CVS Exam Routine & Script Id like to perform a CVS exam .

This will involve me examining your hands, feet face & pulses. Is that ok? General: Comfortable at rest, Anxiety, pallor, distress, breathlessness, sweating, oedema, obesity, thin Feet: Temp, Colour, Sweaty/Dry, Pitting oedema Hands: Temp, Colour, Sweaty/Dry, Dorsalis pedis Nails: Koilonychia, Splinter haemorrhage, Clubbing Wrists: Radial pulse (30 secs) Im going to touch you face is that ok? Face: Colour, Temporal artery Could you pull down your eyelids like this(Demonstrate for them) Eyes: Colour of sclera, Xanthelasma, Corneal Arcus Could you open your mouth & lift your tongue Mouth: Colour, Angular Stomatis, Beefy Tongue, Sublingual Neck: Carotid pulses (one at a time), JVP Ausculation: valves Is it ok to place the heal of my hand on the mid line of your chest? (demo) Palpation: Sternal heave = increased effort & increased heart size Apex beat shift Percussion: to map out the heart if you think it may have enlarged (surface antomy of the heart at bottom of page) Pulses: History
Recent Medical Social

Dyspnoea, Chest Pain, Oedema, Palpitations, Tiredness, Nausea, Syncope, Claudication, NSAID Diabetes, Rheumatic fever, Rheumatic heart disease, Marfans, Family history (hypertension, heart disease, stroke, hyperlipidemia) Exercise, Smoking, Alcohol, Diet Comfortable at rest, Anxiety, pallor, distress, breathlessness, sweating, oedema, obesity, thin If indentation still evident after 10 sec, test again higher up. Congested/R Pitting oedema Temp and colour Temp

Observation General Feet

sided heart failure, vena cava, liver, kidney disorder, DVT, hypoalbuminia (osmotic pressure), low protein diet

Hands

Colour

Same as in hands Hot + Pink = carbon dioxide retention peripheral vasodilatation Cold + blue = poss heart problem. Blood flow, peripheral cyanosis occurs on hands/feet, not mucous membrane. Causes: Raynauds, atheroma (plaque in artery walls) Warm + blue = poss respiratory prob, perfusion, occurs on lips + tongue Causes: Central cyanosis arterial hypoxaemia, pulmonary disease Sweaty hyperthyroidism Pale Raynouds syndrome gangrene

Yellow nicotine Blue peripheral cyanosis Nails

Koilonychia

Splinter hemorrhage Clubbing

Iron deficiency, possibly blood loss Small emboli under nail. Causes: Manual worker, infective endocarditis Fluctuation nail/bed angle, nail curvature, ST bulk Heart Subacute bact endocarditis, Cyanotic congenital heart disease Lung Bronchial carcinoma, Fibrosing alveolitis GI Cirrhosis, Ulcerative colitis, Crohns disease

Idiopathic Face Eyes Capillary bed refill test Colour Xanthelasma Conjunctiva
If takes > 2 secs. Causes dehydration, peripheral vascular disease, raynauds, shock Pallor Oxygenated Hb in skin Blue O2 in blood, Cyanosis

Malar flush Rosy cheeks yellow blisters around eye, cholesterol, hyperlipedemia, poss liver
dysfunction Pale Anemia Blue cyanosis Bleeding capillaries NSAID, hypertension

Mouth Tongue

Corneal Arcus Silvery white line around eye (> 50) in young cholesterol Breathing patterns normal/panting. Shape (Kyphoscoliosis?)
Angular stomatitis

Colour

Crack at corners, dont heal well Anemia, malabsorbtion, iron/folic A, Vit B Big beefy smooth red sore Glossitis, iron/folic acid/Vit B, Pale Anemia Brown/dry Mouth breathers, dehydrated , smokers

Blue central cyanosis Anaemia (+ pain from papillae atrophy) Sub-lingual Auscultation Mitral area Tricusped area Aortic area Pulmonary area
Creamy curd like Candida Albicus (Corticosteroids med) Engorged sublingual veins Portal hypertension

L 5th ICS, mid-clavicular line R 5th ICS, sternal border R 2nd ICS, 1 cm from sternum L 2nd ICS, 1cm from sternum

lub sound Good place for abnormal 3rd and 4th sounds and mitral murmurs Aortic regurgitation heard here Aortic stenosis, murmurs dub sound pulmonary valve murmur

Percussion Heart should be roughly fist size. Tends to enlarge laterally, not medially. Palpation Parasternal heave Heel of hand over Heave present if hand felt lifting with each systole. parasternal area Causes: Right ventricle enlargement (hardworking hearts get bigger), hypertension, Aortic stenosis Apex beat shift Palpate MCL 5th ICS Normally should be 3-4cm in diameter

(Pt rolls 45 degree to their left. start at MCL & move to Mid Axillary Line Apex beat quality

Deviation Causes (enlargement of L ventricle) pectus excavatum/sinus inversion. Cardiomegaly/mediastinal shift (less likely) Absent death/ obesity/pericarditis/emphysema (or other COPD)/sinus inversus/pericardial or pleural effusion Forceful beat CO2 Thrill (vibrations) palpable murmurs Gallop (3rd heart sound) possible L ventricular dysfunction Uncoordinated MI Only one at a time! Found between the anterior border of the SCM above the hyoid bone and lateral to the thyroid cartilage. Over temple just anterior to ear If blocked may lead to blindness in elderly In cubital fossa, just medial to biceps tendon Anterior surface of distal radius. Important for checking radiofemoral delay Mid-inguinal point, halfway between the pubic symphysis and ASIS Get consent first! Posterior knee, easiest to find with knee flexed between 1st and 2nd met (lat to EHL tendon) 2 cm inferior and 2 cm posterior to the medial malleolus Look for double dip 2-4cm above sternal angle Hepatojugular reflex press abdomen, will raise pressure

Pulses Head/neck

Carotid Temporal

UEX LEX

Brachial Radial Femoral

JVP Bradycardia Radiofemoral delay Blood pressure Normal High Low

Popliteal Dorsalis pedis Tibialis posterior Patient at 45, turn head R and observe along SCM < 60bpm aortic stenosis, anorexia, beta blockers >100 bpm Anxiety, hyperthyroidism, vagus nerve lesion If femoral weak possible aortic aneurism Between 90/60 120/80 >160/95 <90/60

anxiety, temp, no cause, drug, disease, aortic coarctation, NSAID Cardiac stenosis, MI Vasomotor control baroreceptor dysfunction, vasovagal syncope, autonomic degeneration (diabetes) Venous return dehydration, prolonged bed rest

What blood pressure would we refer immediately to A&E?

180/100

Visualizing the margins of the heart Surface landmarks can be palpated to visualize the outline of the heart

Upper border = 3rd costal cartilage on right of sternum to 2nd intercostal space on the left side of sternum. Right margin the heart descends from the 3rd costal cartilage to 6th costal cartilage. Left margin from 2nd intercostal space to Apex at the midclavicular line in the 5th intercostal space. Summary: Right = 3CC to 6CC Left = 2IC to 5IC *CC = costal cartilage IC = Intercostal Space