Some slides are taken from different textbooks of medicine like Davidson, Kumar and Clark and Oxford, and some from other presentations made by respected tutors. These resources are free for use, and I do not claim any copyright. Hoping knowledge remains free for all, forever.
2. GENERAL EXAMINATION
• Look at the patient’s general appearance.
• Do they look unwell, frightened or distressed?
• Are there any signs of breathlessness or
cyanosis?
• Is the patient overweight or cachectic?
• Are there any features of conditions associated
with cardiovascular disease such as Marfan’s,
Down’s or Turner’s syndrome, or ankylosing
spondylitis?
3. GENERAL EXAMINATION
Conclude by examining the entire skin surface for
petechiae, checking the temperature and
performing urinalysis
Fever is a feature of infective endocarditis and
pericarditis, and may occur after myocardial
infarction. Urinalysis is necessary to check for
haematuria (endocarditis, vasculitis),
glucosuria(diabetes) and proteinuria (hypertension
and renal disease).
4. WHAT IS PRECORDIUM?
• The Precordium- This is the area on the front of the chest that relates to
the surface anatomy of the heart. Inspect the precordium with the
patient sitting at 45 degree angle with shoulders horizontal.
26. AUSCULTATION
• 1. Palpate the carotid pulse to determine the first heart sound.
• 2. Auscultate ‘upwards’ through the valve areas using the diaphragm of the stethoscope
whilst continuing to palpate the carotid pulse:
• Mitral valve: 5th intercostal space in the midclavicular line.
• Tricuspid valve: 4th or 5th intercostal space at the lower left sternal edge.
• Pulmonary valve: 2nd intercostal space at the left sternal edge.
• Aortic valve: 2nd intercostal space at the right sternal edge.
• 3. Repeat auscultation across the four valves with the bell of the stethoscope.
27.
28.
29. ACCENTUATION MANOEUVRES
• 4. Auscultate the carotid arteries using the diaphragm of the
stethoscope whilst the patient holds their breath to listen for radiation of
an ejection systolic murmur caused by aortic stenosis.
• 5. Sit the patient forwards and auscultate over the aortic area with the
diaphragm of the stethoscope during expiration to listen for an early
diastolic murmur caused by aortic regurgitation.
30. ACCENTUATION MANOEUVRES
• 6. Roll the patient onto their left side and listen over the mitral
area with the diaphragm of the stethoscope during expiration to listen
for a pansystolic murmur caused by mitral regurgitation. Continue to
auscultate into the axilla to identify radiation of this murmur.
• 7. With the patient still on their left side, listen again over the mitral
area using the bell of the stethoscope during expiration for a mid-
diastolic murmur caused by mitral stenosis.
31. BELL VS DIAPHRAGM
• The bell of the stethoscope is more effective at detecting low-
frequency sounds, including the mid-diastolic murmur of mitral
stenosis.
• The diaphragm of the stethoscope is more effective at detecting high-
frequency sounds, including the ejection systolic murmur of aortic
stenosis, the early diastolic murmur of aortic regurgitation and
the pansystolic murmur of mitral regurgitation.
32.
33.
34.
35. FINAL STEPS
• Posterior chest wall
• Inspection
• Inspect the posterior chest wall for
any deformities or scars (e.g.
posterolateral thoracotomy scar
associated with previous lung
surgery).
• Auscultation
• Auscultate the lung fields posteriorly
:
• Coarse crackles are suggestive
of pulmonary oedema (associated
with left ventricular failure).
• Absent air entry and stony
dullness on percussion are
suggestive of an underlying pleural
36. • Sacral oedema
• Inspect and palpate the sacrum for
evidence of pitting oedema.
• Legs
• Inspect and palpate the
patient’s ankles for evidence of pitting
pedal oedema (associated with right
ventricular failure).
37. FURTHER ASSESSMENTS AND
INVESTIGATIONS
• Measure blood pressure: to identify hypotension, hypertension or
significant discrepancies between the two arms suggestive of aortic
dissection.
• Peripheral vascular examination: to identify peripheral vascular
disease, which is common in patients with central cardiovascular
pathology.
• Record a 12-lead ECG: to look for evidence of arrhythmias or
myocardial ischaemia.
38. FURTHER ASSESSMENTS AND
INVESTIGATIONS
• Dipstick urine: to identify proteinuria or haematuria which can be
associated with hypertension.
• Bedside capillary blood glucose: to look for evidence of underlying
diabetes mellitus, a significant risk factor for cardiovascular disease.
• Perform fundoscopy: if there were concerns about malignant
hypertension, fundoscopy would be performed to look for papilloedema.
50. EXAMINATION OF THE
ARTERIAL PULSE
• The character of the pulse is determined
by stroke volume and arterial compliance,
and is best assessed by palpating a major
artery, such as the carotid or brachial
artery.
• Aortic regurgitation, anaemia, sepsis and
other causes of a large stroke volume
typically produce a bounding pulse with a
high amplitude and wide pulse pressure
• Aortic stenosis impedes ventricular
emptying. If severe, it causes a
slow-rising, weak and delayed pulse
• Sinus rhythm produces a pulse that is
regular in time and force. Arrhythmias
may cause irregularity. Atrial fibrillation
produces a pulse that is irregular in time
and volume
53. COMMON ABNORMALITIES OF
THE APEX BEAT
• Volume overload, such as
mitral or
aortic regurgitation: displaced,
thrusting
• Pressure overload, such as
aortic
stenosis, hypertension: discrete,
heaving
• Dyskinetic, such as left
ventricular
54. COMMON ABNORMALITIES OF
THE APEX BEAT
• Palpable S1 (tapping apex
beat: mitral stenosis)
• Palpable P2 (severe
pulmonary
hypertension)
• Left parasternal heave or
‘lift’ felt by heel of hand (right
ventricular hypertrophy)
• Palpable thrill (aortic
stenosis)
58. ITEM QUESTIONS
• CVS General examination findings in - face, hands, neck, legs
• How do we measure pulse? Characters of pulse abnormalities?
• Blood pressure and JVP abnormalities? How to differentiate between jvp and carotid pulse?
• Precordium inspection findings?
• Palpation findings? How do we examine apex beat, right ventricular heave and thrills? Abnormal apex beat
causes?
• Normal heart sounds physiology(timing, causes, character, abnormality)
• Abnormalities of 1st, 2nd and 3rd heart sounds
• How do we examine murmur?
• Name some common valvular diseases
• Causes of systolic, diastolic murmurs? Difference between innocent and pathological murmurs?
• Method of auscultation
• Additional tests after examination
• Common causes of chest pain and dyspnea
• History and complaints of myocardial infarction patient
