to recognise the apex beat.
One can then use the finger tips to narrow down its precise position, which is then recorded.
In women, one must feel as best one can right up underneath the left breast.
Pay attention to the placement of hand and fingers.
Palpation of the Precordium
Heaves
Outline the characteristics of Heaves
Heaves:
A parasternal heave is a Precordial Impulse that can be palpated
Parasternal heaves are present in patients with Right Ventricular Hypertrophy
Place the heel of your hand parallel to the left sternal edge (fingers vertical) to palpate for heaves
If heaves are present you should feel the heel of your hand being lifted with each systole
Important to note: A hypertrophied right ventricle may also give rise to a pulsation in the epigastrium, below the sternum. Feel here too.
Palpating for parasternal heave. Take note of the position and placement of hand and fingers.
Thrills
Outline the Characteristics of Thrills
A thrill is a palpable vibration caused by turbulent blood flow through a heart valve (the thrill is a palpable murmur)
You should assess for a thrill across each of the heart valves in turn
To do this place your hand horizontally across the chest wall, with the flats of your fingers and palm over the valve to be assessed
Auscultation
Auscultation of the heart provides vital diagnostic clues to many cardiac abnormalities
All cardiac areas must be auscultated in a structured and methodical fashion.
Describe the Sounds of the Heart
The heart has two main sounds, S1 and S2.
The first sound - S1- occurs as the mitral and tricuspid valves close, after blood enters the ventricles.
This represents the start of a systole.
The second heart sound - S2 - occurs when the aortic and pulmonary valves close, after blood has left the ventricles to enter the systemic and pulmonary circulation systems at the end of a systole.
Together, they sound as "lub-dub"… "lub-dub".
Auscultation Landmarks
List and Describe the Auscultation landmarks
Aortic Valve
2nd Intercoastal Space, Right sternal edge
Pulmonary Valve
2nd Intercoastal Space, Left Sternal Edge
Tricuspid Valve
5th Intercoastal Space, Left Sternal Edge
Mitral Valve
5th Intercoastal Space, Mid-clavicular Line
Infection control and guidelines for using your stethoscope effectively
Before starting the procedure wash your hands thoroughly with soap and water for 20 seconds
Make sure that your stethoscope has been cleaned with a disinfectant wipe.
The auscultation of the heart is performed using both - the diaphragm and the bell.
The diaphragm is best for high frequency sounds, such as S1 and S2.
The bell best transmits low frequency sounds, such as S3 and S4.
Auscultation of the Heart valves
Outline the Auscultation of the Heart Valves
Step 1: Auscultation is now performed for all four valves of the heart in the following areas with the patient at 45 degree angle:
Aortic valve – on the right edge of the sternum in the 2nd intercostal space.
Pulmonary valve – on the left edge of the sternum in the 2nd intercostal space.
Tricuspid valve – on the left edge of the sternum in the 4th intercostal space.
Mitral valve – where the apex beat was felt.
A good rule of thumb is to palpate down and across the anterior chest wall with your fingers to count and locate the intercostal spaces described above
Have your patient breathing deeply, quietly and slowly throughout the examination. If necessary, show him how he should breathe.
Outline how to Auscultate all the Cardiac valves
Aortic Valve
Place the diaphragm of the stethoscope at the second (2nd) intercostal space, right sternal border.
This is the anatomical landmark for the aortic valve.
Listen for at least five (5) seconds for the second heart sound, which represents the aortic valve closing.
Sounds arising from the left-sided valves tend to be louder on expiration.
Therefore, you must get your patient to expire deeply as you listen in the aortic area.
Pulmonary Valve
Place the diaphragm of the stethoscope at the second (2nd) intercostal space, left sternal border.
This is the anatomical landmark for the pulmonary area.
Listen for at least five (5) seconds for the second heart sound, which represents the pulmonary valve closing.
Sounds arising from the right-sided valves tend to be louder on inspiration.
Therefore, you must get your patient to inspire deeply as you listen over the pulmonary area.
Tricuspid Valve
Place the diaphragm of the stethoscope at the fourth (4th) intercostal space, left sternal border.
This is the anatomical landmark for the tricuspid valve.
Listen for at least five (5) seconds for the first heart sound, which represents the tricuspid valve closing.
3.Sounds arising from the right-sided valves (pulmonary and tricuspid) tend to be louder on inspiration.
Therefore, you must get your patient to inspire deeply as you listen over the tricuspid area.
Mitral Valve
Place the diaphragm of the stethoscope at the fifth (5th) intercostal space, mid-clavicular line (same area as the Apex Beat).
This is the anatomical landmark for the Mitral valve.
Listen for at least five (5) seconds for the first heart sound, which represents the mitral valve closing.
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Looking for Cardiac Signs
The cardiovascular examination is not complete unless you have looked for two other important indicators of heart failure in other systems.
Posterior aspect of the Chest
Abdomen
Assess posterior aspect of chest:
Assess for any oedema.
Whilst the patient is sat forward, listen at the lung bases for pulmonary oedema using the Diaphragm of the Stethoscope
Feel the sacrum for oedema.
Also, assess the ankles for the same.
Assessing the abdomen:
Look for hepatomegaly indicating right ventricular failure with hepatic congestion.
If you are not specifically examining the chest and abdomen.
You should at least examine these two organs in order to complete your examination of the heart.
Completing the cardiovascular physical examination
Thank the patient and allow them to dress.
Make the patient comfortable.
Wash your hands and report your findings to the examiner.
