12.11.22 Cardiovascular exam + management

General inspection

    • Anasarca = Generalised oedema

    • Cardiac cachexia

    • All equipment

      • Scales

      • Oxygen

Hands + arms

    • Look for tremor!

      • Might indicate hyperthyroidism

      • Especially in combination with AF

    • Splinter haemorrhages are really very difficult to see

      • Carefully inspect each nail

    • Tendon xanthoma is a much more sensitive sign than xantholasma

    • ALWAYS comment on the presence or absence of tar stains

      • Key risk factor


    • You can't feel the radial pulse during diastole

      • But you should be able to feel the brachial

    • For collapsing pulse, palpate both pulses

      • See if just one or both disappear during diastole

    • In AF, some beats won't be palpable at the radial artery

      • Aortic valve won't even open for some

      • Auscultate over the apex to get the correct rate


    • Palpate carotids

      • This is the place to feel the CHARACTER of the pulse (collapsing, slow-rising etc)

    • Turn head to the left for JVP, but not too much

      • You don't want to engage the SCM, which lies above the internal jugular

    • Follow a line joining the earlobe to the space between the two SCM heads


    • Don't forget anaemia

    • Look at the eyebrows for signs of hypothyroidism

    • Look inside the mouth with a TORCH


    • Look for, comment on and THINK ABOUT scars

      • e.g. With a sternotomy:

        • Check the arms and legs for graft scars to suggest CABG

        • If there are none, think valve replacement, and listen for a metallic click

    • Heaves represent RV impulse

      • LV is hidden underneath

    • Thrills are palpable murmurs

      • So feel everywhere you'd auscultate

    • Feel right round to the mid-axillary line for apex

Heart sounds

    • Comment on the presence of normal sounds (S1 + S2)

    • Then mention any added sounds

      • S3 is very common in heart failure (rapid ventricular filling)

    • Finally, comment on murmurs

      • Make sure you've timed them against the carotid pulse!

The rest

    • Auscultate the lung bases, with the patient sitting upright

    • Check for sacral and ankle oedema

      • Press in for TEN SECONDS, over a BONY PROMINENCE

      • Move upwards to determine extent, if there's ankle oedema


    • Don't forget the basics

      • Name, date

      • AP/PA

      • Rotation

      • Penetration (vertebral bodies)

    • Look for congested pulmonary veins

      • Vertical or oblique lines in upper zones

    • Kerley B lines are because the lymphatic system tracks along fissures

NYHA Scale


    • Heart failure - A+E

      • GTN

        • Sublingual then infusion

        • Monitor BP

      • Morphine

      • Oxygen

      • Furosemide

    • Drugs with survival benefit in chronic heart failure

      • ACE inhibitor

      • Beta blocker

      • Spironolactone


    • GTN and morphine are good for off-loading heart

      • Much better than furosemide

    • Breathlessness on exertion does NOT come from pulmonary congestion

      • Probably from a systemic response to hypoperfusion