Notes on what should occur during a cardiovascular examination between a patient and doctor. What to assess and the actions to take (includes all possibilities). How to talk to the patient.
Cardiovascular Examination
Introduction
Wash Your hands
Introduce yourself by name and Role
Check the patient’s identity – name and Date of Birth
Explain the procedure – why you need to do it and what does it involve
Ask for consent
Expose the patient appropriately
Check if the patient is currently in any pain
For example: “Good morning, my name is .. and I am a medical student. Can I just check your
name and date of birth? I have been asked to do a cardiovascular examination on you, which
would involve me having a look at your hands, face and chest, and then having a feel and listen to
your chest. Is that ok? For the purposes of this examination I’m just going to position the bed at 45
degrees. Would you mind removing your shirt for me please? And can I just check whether you are
in any pain?”
Bedside Inspection
Observe the patient by standing at the end of the bed.
Comment on whether the patient is ABC:
A – Alert B – (normal) Body habitus C – Comfortable at rest
Observe the surroundings and comment of whether you can see any “paraphernalia
of cardiovascular disease”:
This is a description of the objects or items around a patient’s bedside that will give you
an idea into the condition that they might have. It is important to highlight this to the
examiner as this can give you many clues about the patient’s underlying diagnosis.
Things to look for include:
Oxygen – is the patient currently on oxygen or room air, and what is the flow rate?
Inhalers – does the patient have underlying respiratory disease?
Medication – can you see any medication on the patient’s bedside e.g. beta-
blockers?
Test results – are there any investigation results like ECGs lying around the patient’s
bedside.
Fluid chart – this gives you an idea if they are fluid overloaded.
Pillows – this is a useful marker of the level of heart failure as it shows that the
patient might be suffering from orthopnea.
Mobility aids – gives an idea about the functional status of the patient.
, Hands
Action: Ask the Patient to put the nails of their index fingers against each other. You will
be looking to see if you can detect a small rhomboid shaped window (Schamroth’s
window).
Assess for: Finger clubbing: this is a term which describes swelling of the distal end of
the fingers which leads to loss of the angle between the nail bed and the nail. It is
associated with Congenital heart disease, Infective endocarditis, Atrial Myxoma,
Eisenmenger syndrome.
Action: Ask the Patient to put their hands outstretched. Using the back of your hands,
feel down from their forearms to feel the temperature:
Assess for: Cold peripheries: This is a sign of poor peripheral circulation. This is a
common sign of shock and so may occur in hypovolaemia when the arterioles are
vasoconstricted to reduce blood supply to the extremities.
Action: Look closely at the back of the patient’s hands.
Assess for:
–> Extensor Tendon Xanthomata: These are small non-tender lumps of cholesterol that
can be found of the tendons of the extensor muscles of the wrist and palms. They are
seen in hyperlipidaemia.
–> Peripheral Cyanosis: This is a blue discolouration of the nails and fingers which is
indicative of peripheral ischaemia. It shows the patient is peripherally not perfusing well
which can be seen in shock or hypothermia.
–> Tar staining: This is a black/brown staining of the nails and fingers which is seen in
chronic smokers.
–> Koilonychia: These are spoon-shaped nails which are seen in iron-deficieny anaemia.
–> Splinter Haemorrhages: These are tiny brown spots that look like splinters under the
nails, which occur due to damage of the underlying blood vessels. They are associated
with infective endocarditis.
Action: Pinch the patient’s fingernail for 5 seconds and then release. Measure the
capillary refill time.
Assess for: Capillary refill time: This is the time taken for the capillaries to refill after a
sustained period of pressure. Apply 5 seconds of pressure to the distal phalanx of the
index finger and then release. Count how many seconds it taken to go red (re-
vascularise). If >2 seconds, this shows poor peripheral circulation which could be a sign
of shock.
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