Hi, my name is Athitaya (Aimy). I am a final year medical student from Thailand studying in Malaysia, and I am planning on applying to the UK Foundation Programme (UKFP) soon. In today's blog, I am going to go through an extensive cardiovascular physical examination note that I have made and found useful with you.
I will discuss in this blog the following:
- Starting from the top!
- General examination
- Peripheral and central examination
- Heart-focused physical examination
Starting from the top!
This part may seem super basic, and many may think it’s not as important as other parts of the physical examination, however, making sure you ALWAYS do the following would show the examiner how professional you are and how much empathy and compassion you have towards your patient!
Forgetting these steps can and will reduce your professionalism marks and in some cases, may even result in failure in certain scenarios. These steps include appropriately greeting the patient using respectful pronouns like madam or sir, etc., introducing yourself, confirming the patient’s identity, briefly explaining the procedures (and that certain procedures might result in patient feeling discomfort), and washing or sanitizing your hands.
General Examination
Please note that general examination is not limited to only CVS, it can be applied before diving in other examination such as respiratory or neurological physical examination as well. Exposure should be adequate while minding the patient’s modesty and privacy.
In CVS examination, the patient should be propped up at 45-degree angle and the inspection starts at the end of the bed. In short, we are checking for:
A1: Appearance such as built, position, obvious abnormal postures, or movements, confirming age and gender (if necessary), in paediatrics, we need to confirm by plotting the growth chart as well.
A: Airway such as the patient’s colours (any obvious cyanosis, polycythaemia, pink, paleness, yellowish or normal).
B: Breathing including respiratory efforts (usage of any accessory muscles such as suprasternal, intercostal, and subcostal recession), any obvious breathing sound and in whether the patient is in distress.
C: Conscious level, alertness (confirm by Glasgow Coma Scale)
D: In this case, it will include any obvious deformity, dysmorphic features, and drugs or medications either connected to the patient or placed on the bed/nest to the patient.
E: Equipment and Extras. This includes O2 delivery system (prongs, masks, CPAP, etc.), central neck line, ECG leads attachment/Holter monitoring device, chest tube placement (in pleural effusion for example), CBD drainage, Paul’s tube or any other catheters.
Vital signs including BP, temperature, pain score, input/output monitoring.
Peripheral & Central Examination
1. Ask the patient to extend both arms and hands
By doing this, the patient’s cognition (being able to follow instruction), patient’s ability to maintain the position, tremors, and flapping tremors (by asking the patient to dorsiflex-in case of organ/system failure) can be assessed. Any visible tattoo, cannulation access, and IV drug use marks should be noted.
2. Fingers and Nails
Check for any finger clubbing (identify the stage of clubbing), Osler nodes on the distal parts and Janeway lesions on the palm, splinter haemorrhage, which can be the signs of infective endocarditis. Other things to be checked include leukonychia, koilonychia, capillary refill time (<2 secs), peripheral cyanosis, temperature nicotine staining, and xanthomas at the tendons (in ischemic heart disease).
3. Wrist and Arm
Check for any tattoos, IV marks, pulse rate (rate, rhythm, volume), any radio-radial delay or radio-femoral delay, collapsing pulse (ask if the patient has any pain on the shoulders before lifting), and check for blood vessel wall tension (can be normal in elderly, abnormal in younger patients, also found in ischemic heart disease).
4. Neck
Check to see if there is any raised JVP (>3-4cm-perpendicular to the sternal angle), carotid pulsation, and any thyroid mass.
5. Face
Check for obvious presence of any asymmetry of the face, any drooping of the eyelid/ptosis, other stroke features, rash such as malar rash (in mitral facies which can be presented with mitral stenosis), eyes for pallor, jaundice, subconjunctival haemorrhage, xanthelasmas, corneal arcus (can be caused by high cholesterol).
6. Legs
At the lower limbs, pedal/pitting oedema can be checked by gently pressed on the patient’s medial malleolus and move upward until there is no more pitting as long as patient did not experience any pain (ankle à shin à below knee à knee à thigh). Other features similar to the examination of the hands can be seen such as clubbing, cyanosis, Osler node, Janeway lesions, any nail abnormalities. Any scars such as grafting or small stenting scar should also be noted.
Heart-focused Physical Examination
Inspection
Inspecting for any chest deformity such as precordial bulge, excavatum, carinatum, hyperinflated or Harrison sulcus.
Some common scars such as median sternotomy (open heart surgery for any congenital heart disease or valvular surgery, etc.), left lateral thoracotomy (mitral valve surgery, repair of coarctation of the aorta, ligation of PDA), right lateral thoracotomy (pulmonary artery banding, Blalock-Taussing shunt), infraclavicular (pacemaker, defibrillator implantation), chest drain scars.
Any visible pulsations.
Palpation
Palpating for displaced or normally placed apex beat, and its character (heaving, thrusting, tapping), left parasternal heaves, thrills in 4 valvular areas: mitral, tricuspid, pulmonary, and aortic region.
Percussion
Percussion is not normally done and may not be accepted In all practice settings, however, in certain conditions, it can help identify or confirm pleural effusion (stony dull) if suspected.
Auscultation
Now it is time to listen to the apex beat, and all of the valvular areas and describe whether the 1st and 2nd heart sounds could be heard, if there’s any 3rd or 4th or galloping or any additional heart sound can be heard, and lastly if there is any murmur. Murmurs will need to be noted on the location, grading, loudest area, and its characteristic whether it’s a systolic (timing the S1 with carotid pulse can help!) or diastolic.
Summary
These are the steps and techniques of CVS examination that I have learned and found to be helpful for my classmates and myself. However, medicine itself is never rigid or always straightforward, different experts in different fields from different countries and experiences may have slightly different steps and techniques depending on various factors and some special case scenarios.
The best thing to do is to keep practicing, develop the correct skill sets, and hone those skills to be able to apply and figure out what works best in different situations to make it the most appropriate and suitable for each patient. Medicine is a lifelong learning process; it is also important to keep yourself updated on new machine or medical devices that can be found on the patient’s body.
Need More Help?
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References
1. Davidson, S., Penman, I. D., Ralston, S., J.,director, S. M. W., Hobson, R. P., & Britton, R. (2023). Davidson’s principles and practice of medicine (24th ed.). Elsevier.
2. Talley, N. J., & O’Connor, S. (2020). Clinical examination essentials: An introduction to clinical skills (and how to pass your clinical exams) (5th ed.). Elsevier.