In the cardiovascular station you will be provided with a brief introduction to a case, and then observed examining a patient with clinical signs (or occasionally a healthy individual without clinical signs).  Typically the introduction will give you few clues as to the underlying pathology – but sometimes may indicate that the patient has a murmur or some breathlessness or chest pain.

Many of the diagnoses on this station depend on your ability to identify murmurs so make sure you allow plenty of time to thoroughly auscultate your patient and deploy all appropriate manoeuvres to amplify any subtle murmurs you might otherwise miss.

In detail

Before starting, ensure your patient is adequately exposed and sitting at 45 degrees on the examination couch.  Introduce yourself and ask permission to examine their heart and pulses.

Inspection

  1. From the bedside or end of the bed look for:
    1. Scars (midline sternotomy or left lateral thoracotomy, pacemaker or ICD insertion);
    2. A visible pacemaker implantation;
    3. Cyanosis;
    4. Xanthelasma;
    5. Corneal arcus.
    6. Don’t forget to listen!  Sometimes you can hear a mechanical valve click before you’ve even picked up your stethoscope.
  2. In the hands look for:
    1. Clubbing;
    2. Cyanosis;
    3. Janeway lesions;
    4. Osler’s nodes;
    5. Splinter haemorrhages.
  3. State that you’d like to measure the blood pressure.
  4. Examine the jugular venous pulse (JVP) for:
    1. Height;
    2. Number of waveforms;
    3. Additional waveforms.

Palpation

  1. Check the patient’s nail beds for subtle clubbing;
  2. Check the radial pulse for:
    1. Rate;
    2. Rhythm;
    3. Collapsing pulse character;
    4. Radial-radial delay;
    5. Radio-femoral delay.
  3. Check the carotid pulse for a slow rising or collapsing character;
  4. Locate the apex beat of the heart and assess it’s character.  Allow the examiners to see you measuring which intercostal space it lies in by measuring back to the sternum and counting from the manubriosternal joint;
  5. Palpate for heaves and thrills at the apex, the left lower parasternal edge, and the upper parasternal region:
    1. First palpate at the left lower parasternal edge for a heave – this can be caused by right ventricular hypertrophy, which is usually a consequence of pulmonary hypertension;
    2. Thrills are palpable murmurs that feel a bit like a purring cat.  An apical thrill is usually caused by mitral regurgitation, whereas an upper parasternal thrill implies aortic stenosis.

Percussion

  1. Percussion is rarely of value in examination of the cardiovascular system.  You should omit this unless directed otherwise by the examiners.

Auscultation

Throughout auscultation aim to keep one hand on the patient’s pulse to determine whether any given murmur is systolic or diastolic.

  1. Auscultate in a systematic fashion across the precordium.  Some candidates prefer to start in the aortic area, others in the apex;
  2. Roll the patient into the left lateral position and listen for radiation of murmurs into the axilla;
  3. Auscultate the neck for the radiation of aortic stenosis and possible carotid bruits;
  4. Sit the patient forward.  Again, ask the patient to “Breathe in – and out – and stop – and breathe again“, paying particular attention in end-expiration for a high pitched diastolic murmur due to aortic regurgitation;
  5. While the patient is sat forward, it is reasonable to take the opportunity to palpate for a sacral pad and auscultate the lung bases for any crackles or dull bases due to left ventricular failure.

For a master class in heart sound auscultation be sure to visit our cardiovascular quiz section with a focus on murmurs where you can practice to your heart’s content.  Apologies for the pun.

Conclusion of examination

  1. Briefly palpate the patient’s ankles for any pedal oedema;
  2. Thank the patient and assist them to get comfortable again.