CVS examination

I want to complete my examination by checking his vital signs including blood pressure, performing an ECG
to look for ischemic changes, ordering a urine dipstick for microscopy haematuria, and fundoscopy to look
for Roth’s spots.

I did a cardiovascular examination on patient’s name and age

On general examination, the patient is alert and conscious, able to obey command
He is not in obvious pain or in respiratory distress
- He was in respiratory distress by evidence of increased respiratory rate, use of accessory muscle,
presence of oxygen supply, central/peripheral cyanosis
He appeared pale/jaundiced.
Nutritional status was adequate/cachexic/obese.
There was a branula attached on the left/right dorsum part of the hand connected to the IV drip.
At the bedside, there is the presence of __________ (sputum pot, medication, walking aid)

On peripheral examination, there were no clubbing, peripheral cyanosis, tar staining and stigmata of
infective endocarditis. Capillary refill time was less than 2s. The palm was moist, pink, and warm. Pulse rate
was normal with __ bpm with regular rhythm and good volume. Radio-radial delay was present/absent and
collapsing pulse was present/absence.
- There is the presence of finger clubbing grade (?) by evidence of loss of Lovibond’s angle and
Schamroth’s window
- There is the presence of stigmata of infective endocarditis such as splinter hemorrhage, Osler
nodes, Janeway lesions

On examination of the face and neck, there was no conjunctival pallor, scleral jaundice, corneal arcus and
xanthelasma. There was no central cyanosis and oral hygiene was fair. High arch palate was absent. JVP
was raised measuring about __ cm-water.

On inspection of the chest, there was chest wall deformity possibly pectus carinatum/excavatum, there was
also mid sternotomy scar measuring about __ cm, suggesting of __________. On palpation, apex beat was
palpable at the 5th intercostal space midclavicular line. Parasternal heave and thrills were not palpable/
were palpable. On auscultation, the 1st and 2nd heart sounds present, dual rhythm and no murmur. There
was no carotid bruit. There was also no bibasal crepitation heard in the lungs. There is no pitting sacral or
lower limbs edema.

Scar
- Median sternotomy scar – Open heart surgery (valve replacement, CABG, cardiac transplant)
- Thoracotomy scar at the left infraclavicular area – Pacemaker insertion
- Posterolateral thoracotomy – Pulmonary resection
- Anterolateral thoracotomy – Pneumonectomy, pneumothorax surgery
- Scar within the safety triangle – Chest drainage

Murmur
- Type
- Grade
- Location
- Maneuver
- Radiation
- Heart failure signs

There is pansystolic murmur, grade 3, best heard at the apex area, accentuated by expiration, radiating to
the axilla, suggesting of mitral regurgitation and not in failure.
Lab investigation:
1. FBC (anaemia, leucocytosis)
2. Cardiac enzyme
- Myoglobin start 1-4 hr, peak 6-12 hrs
- Troponin T start 3-4 hr, peak 24 hrs
- Troponin I start 4-6 hr, peak 18 hrs
- CKMB start 4-6 hr, peak 24 hrs
- Creatinine kinase
- Lactate dehydrogenase (48 hr-72 hrs)
3. Blood culture
4. ESR, CRP,
5. Chest x ray, ECG, CT angiogram, Echo,
6. LFT, RP
Finger clubbing
Method
 Loss of Lovibond’s angle
 Loss of Schamroth’s window

Grading
1: Fluctuation and softening of nail bed
2: Increased normal Lovibond’s angle
3: Increased nail bed convexity
4: Clubbed appearance
5: Shiny or glossy change in nail with longitudinal striations

Etiologies
Cardiovascular Respiratory ABCDEF Gastrointestinal Endocrine
- Cyanotic congenital - Pulmonary abscess - Liver cirrhosis - Thyrotoxicosis
heart disease - Bronchiectasis, - Inflammatory bowel - Hyperparathyroidism
- Infective endocarditis bronchogenic disease
- Aortic aneurysm carcinoma - Celiac disease
- Atrial myxoma - Cystic fibrosis
- Don’t say COPD
- Lung empyema
- Lung fibrosis

Dyslipidemia
Clinical manifestations
 Hypercholesterolemia: Corneal arcus, xanthelasma, tendon xanthomata, tuberous xanthoma
 Hypertriglyceridemia: Eruptive xanthoma

Radial pulse
Characteristics
 Pulsus alternans (alternating strong and weak beats) – Left ventricular failure
 Small volume – Aortic stenosis, pericardial effusion, hypovolemia
 Collapsing pulse – Aortic regurgitation, Patent ductus arteriosus (PDA)

Rhythm
 Regularly irregular – Sinus arrhythmia, ectopic ventricular beats
 Irregularly irregular – Atrial fibrillation

Radio-radial delay
Pathophysiology
 Disturbance in aortic diameter proximal to the right subclavian artery

Etiologies
- Atherosclerotic plaque
- Aneurysm
- Subclavian artery stenosis

Radio-femoral delay
Etiologies
- Coarctation of aorta
- Upper limb hypertension
Cyanosis
Definition: Bluish discoloration of the skin and mucosa due to increased deoxygenated hemoglobin >5 g/dL
Central Peripheral
Etiologies Etiologies
 Ventilation:  Cold temperature (peripheral vasoconstriction)
- Airway obstruction,  Fever/hypothermia
- Respiratory muscle weakness  Sepsis
 Gas exchange:  Shock
- Poor pulmonary perfusion (shock, pulmonary embolism,  Hypoglycemia
right to left shunt)  Raynaud phenomenon
- Inadequate gas exchange (pneuthorax, pleural effusion,
pulmonary edema, lung parenchymal disease)
- ↓ O2 carrying capacity (methemoglobinemia)
 Ventilation control

Jugular venous pressure

Characteristics
 Visible but not palpable
 Prominent inward movement
 Biphasic wave
 It decreases on inspiration
 Occludable

Method
 >3cm above the zero point
 Positive hepatojugular reflux: JVP rises with abdominal palpation

Apex beat
Definition: Most lateral and inferior point palpable heart beat
Anatomical location: Left 5th intercostal space at the mid-clavicular line

Abnormal characteristics
 Heaving (pressure overload): Forceful/sustained impulse at the apex area
- Aortic stenosis, systemic hypertension

 Thrusting (volume overload): Displaced, diffuse and non-sustained impulse

- Mitral regurgitation, dilated cardiomyopathy

 Displaced apex beat

- Left/right ventricular hypertrophy

Parasternal heave
Definition: Impulse that lifts the palpating hand at the left sternal edge
Etiologies: Right ventricular hypertrophy, left atrial hypertrophy

Thrills
Definition: Palpable murmur
 Apex: Left ventricular hypertrophy
 Lower left sternal edge: Ventricular septal defect
 Upper left sternal edge: Pulmonary stenosis
 Suprasternal: Aortic stenosis
Heart sounds
S1 (Closure of atrioventricular valve and end diastole) and S2 (Closure of semilunar valve and end systole)
S1 – Heart sound heard with pulsation of carotid artery

Murmur Type Location Maneuver Radiation

Mitral stenosis Mid diastolic murmur Apex Expiration + turn to the left -
Mitral regurgitation Pansystolic murmur Apex Expiration Axilla
Tricuspid stenosis Mid diastolic murmur Left lower sternal edge Inspiration -
Tricuspid regurgitation Pansystolic murmur Left lower sternal edge Inspiration -
Pulmonary stenosis Ejection systolic murmur Left upper sternal edge Inspiration -
Pulmonary regurgitation Early diastolic murmur Left upper sternal edge Inspiration -
Aortic stenosis Ejection systolic murmur Right upper sternal edge Expiration Carotid artery
Aortic regurgitation Early diastolic murmur Right upper sternal edge Expiration + leaning -
forward

Pansystolic murmur
It begins with S1 and ends at S2 with constant intensity
Murmur Characteristics Other signs Etiologies
Mitral regurgitation Tachypnea/dyspnea, Rheumatic heart disease,
Displaced apex beat, Cardiomyopathy,
Thrusting apex beat, Papillary muscle dysfunction,
Apex thrill Infective endocarditis,
Myocardial infarction
Tricuspid regurgitation Raised JVP, Right ventricular failure,
Parasternal heave, Infective endocarditis,
Pulsatile hepatomegaly, Tricuspid valve prolapse,
Right nipple dancing sign, Papillary muscle infarct,
Ascites, edema, pleural effusion, Ebstein’s anomaly,
Pulmonary hypertension Carcinoid syndrome
Ventricular septal defect Loud, harsh, blowing murmur Thrill at lower sternal edge Congenital
Location: Lower left sternal edge Left precordial prominence
Parasternal heave
Displaced apex beat
Apex thrust

Ejection systolic murmur

It begins after S1 and ends before S2 + Crescendo-decrescendo
Murmur Characteristics Other signs Etiologies
Aortic stenosis Exertional chest pain, dyspnea, Degenerative calcification
syncope Rheumatic heart disease
Anacrotic pulse
Apex/suprasternal thrills

Pulmonary stenosis Raised JVP, Congenital

Pulmonary thrills Carcinoid syndrome
Atrial septal defect Location: Left middle/upper Congenital
sternal edge

Late systolic murmur

It begins in late systole and ends at S2 + Decrescendo
Murmur Characteristics Other signs Etiologies
Mitral valve prolapse Blowing murmur preceded by a Myxomatous degeneration of
mid-systolic click mitral valve tissue
Atrial septal defect
Hypertrophic cardiomyopathy
Marfan syndrome
Early diastolic murmur
It begins with S2 and ends before S1 + Decrescendo
Murmur Characteristics Other signs Etiologies
Aortic regurgitation Collapsing pulse Rheumatic heart disease,
Widen pulse pressure Aortic root dilatation
Peripheral signs Infective endocarditis,
Dissecting aneurysm
Pulmonary regurgitation Pulmonary hypertension
Infective endocarditis
Congenital

Mid diastolic murmur

It begins after S2 and ends before S1 + Decrescendo
Murmur Characteristics Other signs Etiologies
Mitral stenosis Dyspnea, orthopnea and Rheumatic heart disease,
hemoptysis Congenital
Mitral flush
Atrial fibrillation
Tapping apex beat
Tricuspid stenosis Raised JVP Rheumatic heart disease
Liver pulsation

Peripheral signs of aortic regurgitation

 Corrigan’s: Prominent carotid pulsation
 De Musset’s: Head nodding with heartbeat
 Duroziez’s: Femoral artery murmur on palpation
 Muller’s: Uvula pulsation
 Quincke’s: Nail bed pulsation