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Cardiovascular exam

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by

Arundathi Jayatilleke

on 12 September 2016

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Transcript of Cardiovascular exam

Clues around the room: nitroglycerin tabs, those heart pillows that patients get after bypass surgery

Does the patient look comfortable?
short of breath
clutching his chest?

Extras: sternotomy scar, pacemaker
Hands
peripheral cyanosis: bluish discoloration of nails (<85% oxygen saturation)

cool extremities

clubbing: increased tissue at the nailbed related to decreased oxygen
loss of Schamroth's window
the eponym might impress someone

signs of endocarditis
Janeway lesions
Osler's nodes
splinter hemorrhages
Legs
peripheral edema
scars from a saphenous vein "harvest" site

lack of hair on the leg can be a sign of peripheral vascular disease
General inspection: use your powers of observation!
BP and pulses
measure blood pressure. note the difference between systolic and diastolic, for wide (AR) and narrow (AS) pulse pressure

pulses: radial, brachial, carotid, femoral, posterior tibial, dorsalis pedis (and more!)
careful with palpation of the carotid pulses
abdominal aorta: assess the width of the pulse above the umbilicus
wide, pulsatile mass suggests abdominal aortic aneurysm

capillary refill: normal is <2 seconds – if prolonged may suggest hypovolemia
Hepatojugular reflux
Apply pressure to the liver

Observe the JVP for a rise

a sustained rise or rise > 4 cm is a positive hepatojugular reflux sign
suggestive of right sided heart failure / tricuspid regurgitation
Jugular venous pressure
1. Ensure the patient is positioned at 45°
2. Ask patient to turn their head away from you
3. Observe the neck for the JVP – located inline with the sternocleidomastoid
4. Measure the JVP – number of cm from sternal angle to the upper border of pulsation

Raised JVP may indicate
Fluid overload
Right ventricular failure
Tricuspid regurgitation
Auscultate in all four valvular areas
use the diaphragm of the stethoscope
then switch to the bell (for low-pitched noises)

Aortic valve – 2nd intercostal space – right sternal edge
Pulmonary valve – 2nd intercostal space – left sternal edge
Tricuspid valve – 5th intercostal space – lower left sternal edge
Mitral valve – 5th intercostal space – midclavicular line (apex beat)


Radiation of the murmur: carotids (AS), apex (MR), left sternal edge (AR)
Normal exam
1. regular rate and
2. rhythm,
3. normal S1 and S2,
4. no murmurs, rubs, or gallops
Inspection
Palpation
Auscultation
Cardiovascular exam
By Timpo - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=17806729
By Warfieldian - Own work, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=42835381
The beating heart
heaves: at the left sternal edge, suggest hypertrophy

thrills: palpable murmur

apex beat: 5th intercostal space, mid-clavicular line
Full transcript