Cardiology

General Inspection

• Alert / Well or Unwell ; Drowsy/Confused

; tachypnoeic
• BMI e.g. cachexia; increased body
habitus
• Breathing
o Rapid/laboured breathing
o Respiratory distress / SOB
• Circulation
o Colour e.g. jaundice/cyanosis
/Malar Flush
o Abnormal pulsations
o Pallor / Cyanosis [peripheral vs
central]
• Devices
o O2 delivery ; ECG monitor ; IV
fluids; Catheter bag ; Pulse
oximeter
o Medications e.g. GTN spray Pillows
• Exposed
o Position at 45° supine, undressed to waist
o Obvious scars
o Oedema (pedal/abdominal – may go up as far as shoulders)

Hands

Dorsum of the Hands:

• Tar staining
• Peripheral cyanosis peripheral
blood supply to skin, NOT mucous membranes
= PVD, HF, Shorck, Raynauds, Sever Central
Cyanosis
• Stigmata of IE - Osler’s nodes, Janeway
lesions, Splinter haemorrhages
“There are no peripheral stigmata of endocarditis”
• Clubbing

• Palmar pallor

Palpation

• Temperature Determine that they are warm and well-perfused

• Capillary refill time (<2 secs)
Closer Inspection

Palpation of Pulse:
• Palpate radial pulse using pulp of 2nd and 3rd fingers

Rate
Normal 60-100 bpm
Bradycardia < 60bpm
Tachycardia > 100bpm

Rhythm
Regularly regular: Sinus rhythm
Regularly irregular: Heart block
Irregularly irregular: Atrial fibrillation

Volume

Character
• Radio-radial delay (Assess over 10 seconds) Cervical rib ; Aortic coarctation; Aortic dissection; Aortic embolism
Palpate both radial pulses together
Inequity in timing/volume = aortic dissection/large
arterial occlusion

Delay of femoral pulse = coarctation of the aorta; Congenital heart

• OFFER Radio-femoral delay (Assess over 10 seconds) disease; Aortic dissection
Palpate radial and femoral pulses together - Ascending aorta: Type A
- Descending aorta: Type B

• Collapsing pulse
Aortic regurgitation
Ask ptn if they have any shoulder pain
- Metacarpals of open palm against radial pulse
- Lift shoulder in air and support “John’ s pulse is 64 beats per minute with
- Pulse will thump against your fingers regular pulsation of normal volume”

Inspection of Face

Face: Causes of central cyanosis:

• Malar flush [MS] • Hypoxic lung disease
• R → L shunt
• Colour e.g. pallor/jaundice - Eisenmenger’s syndrome
Eyes: - Cyanotic congenital heart disease
• Pallor of conjunctivae • Methemoglobinemia
- Drugs
• Jaundice in conjunctivae [Severe congestive cardiac failure leads to - Toxins
hepatic congestion, causing intra-hepatic jaundice]
• Xanthelasma [Hyperlipidaemia]
• Corneal arcus [Hyperlipidaemia = grey opaque ring around cornea]
Mouth
• High-arched palate [Fx of Marfans Syndrome a/w AR. Distinctive = tall
& thin; arm span that exceeds height (arachnodactyly)]
• Dentition [source of IE]

Mucous Membranes - Lips and Tongue:

• Central cyanosis [reduced arterial oxygenation = >5g/dL deoxygenated
haemoglobin]
- Examine beneath the tongue for blueish discolouration
- Affects the mucous membranes and is improved with
oxygen therapy
Neck [JVP]

Assessment of Carotid Arteries:

• Informs us about Aorta and LV function
• Inspection of carotids:
- Medial to the sternocleidomastoid muscles
- Ask patient to turn head to the left
- Palpable pulsation
- Look - pulsation (Corrigan’s sign = AR)
- Only palpate one side at a time
• Evaluate the pulse wave form [collapsing pulse = AR]

“This patient has strong carotid pulse”

Jugular Venous Pressure (JVP)

• Internal jugular vein used to examine the function of the Features of Elevated JVP:
right side of the heart (internal jugular vein has no valves o Palpation: Non-palpable
and gives good indication of the function of the right side of o Occludable, fills from above
heart) o Location: Between heads of SCM, lateral to carotid artery
- Internal jugular vein = medial to SCM o Inspiration: Decreases with inspiration
- External jugular vein = lateral to SCM o Contour: Biphasic waveform
o Erection/Position: Decreases on sitting erect, increase with
• Measurement of the JVP upward pressure of the liver (hepatojugular reflux)
- Ptn at 45°
- vertical distance between sternal angle and top of the
venous column Causes of Elevated JVP:
- Look for internal jugular vein pulsation o Right ventricular failure
- Manubriosternal angle [1 rib down from sternal notch] o Renal failure - fluid overload
- Distance from manubriosternal angle to the height of o SVC obstruction
the JVP o Tricuspid regurgitation/stenosis
o Pericardial effusion
- Anything > 2cm is abnormal o Constrictive pericarditis
- Causes: Tricuspid valve stenosis o Cardiac tamponade
• Fluid overload (if someone has forgotten to take IV out)
• If patient is laid down flat, there would be a venous
pulsation in his neck
• The column of blood in the internal jugular vein extends into
the right atrium so enables us to observe pressure changes
in the right atrium

“This patient does not appear to have an elevated JVP”

Hepatojugular Reflux:
• Pressure on the liver or abdominal area (RUQ)
• Put a flat hand over the liver = Transient rise in JVP
• Abdominal compression increases venous return and
pressure and facilitates analysis of the JVP
Inspection of Precordium

• Symmetry
• Scars
- Sternotomy (CABG / Valvular surgery)
- Thoracotomy (MV replacement)
- Groin (catheter)
- Pacemaker / ICD
• Deformities
- Pectus Carinatum/Excavatum
- Barrell Chest
• Skeletal abnormalities
- Marfan’s = Pectus Excarvatum +/- Kyphoscolisis
- Severe deformity = distort great vessels & compromise lungs
• Pacemaker

Palpation of Chest

Apex Beat: Causes of Impalpable Apex Beat:

1. Obesity
2. Emphysema (hyper expansion)
• Most lateral & inferior point at which the palpating fingers 3. Pericardial effusion
are raised with each systole 4. Shock
5. Dextrocardia
• Begin in the axilla with flat of the hand underneath the
nipple because you may miss an enlarged heart
Causes of Displaced Apex Beat:
• Move medially until apex beat is located 1. Left ventricular dilatation
• Normal position = 5th ICS MCL 2. Right ventricular dilatation
- To locate position of apex beat count down the 3. Cardiomegaly
4. Chest wall deformities
number of interspaces
5. Mediastinal mass
- [Reference point is the 2nd ICS lies just below the
manubriosternal angle]
• Apex beat may be displaced laterally or inferiorly or both
[enlargement / chest wall deformity]
• Dextrocardia [rare] = inversion of the heart and the great
vessels = apex beat to the right of the sternum
• Apex beat is best located with the patient in the left lateral
position, in order to position the apex closer to the chest wall
• Assessment of character of apex beat:
- Heaving (LVH)
- Thrusting
- Mitral regurgitation
- Aortic regurgitation
- LVF
- Tapping (mitral stenosis)

Parasternal Heave
• Heel of the hand rested just to the left of the sternum, place
the hand onto the chest with fingers spread
• Positive = RV enlargement/hypertrophy
• Fingers in the intercostal spaces down the LSE

Thrills
• Palpable murmurs = Grade 4 or >
- Murmur is due to turbulent blood flow
• Use flat of the hand
• Palpate over the apex, left sternum & base of heart
• Apical thrills are best elicited with the patient in the left
lateral position, in order to position the apex closer to the
chest wall
Auscultation of Chest

• PALPATE CAROTID PULSE

• Auscultate all 4 areas of the chest A (2) > P(2) > T (4) > M (5)
• Listen for
- S1 = Mitral & Tricuspid closure; Start of Systole
- S2 = Aortic & Pulmonary Valve closure; Diastole

“On auscultation of this patients heart, heart

sounds 1 & 2 were heard and there were no
added cardiac sounds”

• Added sounds
- S3 = GALLOP [low pitch, mid-diastolic]
LVF [reduced ventricular compliance so poor fill]
Normal in Pregnancy & some children

- S4 = GALLOP [late diastolic]

HTN / Always ABSENT in A.Fib
Mechanical valve click

• Diaphragm = All areas

• Bell = Apex (M area) = MS [Lie ptn on their Left side]
= Carotids = AS

Complete the Examination

Lung Bases
• Auscultate lung bases = crepitations = LHF /CCF • Thanks patient
• Wash hands
Abdomen • Summarise
• Liver = Tender/ Enlarged hepatic vessels = RHF • Further Ix :
• Spleen = infective endocarditis may cause enlargement - ECG
- Echo
Sacrum - CXR
• Palpate for oedema = RHF - Urinalysis [micro haematuria = IE]

Legs
• Scars = GABG Harvesting veins

Ankles
• Palpate = Pitting oedema +++ tender = distal tibia = RHF etc.
- Behind medial malleolus of tibia & distal shaft of tibia 15s
- If oedema present move upwards and establish what level
i.e. Knee, abdomen
• Pulses = coexisting vascular disease assessment