Clinical Examination Guide

Cardiovascular Examination

Components of the examination

• Introduction and general inspection • Hands • Neck • Face • Anterior Chest - close inspection, palpation, chest expansion, vocal fremitus/resonance, percussion, auscultation • Posterior Chest - close inspection, palpation, chest expansion, vocal fremitus/resonance, percussion, auscultation • Back and Ankles • Conclusion

Introduction

• Introduce yourself, confirm patient ID • Explain examination and gain consent, position patient at 45o and expose chest. Ask if they are in any pain • Gel hands and clean stethoscope

General Inspection

• General inspection of patient: Look well/unwell? Sweating or in pain? Consider colour: pale, red (vasodilation from

CO2 retention), blue (cyanosis), breathlessness, presence of ECG leads • Surroundings: Monitoring devices, GTN spray, oxygen

Nails, Hands, Arms

• Inspect nails for: splinter haemorrhages, clubbing • Inspect fingers and hands for: Osler’s nodes (painful, raised), Janeway lesions (non-tender, haemorrhagic, generally palm), tar stains • Examine both radial pulses, assess rhythm. [Raise arm and feel for collapsing pulse - very rare sign of aortic regurgitation] • Measure: - Capillary refill by squeezing fingertip to occlude blood flow then release and counting seconds until it refills (Up to 3 seconds is normal at the level of the heart) - Pulse rate and rhythm - Blood Pressure Document Owner: Clinical Skills/LK Last Updated: March 2018

Face

• Inspect face for: malar flush • Inspect eyes for: corneal arcus (white ring of lipid deposit around iris), xanthalasma (deposit in skin around eyes), conjunctival pallor of anaemia, • Inspect mouth: under tongue for central cyanosis and dental hygiene as risk factor in endocarditis

Neck

• Palpate carotid pulse for character • With patient still reclined at 450 ask them to turn their head to left whilst you look across the sternocleidomastoid for the jugular venous pressure (JVP). If visible pulsation, measure the vertical distance from the manubriosternal angle. • To differentiate JVP from arterial pulse consider the following: - JVP disappears when occluding venous return at base of the neck - JVP is not palpable - JVP increases as you gently press over the abdomen for 10sec to elicit the abdomino-jugular reflex.

Precordium

• Look for: chest shape, surgical scars (sternotomy, thoracotomy, pacemaker) • Palpate for: - Heaves (forceful beat) and thrills (murmur) either side of the sternum - Apex beat (5th IC space, mid-clavicular, best felt when patient rolls to left). Note any displacement

• Whilst palpating a carotid pulse, auscultate for heart sounds I and II, and any added sounds/murmurs at: - 2nd right IC Space - Aortic - 2nd left IC Space - Pulmonary - Lower left sternal edge - Tricuspid - Apex - Mitral (with bell of stethoscope, best heard when patient rolls to left) A P

• Ask patient to lean forwards, breath out and hold their breath T • Auscultate again at 2nd right IC space whilst patient holds the outbreath to M accentuate aortic sounds. Tell the patient to breath normally • Auscultate over carotid /axilla for radiation of any murmurs

Back and Ankles

• Inspect for: scars to the back of the chest suggestive of previous surgery • Auscultate for crackles at the base of lungs suggestive of pulmonary oedema • Palpate for: sacral and ankle oedema

Conclusion

• Thank patient, ask them to get dressed, report/record findings • Consider: respiratory examination, ECG

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