Cardiovascular examination:

 

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

·     Signs of hypoxia: cyanosis, clubbing

·     Stigmata of IE: splinter haemorrhages, JLs, ONs

 

 

 

Head and neck

·     Eyes: conjunctival pallor, xanthelasma

·     Face: cyanosis, malar flush

·     Mouth: high arched palate, dentition

·     JVP: height, waveform

·     Carotid pulses: volume, thrill

 

 

 

 

Praecordium

·     Inspection: surgery, pacemaker, deformity

·     Palpation: apex beat 5th ICS MCL, heave, thrill

·     Auscultation: four spots + carotid + axilla; S3 or S4, murmur

o  Resp change: inspiration, expiration

o  Posture change: left lateral, sitting forward

o  Dynamic change: Valsalva, squatting

 

 

 

 

 

 

Chest

·     Inspiratory crackles

 

Abdomen

·     Hepatomegaly + hepatojugular reflex

·     Aortic pulse

·     Sacral oedema

 

Lower limbs

·     Pulses

·     Oedema

 

 

Bedside tests

·     ECG

·     TTE

 

 

 

Jugular venous pressure:

Waveform

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

 

Common abnormalities:

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

 

Murmur differentials

 

Systolic:

Mid

·     Innocent

·     Flow (pregnancy, anaemia, sepsis, thyroid)

·     Aortic (stenosis, sclerosis, HCM)

·     Pulmonary (stenosis)

Pan

·     MR

·     TR

·     VSD

Common causes

·     Flow

·     AS

·     MR

·     HCM

 

Diastolic:

Early

(decrescendo)

·     AR

·     PR

Mid

(Decrescendo-crescendo)

·     MS

·     PS

 

Common valvular lesions:

 

Aortic stenosis:

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

 

Aortic regurgitation:

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

 

Mitral stenosis:

Symptoms

·     Fatigue

·     Dyspnoea

·     Orthopnoea

·     Paroxysmal nocturnal dyspnoea

Signs

·     Palpable ‘tapping’ apex beat

·     Opening snap, loud S1

·     Low-pitch, rumbling diastolic murmur at apex +/- thrill

Complications

·     Atrial fibrillation

·     Left heart failure

·     Pulmonary hypertension

 

Mitral regurgitation:

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

 

 

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