1. Cardiovascular Examination SESSION 2

2. Overview of Session An introduction to physical examinations Systematic run through of cardiovascular examination Chance to practise in the sessions

3. Introduction to Physical Examination “Inspection, palpation, percussion, auscultation” “Looking, feeling, moving”

4. Introduction to Physical Examination Tell/show the patient exactly what you want them to do with clear instructions Cover the patient up when you’re not examining them Always exam from the patients right hand side

5. Beginning a Physical Examination Introduce yourself: Full name, position and intent Explain what is going to happen and state that they can ask you to stop at any time Gain the patients consent and ask if they have any questions Confirm patient’s full name and DOB Position the patient appropriately 45 degrees for CV examination

6. WASH YOUR HANDS

7. General Inspection Looking Stand at the end of the bed and look Does this patient look unwell? Is there anything to indicate disease around them? “The patient is in no obvious signs of discomfort” “Nothing around the bed indicating cardiac pathology”

8. Schedule for CVS examination Hands Arms Neck Face Chest Back Legs/Feet Other Examinations

9. Hands Examine the patients hands do not turn the patient’s hands over, ask them to do it themselves (ask if they have pain in hands or wrists) Capillary refill – Gently press the nail/ back of the hand for 5s: it should refill within 2s. Any evidence of? Clubbing Janeway lesions (palmar), Osler’s nodes (on finger pulps) and splinter haemorrhages (indicate infective endocarditis) What's the appearance of the palmar creases?

10. Hands http://emergencymedic.blogspot.com/2008/11 /peripheral-signs-of-infective.htmlhttp://emergencymedic.blogspot.com/2008/11 /peripheral-signs-of-infective.html - janeway http://morningreporttwh.blogspot.com/2008/09/h opingkong-isms-1.htmlhttp://morningreporttwh.blogspot.com/2008/09/h opingkong-isms-1.html - oslersnode http://vasculitis.med.jhu.edu/typesof/polyangiitis.html http://jama.ama- assn.org/content/304/2/159/F1.expan sion.html

11. Arms Radial Pulse – pads of digits 2,3 & 4 placed lateral to the tendon of flexor carpi radialis Note the rate and rhythm – time for 15 seconds ‘Collapsing’ pulse – ask patient if they’ve had any problems with their shoulder. If no, raise arm and check for collapsing pulse Compare both sides for radial-radial delay Brachial Pulse – extend the arm at the elbow and place thumb medial to the tendon of biceps brachii Note the character and volume Take the patient’s BP (not in the OSCE)

12. Neck Jugular Venous Pressure (JVP) This is why your patient needs to be at 45 degrees Ask patient to turn their head to their left (Try not to say ‘look’; they will look…) Get eyes down below neck and look upwards The height of pulsation along the right internal jugular vein is measured vertically in cm from the sternal angle, then 5cm is added to this to give the JVP Normal JVP is 8cm of blood Carotid Pulse: Don’t palpate both at once…!

13. Face Eyes Pale conjunctiva – ask pt to look up. Gently pull lower lids down – sign of anaemia Xanthelasma Corneal Arcus Mitral ‘facies’ – associated with mitral stenosis A facies is a distinctive facial appearance associated with a condition Mouth Look for central cyanosis (below tongue) and peripheral cyanosis (lips) Note dental hygiene

14. Face http://www.stmellionclinic.com/index.php?page=xanthelasma http://www.kardionet.com/Herzkrankh eiten/Klappenfehler_Int.html

15. Chest – Inspection & Palpation Expose the patient at this point Look closely for any abnormalities Scars/ deformities Ensure you also look at the lateral aspects of the thorax Apex beat: Place R. hand flat on chest, inferior to the R. nipple Practice! 5 th ICS, L. MCL. Always find apex first, then check it’s position, not the other way around Heaves and Thrills Thrill – due to a murmur Heave – Suggestive of hypertrophy of the heart

16. Counting Ribs http://parkin09.wikis.birmingham.k12.mi.us/Ecosystems+Glossary Feel sternal angle and move laterally – this is the 2 nd rib Now move inferolaterally and count down the ribs The ‘x’th intercostal space is the space below the ‘x’th rib

17. Using Your Stethoscope Earpieces facing anteriorly in the ear ‘Diaphragm’ – Large face with membrane Tap it (gently) to check you’re listening through the right part Most heart sounds ‘Bell’ – Looks like a bell… Twist the tubing 180° to change to the bell Deep sounds – Mitral stenosis Place it on the patients skin – no need to press. Find a way you’re comfortable with

18. Chest – Auscultation “All Prostitutes Take Money” – start at ‘A’ Aortic – 2 nd ICS, RSE Pulmonary – 2 nd ICS, LSE Tricuspid – 4 th ICS, LSE Mitral – 5 th ICS, L. MCL You need to practise listening to these sounds ‘Lub’ HS 1 – Beginning of systole: inflow valves closing ‘Dup’ HS 2 – End of systole: outflow valves closing If you cannot tell which is which, palpate the carotid pulse This HS 1

19. Valves http://parkin09.wikis.birmingham.k12.mi.us/Ecosystems+Glossary Mitral Tricuspid Pulmonary Aortic

20. Chest – Auscultation Specific Tests: Mitral regurgitation – Auscultate in L. axilla. Mitral stenosis – Roll patient onto left hand side. Re- palpate the apex beat. Listen over this place with the bell. Aortic regurgitation – Sit patient forward. Listen over the 4-5 th ICS, LSE. Ask patient to take a deep breath in and hold Aortic stenosis – Ask patient to hold their breath and auscultate over the R. common carotid artery use the bell.

21. Chest Exam – Problems Breasts

22. Back With the patient sitting forward auscultate the lungs Ask patient to take deep breaths in and out – then tell to breathe normally Listen for ‘crackles’ over the lung bases on posterior thoracic wall Due to pulmonary oedema: fluid within the interstitium of the lungs – this closes the small airways in expiration. Crackles are due to the airways ‘snapping’ back open on inspiration ∴ this is heard on inspiration Press gently over sacrum (‘lower back’) to check for pitting oedema

23. Legs Re-cover the patient Press over the tibia to check for pitting oedema http://www.ptconsultan ts.biz/photos.html

24. Other examinations The conclusion Thank the patient WASH YOUR HANDS Conclude with stating what other investigations you would do A full peripheral vascular examination Fundoscopy Temperature Urine Dipstick Abdominal examination for ascites and hepatosplenomegaly

25. Schedule for CVS examination Hands Arms Neck Face Chest Back Legs/Feet Other Examinations

26. The OSCE You will be performing a full CVS examination in the OSCE You have to do the full examination in 5 minutes Practise Practise Practise

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