CVS
Introduce yourself and take permmision Say that you want to wash your hands or use a
hand sanitizer
Put the patient and the bed in the correct position, for CVS it’s 45 degrees
Ask the patient to expose the necessary areas, for CVS it’s from the umbilicus and upwards
General If it’s a general CVS exam begin from General examination, if it’s a precordium exam jump
to the precordium
General look :-
orinted Comfortable?? in pain? in distress? Respiratory distress? tachypneic?
General enviroment:
Temp, Light, Privacy,
equipment eg , Face mask, Inhaler, nasal prong, chest tube
Prong, IV Line, Stomal, foley's catheter, wheel chair
• From the end of the bed comment on
Appearance -> well, not agitated
Body build -> well nourished, not cachectic, not obese…etc.
Color -> not cyanosed, pale or flushed
Distress -> not in acute distress
• Go to the right side of the patient
• Ask the examiner to examine the vital signs (BP, HR, Temperature, RR)
The patient is sitting at 45 degrees , Comfortable, conscious , alert, oriented to place
comment→ time ane
person, No attachment to medical equipment, Not cyanosed , Not in distress, Not
tacypnic.
inspection: Both hands to compare, Look
Finger $ nails : ."ٮﻠﺶ ﻣﻦ اﻻ*ﻃ*ڡﺎر
Hand Finger clubbing, Koilonychia, Leuknychia, splinter hemorrhages,Peripheral
Cyanosis,
.ٮﺔ1ﺪ اﻟ*ﺤﺎر"ﺣ1 "ٮﻌﺪﻫﺎ اﻻٮDorsum hand : Tar staining, tremor (fine or flapping). Xanthomata, hand
shape deformity small muscles of the hand
↓
Ulnar deviation /Swan neck deformity /Boutonniere deformity
inspection Palm of the hand for: .ﺪ ﻣﻦ "ﺣوا1 "ٮﻌﺪﻫﺎ اﻻٮ
_ Shape deformity: Dupuytren's Contractur ,Trigger finger • Palpate
_small muscle of the hand: Thenar & hypothenar
Capillary refill time
_ Creases: pale or not?
_ warm? Cyanosed, Sweaty? Hand temperature
_ Osler's nodes? Janeway lesions?
* Warm, Sweaty, red Palms COPD, because CO₂ retention cause vasodilation so redness
Fine tremors: hyperthyroidism
Anxiety (M.C)
Beta-agonist
Drug with drawal symptoms
Caffiene excess
• Radial • Located lateral to flexor carpi
radialistendon, feel with 3 fingers
Rate, Rhythm • count for complete 1 min to
Pulse Assess Radio-Radial Delay calculate the Rate and check the
Rhythm and compressibility
Comment on Radio-Femoral Delay
Ask the patient if they have pain in their shoulder then do collapsing pulse
For example Rate 80 beats per minute , regular rhythm , Normal volume, normal Character (No
collapsing pulse, No pulse deficit, No radioradial delay, No radiofemoral delay) , Compressible
Brachial pulse:
•Character abnormalities: Bisferience Pulse, pulses Biferiences, Pulsus
tardus, Pulsus alterans
Volume:
0: Absent, 1: weak , 2: full pulse (normal)
*Compare both hands
BP:
Measure it in both hands if the difference is
< 10 : normal... If >10 abnormal, e.g radio-radial delay
Ankle Brachial Index
BP while the paitent standing: Look for Postural hypotension: Systolic drop of
BP > 20, or diastolic : 15 :
Within 3 mins
-BP during Inspiration: Normally systolic BP drop < 10... If drop >10 Pulsus
Paradoxus Hallmark of cardiac tamponade{ severe asthma,severe copd ,
Tension pneumothorax, Pericarditis}
Normal volume, Normal character, compressible
1. Weak (Thready) Pulse - Low amplitude, difficult to palpate (e.g., shock, heart failure).
2. Bounding Pulse- Strong and forceful (e.g., fever, anemia, hyperthyroidism).
3. Pulsus Paradoxus - Decrease in pulse amplitude during inspiration (e.g., cardiac
tamponade, severe asthma).
4. Pulsus Alternans -Alternating strong and weak beats (e.g., left ventricular dysfunction).
5. Pulsus Bisferiens- A double-peaked pulse per cardiac cycle (e.g., aortic regurgitation,
hypertrophic cardiomyopathy).
6. Pulsus Parvus et Tardus - Weak and delayed upstroke (e.g., aortic stenosis).
carotid pulse : 7. Dicrotic Pulse - A second peak during diastole (e.g., sepsis, dilated cardiomyopathy).
• feel it at angle of jaw , anterior to sternocleidomastoid muscle
• facing the patient ,rt hand of examiner measures left carotid pulse of the patient
• use 2 fingers GENTLY, NEVER feel both sides together!
• auscultate for bruit while the patient holding breath.
Comments:
Normal volume, Normal character, compressible, No bruit
- eye :Puffiness, exophthalmous, Peri- orbital edema xanthelasma, (ptosis,
anhydrosis, myosis)= Horner's syndrome
Face
-Conjuctiva: pallor, jaundice,{hyposphagma =Sub-Conjuctival hemmoraghe}
examination:
- Iris: Corneal arcus, Lipidus, Kiesser fliesher ring
-retina: Fundoscopy normally clear ( )زي اﻟ&ٮﺴﺎط اﻻﺣﻤﺮ-
1- Roth spots
2-white spots: exudate,.
3-Red spots: hemorrhage
-Optic disc : normally clear edges, if blurred engorged edges Papilledema :
1-with HTN: malignant HTN, 2-severe ↑ ICP
-Cheeks: Mallor flush: Severe mitral Stenosis, SLE,
-Mouth: Dental hygiene, central cyanosis hydration , Angular Stomatitis
Glossitis , high arch palate, oral ulcers
No Xanthelasmata, No corneal archus, No pallor , No petechial hemorrhage, I need
comment→ fundoscopy to check HTN, DM changes and Roth spots , No malar rash, No Central &
peripheral cyanosi
ﻠﻒA اﻃﻠﺐ ﻣ(ٮﻮ ٮ-٢ در=ﺣﺔ45 ى ع زاويﺔ 5 ڡ#ٮﻠ#ﺄﻛﺪ ا(ٮﻮ اﻟﻤريﺾ ﻣﺴ#ٮ-١
Neck : ٮﺴﺎرAو=ﺣﻬﻮ ع اﻟ
=ٮ(ٮﺸﻮفhepatojugular reflux اوtoruchٮ(ﺤﺪام ال#ﺎ =ٮﺎﺳA ٮ-٣
JVP 5 ڡ# وﻣﺪ ﻣ(ٮﻬﺎ (ﺣﻂ ا(ڡpulse ٮهﺎAڡﻄﺔ (ڡ#اﻋﲆ (ٮ
وازي الA =ﺤﺎه ٮ#ى =ٮﺎٮ
sternal angle
ٮهﺎAﻜون =ٮﺸكﻞ ﻋﺎﻣﻮدي ﻋﻠ# وٮsternal angle ﺣﻂ اﻟﻤﺴﻄﺮة ﻣﻦ-٤
ﺎ ﻛﻢ ﻃﻠﻊ ﻣﻌﻚA ڡﺎﻃﻊ ﻣﻊ اﻟ(ﺤﻂ اﻟﻌﺮﴈ وﺷﻮف ﻋﺎﻣﻮدٮ#ت#وٮ
اﻟﻤﺴﺎ(ڡﺔ ع اﻟﻤﺴﻄﺮة
ٮﻞ اﻟﻤﺴﺎ(ڡﺔ ﻣﻦkٮﻤ#ى =ٮ 5 ىه 5 ﺳﻢ وال٥ ى ﻃﻠﻊ ﻣﻌﻚ 5 ڡﻢ ال#ٮﻒ ﻟﻠﺮAﺿ-٥
RA اﻟﻰsternal angle
Important Question: How to differentiate veins from arteries? (٩-٦) ﻜونA اﻟ(ٮورﻣﺎل ري(ٮﺞ ٮ-٦
Arteries: one Point, veins: multiple waves inward & outward
veins : easily appolished: due to very low pressure 2-3
mmHg
→ In artery ~120 mmHg
Arteries are usually fixed and not related to position
However, vein mave with Position: ↓ with upright position
Arteries are not affected by inspiration, veins are affected
→ vein go down with inspiration
hepatojugular reflux veins ↑
Examine the Precordium
If you’re continuing a general CVS exam do the inspection from the rt side
of the patient and skip the ABCD, but if you’re starting with the
precordium, do it from the end of the bed
Inspection
3S (Scar) (shape) (spider navi)
Pectus Carinatum
central: CABAGE, open heart surgery
Excavatum
sub-clavicular: Pacemaker , icd Barrel chest
Kyphosis & scoliosis
• Infra-mammary: mitral valve surgery
Lateral thoracotomy: Lung surgery,
chest tube
hair distribution,
dilated veins,
visible pulsation,
Type of respiration,
gynecomastia
Accessory muscles of respiration : Subcostal & intercostal retraction ,
bulging of the heads of sterocleadomastoid
1-Warm your hands
2-Ask if there is any area of tenderness on the chest
Palpation 3-Keep eye contact with the patient as you palpate
4-Generally, palpate the chest for tenderness and subcutaneous emphysema
1 Locate Apex Beat and describe it (gently tapping + location @ Lt 5th ICS
MCL), if you can’t feel it ask the patient to turn to his left side and palpate
again + make sure to show the examiner that you’re counting the IC spaces
from the sternal angle
2 Ask the patient to hold his breath at expiration after a deep inspiration and
palate for:
1-Left ventricular heave at the apex using palm
2-Right ventricular heave at the left sternal margin (left parasternal)
3 Palpate for thrills using the pulps of your fingers at the apex and both
sides of sternum
How much Loudness? above 3-6 during expiration
1. Palpate the carotid pulse or radial to determine the first heart sound.
2. Auscultate 'upwards' through the valve areas using the diaphragm of
the stethoscope whilst continuing to palpate the carotid pulse:
Auscltation Mitral valve: 5th intercostal space in the midclavicular line.
Tricuspid valve: 4th or 5th intercostal space at the lower left sternal edge.
Pulmonary valve: 2nd intercostal space at the left sternal edge.
Aortic valve: 2nd intercostal space at the right sternal edge.
3. Repeat auscultation across the four valves with the bell of the
stethoscope.
Radiation : Auscultation over the radiation sites: 2 radiation sites:
I- Over the carotid artery, using the diaphragm, during the expiration, Lisken
for radiation of an ejection Systolic murmur, Caused by aortic stenosis
2 - Over the axilla, using the diaphragm, during expiration, listen for
radiation of pansystolic murmer cused by mitral regurgitation
Added manoeuvres:-
1- Let the patient sleep on the Lt lateral decubitus Position, listen over the
mitral valve, using the bell, during expiration for (mid-diastolic murmur,
accentuation, opening snep, Loud S1) Caused by mitral Stenosis
2- Sit the patient forwards, auscultate over the erb's point Left Lower
Parasternal, tricuspid valve, using the diaphragm, during the expiration,
Listen for early diastolic murmur, Caused by aortic regurgitation
To complete the exam
Comment on the need to palpate for sacral and ankle edema
Auscultation of the lung bases for crackles
Examination of the abdomen for a pulsatile liver and aortic aneurism
Abdomen Look for signs of Ascites (Everted umbilicus abd distention full flanks Shifting
dullness in small, or middle effusion
Large effusion : transmitted thrills
Lower limbs: pulses, DVT, signs of ischemia
Lower Limb edema
Venous ulcers: painless+goiter area
Arterial ulcers: Painful+ pressure area
Thank the patient
Done by : Abdullah Alqaisi
