IB CSL MED:

IB CSL MED:

CVS
Dr HF Tse

Medicine

Wed 04-09-02
GENERAL INSPECTION

HAND

Clubbing: observe then feel (sponginess)
Osler node: painful
Janeway lesion: not painful
Splinter haemorrhage

LOWER LIMB

Cyanosis: some diseases have differential cyanosis - eg. PDA has cyanosis in lower limb, but not in upper limb
Oedema: press on/above medial malleolus (look and feel for pitting oedema), if present, move upward. If Pt bed-bound - present in sacral area?
Pigmentation: extravasation from capillaries, varicose veins
Atrophic changes: eg. Peripheral vascular disease - thin skin, losing hair, change nail colour, decreased filling

PULSES

Dorsalis pedis
Popliteal
Femoral: midpoint between pubic symphysis and ASIS

Any discrepancy between R and L? Any bruit?

Brachial
Radial
Carotid: bruit?

Describe in terms of

Rhythm
Volume: regularity
Rate: regularity
Consistency of artery

Atrial fibrillation

CO and pulse varies
Therefore, auscultate for heart sound to measure pulse

Collapsing pulse

Hold Pt's hand with one hand

Grip Pt's forearm with other hand's palm until you feel the pulsation

Release pressure until you cannot feel pulsation

Elevate arm

If you can feel pulse ® +ve collapsing pulse (wide pulse pressure) ® eg. Aortic regurgitation, PDA, thyrotoxicosis, pregnancy

Normal = cannot feel pulse again on elevation

Pulsus paradoxus

¯ SBP during inspiration

Inspiration ® -ve intrathoracic pressure ® VR to heart (RV) ® heart expands both outwards and shifts septum to press on LV

In pericardial effusion: blood cannot expand to outside \ all pressure transmitted to septum \ more of a drop in SBP with inspiration

+ve sign if decrease in SBP > 10 mmHg

If 1^st time to see Pt, measure both sides to note any discrepancy

FACE / NECK

Pallor
Jaundice

JVP

Pt at 45 degrees
Note any pulsation
Measure height from sternal notch (normal 3-4 cm; abnormal > 5 cm)

How to differentiate between JVP and carotid artery?

	JVP	Carotid artery
Location (wrt SCM m)	Lateral	Medial
Posture (standing)	Disappears	Unchanged
Respiration (inspiration)	More prominent	Unchanged
Palpation	Obliterated	Unchanged
Biphasic	Yes *	No
Hepatojugular reflex	Increased	Unchanged

* Except with atrial fibrillation

PRAECORDIUM

Inspect

Visible peristalsis
Scar
Deformity

Palpate

Apex

Location: use one fingertip, most lateral and inferior point
Character: use palm – eg. Mitral stenosis = tapping apex beat
Cannot feel apex?

Obese turn Pt laterally
Emphysema
Dextrocardia: feel right side

Parasternal heave: palm over sternum, indicates RV hypertrophy, palm lifted up
Thrill: palpable murmur

Auscultate

Heart sounds

Must localise heart sounds
To differentiate between1st and 2^nd heart sounds – palpate carotid artery

Added sounds

Eg. 3^rd and 4^th heart sounds, opening stent
Physiological splitting of 2^nd heart sound (in young people): pulmonary and aortic components

Murmur

Time interval: systolic / diastolic

Note: if you can hear 2^nd heart sound, it is not a pan-systolic murmur; it is an ejection systolic murmur

Locations

Apex

1^st heart sound loudest here

Bell: mitral stenosis (low-frequency) [note: do not press too hard – otherwise stretched skin acts like diaphragm and low-frequency sounds are missed)

Diaphragm: mitral regurgitation (high-frequency): sound in expiratory phase, radiates to axilla (direction of turbulence)

L parasternal: septum

Pulmonary 2^nd heart sound loudest here + aortic

Aortic

Pt to sit-up and lean forward to check for aortic stenosis (radiates to neck)

Tricuspid

tricuspid regurgitation murmur on inspiration

Note

Apex: bell for mitral stenosis and diaphragm for mitral regurgitation

Other areas: diaphragm

Check

Radiation

Aortic stenosis: radiates to neck
Intensity: must listen at appropriate site (eg. Apex for 1^st HS; Pul/Aortic for 2^nd)

Change with posture

If murmur not heard, turn Pt laterally

Standing: blood moves to legs ® ¯ VR ® ¯ CO \ sound in hypertrophic cardiomyopathy + mitral valve prolapse (related to ¯ heart size on standing)

Also auscultate

Lung base – crepitations?

Liver – tricusupid regurgitation