Cardiovascular System Examination:

Begin:
1. Wash Hand
2. Introduce yourself and explain what you are going to do.
3. Position patient at 45
4. Expose patients from waist up

Inspection:

Foot of the bed:

1. General appearance
a. Alert/Drowsy
b. Well, comfortable at rest/Toxic/Respiratory distress
c. Pink/Blue in room air/with supplemental oxygen
2. Surrounding:
a. IV (Saline/Dextrose/Antibiotic)
b. Chest tube/DPL
c. Pulse Oximetry
3. Chest: Ask patient to take 2 deep breaths
a. Asymmetry/Chest Deformity
b. Scars (Midline sternotomy  CABG)
c. Visible Pulsation (Cardiac Dilation)

Right of the bed:

1. Hands:
a. Nails: Clubbing, Splinter hemorrhages, peripheral cyanosis
b. Palms: Janeway lesions (Non-tender)  secondary to vasculitis, Osler
nodes (Tender) secondary microemboli infarcts, Palmar crease pallor
 Anemia
c. Capillary refill time (<2s)
2. Radial Pulse:
a. Rate: 15 seconds x4 (60-100bpm normal)
b. Rhythm: Regular  sinus rhythm, regularly irregular  sinus
arrhythmia, irregularly irregular  atrial fibrillation
c. Character
3. Radio-radial Delay:
a. Coarctation of aorta
4. Collapsing pulse (Aortic Regurg)
a. Ask patient for any shoulder pain
b. R fingers to occlude radial pulse, L thumb over brachial pulse and L hand
to raise arm over elbow
c. Feel for the non-synchronous beat between the brachial and radial pulse.
5. Request for Radio-femoral delay  DO NOT REQUEST IN ADULTS
a. Coarctation of aorta
6. Face:
a. Eye: Sclera icterus, conjuctival pallor
b. Mouth: central cyanosis under tongue, hydration, high-arched palate,
dentition
7. Neck:
a. JVP (<4cm above sternal angle)
b. Carotid pulse
Palpation:

1. Apex Beat:
a. Start from lateral  medial
b. 5th IC Mid-clavicular line
c. Non-palpable apex beat:
i. Cardiac Factors: Pericardial effusion, dextrocardia
ii. Non-cardiac Factors: Thick chest wall, emphysema
d. Displaced apex beat:
i. Cardiac Factors: LV Dilatation
ii. Non-Cardiac Factors: Pneumothorax, lung collapse,
kyphoscoliosis
e. Heaving apex beat  LVH
f. Thrusting apex beat  LV Dilatation
2. Palpable thrills
a. Grade 4 murmurs or above
3. Parasternal Heave
4. Palpable P2
a. Pulmonary Hypertension

Auscultation:
S1 is normal, S2 is normal. No extra heart sounds heard.
 Wide splitting  Pulmonary stenosis (secondary to delayed RV emptying)
 Fixed splitting  ASD / VSD

Time with carotid pulse

1. Apex Beat (Mitral Region)
a. Bell for MS (Mid-Diastolic Murmur)  Turn patient to left to accentuate
MS murmur.
b. Diaphragm for MR (Pan-Systolic murmur)  Axilla area for radiation
2. Tricuspid Region
a. Tricuspid stenosis/regurgitation
3. Pulmonary Region
a. Pulm. Stenosis/regurgitation
4. Aortic region
a. Aortic regurgitation (Early Diastolic Murmur)
b. Aortic stenosis (Ejection-systolic murmur)  Bell for carotid bruits and
ask patient to hold his breath.

5. AR maneuver:
a. Patient to sit up and lean forward Diaphragm at LLSE
b. Ask the patient to breath in, and out completely hold breath to listen for
AR murmur.
6. Basal Crepitations at the back
a. Pulmonary edema due to LHF.

Listen carefully for clicking  prosthetic heart valve:

 2 Type:
a. Disc  Mechanical click which corresponds to S1/S2 depending on
the valve replaced (mitral  S1, Aortic S2)
b. Ball and Cage 2 Mechanical click per valve)
i. First mechanical click corresponds to S1/S2 depending on the
valve replaced (mitral  S1, Aortic S2)
 ii. Second mechanical click after the next heart sound due to
opening of valve
1. S1 (Mitral) click  normal S2  click  S1 (mitral click).
2. S1 normal  click  S2 (Aortic) click  S1 normal
3. If its 4 clicks  Mitral and Aortic ball + cage valve
replacement.
 Rationale for valve replacement:
a. Stenosis  Pressure overload  Apex beat not displaced
b. Prolapse/Regurgitation  Volume overload  Apex beat displaced

Others:

1. Sacral Edema
2. Pedal Edema:
a. Ask patient to tell you if it is painful when you press on it
b. Always look at patient’s face
c. Ascend along tibial upper shin
3. Thank patient and help him cover up
4. Wash hand

5. Wish List:
a. Peripheral arterial pulses: dorsalis pedis, posterior tibial, popliteal,
femoral pulse
b. Fundoscopy for IE
c. Urine dipstick
d. Abdo examination  RHF  tender hepatomegaly
e. Vital signs: Temperature chart, pulse oximetry, blood pressure,
respiratory rate
6. Glossary
7. Osler’s nodes
8. – painful red-brown nodules found on the finger pulps, seeninIE
9. Janewaylesions
10. – painless erythematous macules on the palms, seeninIE
11. Tendon xanthomata
12. – rubbery yellow deposits on the tendons, seenin hypercholesterolaemia
13. Pulsus arterans
14. – alternate strongand weak beats,seenin LVF
15. Pulsus bisferiens
16. – a double peak per cardiac cycle, suggestive of mixed aortic valve disease
17. Pulsus pardoxus
18. – appallingly named sign, since it is neither a pulse nor paradoxical. It is the
19. exaggeration of the normal decrease in systolic BP and pulse pressure on
inspiration. This is seen is severe
20. asthma, tamponade and constrictive pericarditis).
21. Malar flush
22. – purple colour over the nose and cheeks, seen in mitral stenosis.
23. Xanthelasma
24. – periorbital lipid deposits, seen in hypercholesterolaemia.
25. Corneal arcus – a grey rim around the iris, suggestive of hypercholesterolaemia
(but also a normal finding
26. in the elderly, whenit is called arcus senilis)
27. Roth spots
28. – small red haemorrhages onthe retina, suggestive of IE.
29. Jugular venous pressure
 30. – there are no valves between the internal jugular vein and the right atrium, so
31. pressure changes in the internal jugular vein reflect pressure changes in the
right atrium. The distance from
32. the manubriosternal angle to the top of the column of oscillatingblood should be less than3cm when
the
33. patient is at 45°.
34. Thrill
35. – ‘palpable murmur’
36. Heave
37. – pronounced movement of the precordium, suggestive of heart failure.
38. Murmur
39. – turbulent flow through a heart valve or septal defect
40. 3
41. rd
42. heart sound
43. – “Kentucky”, heard best at the apex. Normal in children, also found in heart
failure.
44. 4
45. th
46. heart sound
47. – “Tennessee”, heard best at the apex. Sign of still ventricular walls, egin LVH, fibrotic left
48. ventricle, hypertrophic cardiomyopathy
Script for CVS Examination:
1. My name is Wilson
2. Thank you for allowing me to examine you
3. How many I address you?
Remove clothes (expose adequately chest/abdo, legs and arms).
Lie one hand with palm facing up and one hand with dorsum facing up.

Presentation:
This is a middle-aged gentleman/lady who has aortic valve replacement of ball and
cage/disc variety due to previous stenosis/regurgitation. The prosthetic valve is
functioning well because I do not hear a diastolic murmur.

I say this because PR normal 60-80 and is regular, apex beat not displaced. Normal S1 +
S2 with soft ESM over the aortic region (likely to be a flow murmur  if does not radiate
to carotids).

Patient does not have complications such as CCF/ Pulm HTN/AF/IE as I do not notice
any increase in JVP, bilateral creps.

Note:
AR  Marfan’s syndrome  Check high arch palate + long arm span
 Tertiary syphilis  Check eye for AR pupils
 Ankylosing spondylitis  Check chest expansion

Functionally patient is well as he does not need any oxygen.

Always include:
1. Diagnosis
2. Complication
3. Differential Diagnosis
4. Functional Status
Causes of Valve replacement:
1. Ischemic causes  Aortic sclerosis
2. Rheumatological causes (RHD etc.)
3. Infective Endocarditis (rare)
Presentation:

- On general inspection, patient appeared to be well, alert, comfortable at rest and

in no obvious respiratory distress.
- Specific inspection of the chest showed no scars (indicating no previous CABG
or valve replacements), no deformities, and no obvious masses.
- Patient’s pulse rate is XX, as this is in the normal range, patient is not
tachy/bradycardic.
- There was no radial-radial delay or collapsing pulse elicited (these are indicative
of coarctation of the aorta and aortic regurgitation respectively
- On inspection of patient’s hands, there was no stigmata of infective endocarditis
such as clubbing of the nails, splinter haemorrhages, janeway lesions or osler
nodes
- No peripheral cyanosis, anemia of palmor crease pallor were noted
- Inspection of the arms showed to bruising (which may be indicative of
overwarfarinism) or needlemarks, suggesting that the individual may be an IVDA
- Examination of the eyes showed no scleral icterus, no conjunctival anemia
- Examination of the oral cavity and the tongue including its underside showed no
dehydration, no central cyanosis, good dentition, and no high arching palate
- The JVP was not raised, even after eliciting the hepatojugular reflex
- Palpation of the carotid pulses bilaterally was normal
- Apex beat was not displaced, it is located at the 5th intercostal space, slightly
(1cm) medial to the mid clavicular line
- There was no parasternal heave, palpable P2 or thrills present
- On auscultation, there were no extra heart sounds nor murmurs
- No basal crepitations were heard over the lower lobes of the lungs posteriorly
- No sacral or pedal edema were noted

Investigations:

1. ECG
2. Chest X-ray
3. Special Lab tests: Angiogram, 2D-Echogram
Thyroid Examination:
Begin:
1. Wash Hand
2. Introduce yourself and explain what you are going to do.
3. Position patient by making him sit on the side of his bed
4. Expose patient’s entire neck, clavicle and superior portion of sternum

Inspection:

On the front:
1. General appearance
a. Age, gender, obese/thin
b. Well, comfortable at rest/Toxic/Respiratory distress
c. Anxious, restless/lethargic
2. Surrounding:
a. Pulse Oximetry
3. Face:
a. Cutaneous flushing: thoracic outlet obstruction
b. Glaring thyroid eye disease/frightened facies (Graves)
4. Neck:
a. Obvious neck lump
5. Skin:
a. Sweaty/Dry/Puffy skin

Presentation:

Mr. X is a XX year old race gender. He/she appears alert; well, comfortable at rest, with
no obvious signs of anxiety, restlessness or lethargy. On general inspection, the patient
no cutaneous flushing of the face or sweaty/dry skin is observed.

Inspection:

On the front:
1. Scars
a. Thyroidectomy scar just above clavicles
2. Neck Lump:
a. Location: Anterior/Left/Right
b. Rough size using a ruler
3. Assess movement of swelling with swallowing
a. “Sir, can you take a sip of water, hold it in your mouth, don’t swallow
until I tell you to do so.”
b. Watch if it ascends (goitre or thyroglossal cyst)
4. Assess movement of swelling with protrusion of tongue
a. “Sir can you open your mouth and keep it there, stick out your tongue
like this”
b. Watch if it ascends or not

Presentation:

There appears to be an anterior neck swelling that is symmetrical/asymmetrical,

roughly about XXcm in size. It appears to move with swallowing but not with protrusion
of the tongue. It is most likely to be goitre than a thyroglossal cyst.
Palpation:

On the back:
1. Assess for tenderness:
a. “Mr X, I am going to feel for the lump now. Let me know if there is any
pain when I touch”
b. Use the pulps of your fingers and palpate along the lateral lobes of the
thyroid
2. Assess:
a. Size
b. Shape: Regular/Irregular
c. Margins: Well-delineated lower margin
d. Consistency: Firm/rubbery  Graves
e. Surface: smooth/nodular
f. Temperature over skin

3. Ask the patient to swallow again to confirm the lump moves

4. Palpate cervical lymph nodes
a. SubmentalSubmandibularAnt. trianglesupraclavicularPost.
Triangle Pre-auricularPost-auricularOccipital LN.

Presentation:

On palpation, the swelling appears to have well-delineated lower margins. It appears to

be unilateral/bilateral. The swelling is irregular/regular and is firm/soft with
smooth/nodular surface. The skin over the lump does not appear to be a different
temperature from surrounding skin.

Others:

1. Percuss for retrosternal extension

a. Percuss on the two sides lateral to the manubrium
2. Check for trachea deviation
3. Auscultate for thyroid bruits at the superior lobe.
4. Feel for carotid pulse on both sides
a. Check for berry’s sign (malignant encasing of carotid artery by the tumor
resulting in absent carotid pulse

Inspection:
5. Eye signs/Face signs:
a. Eye:
i. Conjunctiva congestion, Chemosis, Periorbital edema, increase
tearing
ii. Lid retraction: visible superior limbus of cornea due to higher
upper eyelid
iii. Exophthalmos: protrusion of eye anteriorly, observed from the
top of the head
b. Lid lag:
i. “Sir can you follow my finger, moving your eyes only and not
your head”
ii. Move finger up and down for 2-3 times
iii. Positive lid lag lag in descent of eye lid following eyeballs
downwards due to overactivity of the sympathetic control of
levator palpebrae muscle.
 c. Thyroid ophthalmoplegia:
i. “Sir, tell me how many fingers can you see? Let me know when
you see two of my fingers instead of one”
ii. Do H-Test
iii. Inferior rectus affected first  diplopia when looking down)
6. Hands:
Stretch arms out palms facing top
a. Palms:
i. Palmar erythema
ii. Sweaty/Dry palms
Turn palms facing down
b. Nails:
i. Acropathy and onycholysisGraves disease
c. Check for tremors:
i. Place a piece of paper on top of patient’s underhand

d. Radial pulse
i. Tachycardia/AFHyperthyroid/Thyrotoxicosis
ii. BradycardiaHypothyroid
7. Check for proximal myopathy:
a. Biceps reflex
i. HyperreflexicHyperthyroidism
ii. HyporeflexicHypothroidism
b. Request to test ankle reflex
c. Ask patient to shrug shoulder against resistance:
i. Shoulder abduction power decreased
8. Check for pre-tibal myxodem
a. For grave’s disease
9. Request for Pemberton’s test:
a. Ask patient to raise hand for 1 minute as assess for signs of thoracic
outlet obstruction
b. Cutaneous facial flushing, respiratory distress, distended neck veins
10. Thank patient and help him cover up
11. Wash hand
12. Wish List:
a. Full test of patient’s reflexes and power
b. Thyroid hormone measurements
Presentation:

Mr. X is a XX years old race gender, with a goitre, currently presents with mass effect
and/or endocrine disturbances or is euthyroid. No signs of superimposed infection.
OR
Mr. X is XX years old race gender, with disfused enlarged goitre without any features of
an aggressive malignant process. He is clinically non-toxic and eye signs of graves
disease are absent.

Note: Risk of malignancy in SNG similar to MNG. Diffuse mass  Graves/physiological

goitre. Nodular mass MNG/cancer/cyst

Investigations:

1. Thyroid hormone measurements

2. Ultrasound
3. Fine-needle aspiration cytology (FNAC)
Thyroid History Taking
1. Wash hands
2. Greet patient, Introduce self to patient, ask patient how to address him. Tell him that
you’ll be asking a few questions about the neck swelling
3. Ask about the lump –
a. Onset: How long has it been there,
b. Site: Where is it,
c. Size: How big is it and has it been growing,
d. Skin: Any skin changes
e. Surface: Rough(nodular), smooth
f. Shape: -
g. Scar: Any previous surgery
h. Tenderness: Is it painful?
i. Consistency: Firm, soft, rubbery
j. Adhesion/mobility: Can it be moved
k. Pulsatility: does it move with your heart rate (if yes, think, carotid body
tumour)
l. Regional lymph nodes: any other neck swelling
4. Determine possibility of malignancy:
a. Hoarseness of voice, enlarged cervical lymph nodes, previous history of neck
irradiation for thyroid carcinoma
5. Determine extent of mass effects:
a. Dyspnea, Dysphagia, SVC syndrome (Headache, facial swelling)
6. Ask for family history and personal history of thyroid problems (simple goitre, MNG,
AI thyroidits, thyroid CA)
7. Check thyroid status:
a. Hyperthyroid: Palpitations, heat intolerance, weight loss despite increase in
appetite, diarrhoea, anxiety, restlessness
b. Hypothyroid: Bradycardia, cold intolerance, weight gain, constipation,
lethargy
8. Thank patient

Summary:

Mr/Mdm XX is a young/middle-aged/elderly race gentleman/lady whose main presenting

complaint is an painful/painless anterior neck swelling since ____. Patient describes the
swelling to be located in the location and is ____ in size and has been increasing/decreasing.
He/she describes the mass to be surface, of ____ consistency, with ____ margins/edges and
is (im)mobile. He/she claims that there has been (no) previous surgery for the thyroid and the
lack of other neck swellings.
Patient also claims the presence/absence of symptoms caused by the mass effects of the
enlarged thyroid such as dypsnea, dysphagia and the SVC sydrome
Patient denies/reports any family history of thyroid related diseases
Patient reports symptoms of hyper/hypothyroidism

Summary Statement:

Mr/Mdm XX is a young/middle-aged/elderly race gentleman/lady whose main presenting

complaint is an painful/painless anterior neck swelling since ____. He presents with
symptoms of a thyroid swelling that are highly suggestive of ____ (in terms of characteristics
of the nodule itself and characteristics of malignancy/benign) on a background of
hypo/hyperthyroidism.