• How to perform P/E for the CVS and underlying principles
• Commonly performed tests and usefulness in CVS

• Arrive at Dx or provisional Dx in CVS disease
• Clues to suggest other differential Dx
• Detected of severity of disease (eg. CHF, Valvular heart disease)

• General condition: well and alert vs. confused, sweating
• Resp rate: tachypnoea, respiratory distress
• Normal: 12-15 breaths/minute
• Resp distress: difficulty breathing
• Cyanosis: central (eg. R to L shunting) and peripheral cyanosis (poor perfusion - eg. Cardiogenic shock)
• Central cyanosis: bluish tinge to tongue; Presence of unusual colour showing predominance of desaturated blood rather that saturated blood
• Peripheral cyanosis: dry scaling and cold hands; bluish tinge in nails]
• Clubbing (loss of usual angle bet nail and nailbed): IE, cyanotic CHD
• Other signs of IE (virulent organisms infecting heart values): splinter haemorrhage, Osler nodes, Janeway lesion

• BP: SBP, DBP, large and small pulse pressure
• Pulse: rate, rhythm, volume, character, delay (corarctation of aorta) or unequal (aortic dissection)
• [Regularly irregular: eg. Ectopic beats, irregularly irregular]
• Conjunctiva: pallor, plethoric (polycythaemia), petechial haemorrhage
• JVP (degree of fluid overload) - Pt lie at 45 degree: vertical ht (from sternal angle as reference pt), occlude by finger pressure (as base of neck; to tell from carotid impulse - single wave form), time with opposite carotid pulse, hepatojugular reflex (press on RUQ - squeeze liver by increasing venous return, heart should accommodate increase VR but increasing JVP, then JVP quickly reduces to normal. In fluid overload, there is persistent of JVP increase even after many beats. Due to decreased ability of heart to deal with increased VR), change with posture (if jugular wave is very high, eg. Reaches angle of jaw - need to change posture, sit Pt upright (note the wave form, giant CV wave (severe tricuspid regurgitation), cannon wave, etc)
• Ankle or sacral oedema (or anasarca)
• Features of peripheral vascular disease eg. Extremities esp. lower limbs, dry, cold, scaly skin, loss of hair, dystrophy of nails, pulses (weak / decrease volume), ischaemic ulcers - femoral, dorsalis pedis, posterior tibial, popliteal

• Scar
• Deformity
• Visible impulse: eg. Severe cardiomegaly

• Apical impulse: displacement (down and lateral), abnormal character - volume overloading (causing haemodynamic stress to heart, esp. LV, mitral or aortic regurgitation, cardiomyopathy - sustained, weak impulse), pressure overloading (severe aortic stenosis, hypertrophic obstructive cardiomyopathy - obstruction to outflow of blood, heart compensates by hypertrophy, apical impulses therefore has less displacement than volume overloading, pulse beat is very forceful and strong, becomes sustained because of increased thickness of the muscle), tapping (mitral stenosis, can feel palpate 1st heart sound), double impulse (previous MI with aneurysm formation)
• Parasternal heave: heaving sensation when leaving palm on left parasternal region. Heave indicates ventricular hypertrophy or atrial enlargement
• Abnormal impulses: esp. Pulmonary and aortic areas (AS)
• Thrill: systolic, diastolic, continuous (blood flows across valves or ventricle below palm)
• Palpable heart sound: 1st HS vs. P2

• Heart sounds: 1st, 2nd, abnormal intensity, splitting of 2nd HS (fix or paradoxical), 3rd or 4th HS
• Heart murmurs: phase, grading, pitch, location, radiation, change in intensity with manoeuvres (eg. Mitral stenosis: murmur increased when Pt in left lateral position) (Aortic murmur increase when Pt leaning forward fully expired) [abnormal turbulence across valves] [systolic, pan systolic, late systolic etc] [high or low pitch]
• Other added sounds: clicks, opening snap
• Carotid bruits and other vascular bruits (renal, aortic)

• Resp exam: fine basal crepitations (pulmonary oedema), bilateral pleural effusion
• Ab examination: hepatomegaly, pulsatile liver (tricuspid regurgitation), ascites (RH failure), spleen tip (IE)
• Fundal examination
• Bedside urine stix: eg. RBC (valvular infection)

Nodules on extensor regions in knee area and hand knuckles

Familial hypercholesterolaemia

Xanthoma

Early CHD

Die of heart failure + MI at teenage

Finger clubbing

Floating sensation showing increased fluid in this area

Waveforms of jugular venous pressure

2 Dominant waves: A wave and V wave

A: atrial contraction

V: ventricular systole (transmission of ventricular contraction)

Time carotid and compare with JVP: usually jugular A, then carotid impulse, then jugular V wave

Tricuspid regurgitation: V wave exaggerated, blood direct from RV to RA during systole

Pulse characters

- Normal dicrotic notch: where aortic valve closes during diastole

- Aortic stenosis: Uptake flattened,

Decreased volume (slow rising, plateau pulse)

- Aortic regurgitation: upstroke fast and normal, pulse goes down quickly during diastole - therefore, pulse volume increased, large volume pulse then second phase (relaxation): Waterhammer, collapsing pulse

- Aortic stenosis: slow rising character, then large volume due to regurgitation, pulse volume goes off quickly

Heart murmurs

Stetho at

- Apical (normal 5th IC)

- Mitral regurgitation (use diaphragm sue to high pitch)

- Lower sternal border - tricuspid murmur

- Pulmonary area: 2nd IC lateral to sternal edge - pul stenosis, abnormal splitting of 2nd heart sound

- Aortic area: radiate upward to carotid, esp. on right side

2nd heart sound

Reversed splitting of heart sound (paradoxical): during inspiration, instead of widening, they are closer together - eg. Aortic stenosis. Caused by increased timing of A2

• Pallor: eyes
• Central cyanosis: tongue
• Hand: finger clubbing (IE?), splinter haemorrhages (IE)
• Palm: erythema, Osler nodes, Janeway lesions
• Lower limbs: ankle oedema (if none - sacral oedema)
• Jugular venous pulsation (expose neck): JVP not obvious in this Pt (minor pulsation above clavicle)

• Rate
• Regularity
• Rhythm
• Volume
• Collapsing pulse: flat of hand over radial artery, lift up pulse
• Periphery: femoral, lower limbs

• Praecordium: visible pulsation

• Hand over praecordium: find cardiac apex (lowermost and lateral most pulsation of heart capable of lifting 2 fingers - normal 5th IC MCL)
• Parasternal heave: RV hypertrophy
• Thrills: loud systolic or diastolic murmur
• If apex cannot be felt: Pt sit and lean fwd
• Dextrocardia: heart on opposite side

• Stetho
• Bell: low freq (2nd and 3rd HS, low pitch murmur like mitral stenosis)
• Diaphragm: high freq, aortic regurgitation
• Listen to specific areas: apex, left parasternal area, pulmonary area (left 2nd IC), aortic (right 2ndIC space)
• Listen to Pt in supine position, left lateral, sitting up position
• Apex: bell - mitral stenosis, diaphragm - mitral regurgitation note direction of propagation
• Pulmonary area: pulmonary murmur
• Aortic area: aortic stenosis
• If abnormality detected, look for direction of propagation of murmur - aortic stenosis to carotid artery, mitral regurgitation to left axilla
• Listen to Pt sitting up and learning fwd: aortic regurgitation murmur, diaphragm, along left sternal border,
• Pericardial friction rub in this position
• Auscultation bases of lungs - basal crepitation
• Tricuspid regurgitation murmur sometimes assoc. with pulsatile abdomen
• Measure BP: sitting position, use cuff sphygmomanometer, estimate systolic BP by palpation method, use auscultation method to find SBP and DBP, read to nearest 2mmHg, if seeing Pt for first time measure both arms, if irregular rhythm then measure 3 times and take average
• JVP: occlude with finger to distinguish from carotid pulsation - if JVP the pulse will decrease, sit pt up and pulsation should diminish
• Auscultation: bell then diaphragm (for mitral stenosis)
• Ab: organomegaly, local tenderness, ascites, palpate for liver, palpate for spleen

Mitral regurgitation

• Pan-systolic murmur
• Propagate to left axilla

Mitral stenosis

• 1st heart sound very loud
• 2nd heart sound may be loud in pulmonary HT
• search at apex for site of mitral stenosis which can be localised

Aortic stenosis

• Ejection systole murmur hear at aortic area
• Maximally propagated to neck

Aortic regurgitation

• Blowing high pitched diastolic murmur heard along left sternal border
• Pt sit up and learn fwd and expire

Continuous murmur

• Communication between a and v system
• PDA, AV fistula within bronchial communications
• Machinery like murmur
• Heard in left infraclavicular area