General inspection |
· Conscious state: ↑↓↔ · Respiratory effort: ↑↓↔ · Colour: pink, pale, blue · Body habitus: ↑↓ · Syndrome: acromegaly, Down’s, Turner’s |
Vital signs |
· Heart rate · Blood pressure +/- both arms |
Hands |
· Radial pulses, radiofemoral delay · Capillary refill time · Stigmata: clubbing, JW, ON |
Head and neck |
· Eyes: conjunctival pallor · JVP: height, waveform · Carotid pulses: volume, thrill · Stigmata: high arched palate, malar flush, dentition |
Praecordium |
· Inspection: surgery, pacemaker, deformity · Palpation: apex beat 5th ICS MCL, heave, thrill · Auscultation: four spots + carotid + axilla; S3 or S4, murmur · Dynamic change: inspiration, expiration, Valsalva · Postural change: left lateral, sitting forward |
Chest |
· Inspiratory crackles |
Abdomen |
· Hepatomegaly |
Lower limbs |
· Pulses · Oedema |
Bedside tests |
· ECG · TTE |
A wave |
· Atrial contraction |
C wave |
· Closure of tricuspid valves |
X descent |
· Atrial relaxation |
V wave |
· Bulging of tricuspid valves during isovolumic contraction |
X’ descent |
· Elongation of atrium during systolic ejection |
Y descent |
· Opening of tricuspid valve |
Atrial fibrillation |
· Absent A wave |
Pulmonary hypertension |
· Large A wave |
Pericardial tamponade |
· Reduced or absent Y descent |
AV dissociation |
· Cannon A wave |
Tricuspid regurgitation |
· Large |
Tricuspid stenosis |
· Large A wave |
Symptoms |
· Angina · Syncope · Dyspnoea |
Signs |
· Small volume, late-peaking pulse · Hyperdynamic, displaced apex beat · Ejection systolic murmur at RUSB radiating to carotid, +/- thrill |
Severe |
· Weak pulse · Late peaking murmur · Thrill · Soft S2 |
Symptoms |
· Fatigue · Dyspnoea |
Signs |
· Weak pulse · Displaced, hyperdynamic apex beat · Soft or absent S1; S3 present · Pansystolic murmur at apex radiating to axilla, +/- thrill |
Severe |
· Weak pulse · Loud S3 |
Complications |
· LV failure · Pulmonary hypertension · Atrial fibrillation |
Symptoms |
· Fatigue · Dyspnoea · Palpitations · Angina |
Signs |
· Water hammer pulse, wide pulse pressure · Displaced, hyperdynamic apex beat · Decrescendo diastolic murmur LLSB (?) · S3 |
Severe |
· Collapsing pulse, very wide pulse pressure (>80) · Bisferiens carotid pulse · Long murmur |
Cause |
· Infective endocarditis · Marfan’s syndrome |
Complications |
· LV failure |
Symptoms |
· Fatigue · Dyspnoea · Orthopnoea · Paroxysmal nocturnal dyspnoea |
Signs |
· Palpable ‘tapping’ apex beat · Opening snap, loud S1 · Long diastolic murmur at apex +/- thrill |
Complications |
· Atrial fibrillation · Pulmonary hypertension |
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