In this MRCS Part B scenario you are in preassessment clinic. Mr Jones is a 60-year-old gentleman due to have a elective hernia repair next month.
Please examine his cardiovascular system.
Here is a proforma that can be adapted to whatever cardiology examination you are asked to perform
Wash your hands
Permission – may I examine you today please?
Exposure – Upper limbs, chest and abdomen exposed
Reposition – Patient supine, at 45o head supported by pillow
Ask the patient if they are in any pain
Look around the bed for oxygen, medication, walking aids, observation chart, ECG. Get a general impression as to how well this patient is. Note any obvious abnormalities such as a midline sternotomy scar.
Then start your examination at the hands
Look for stigmata of infective endocarditis – splinter haemorrhages, Janeway lesions, for clubbing, tar staining, peripheral cyanosis, and measure the capillary refill time.
Palpate the radial pulse for rate and rhythm, then for radial-radial delay.
Feel for pulse character at the brachial or carotid pulse
A slow rising pulse fits with aortic stenosis
A collapsing pulse fits with aortic regurgitation. This is tested by placing your palm over the radial pulse and lifting the arm above the patient’s head. A collapsing pulse will feel like knocking against your palm. Remember to check that patient doesn’t have shoulder pain first.
Offer to measure the patient’s blood pressure. Here you are often told what it is rather than having to actually perform the measurements but ensure you can do so slickly.
Pay attention to the pulse pressure
A narrow pulse pressure eg 120/100 is consistent with aortic stenosis.
A wide pulse pressure eg 180/60 is consistent with aortic regurgitation
Assess the JVP in the neck by asking the patient to look over to the left by around 30 degrees (the sternocleidomastoid muscle should be relaxed). JVP is the vertical height from the sterno-manubrial joint. It has a double pulsation, which is not palpable to distinguish it from the carotid pulse.
Examine the eye and mouth, looking for pale mucous membranes (anaemia), corneal arcus (hyperlipidaemia, although can be a normal finding in the elderly), central cyanosis and Roth spots (retinal hemorrhages with white or pale centres found in infective endocarditis)
Now inspect the chest
Look carefully for old scars, they may be hidden around the left hand side in the case of an old left thoracotomy scar. Look for a pacemaker or defibrillator under the left clavicle.
Palpate for the apex beat (normally the mid clavicular line 5th intercostal space)
Feel for heaves (flat hand against the chest wall) and thrills (with the medial aspect of your open hand)
Always have your left hand on their right carotid pulse to time the systolic / diastolic phases
First for mitral stenosis – bell of stethoscope over the apex beat. Ask patient to roll into a left lateral position, and hold their breath in expiration. MS is a mid diastolic murmur.
Mitral regurgitation – diaphragm onto apex beat, then over the axilla. MR is a pan systolic murmur, which radiates to the axilla
Aortic stenosis – diaphragm over the 2nd intercostal space right parasternal edge, then over the carotid pulse. AS is an ejection systolic murmur that radiates to the carotids.
Aortic regurgitation – sit patient up and lean them forward. AR is a early diastolic murmur heard best in expiration over the tricuspid area – left parasternal edge 4th intercostal space
Listen for a metallic heart sound. This will be a loud click or two clicks depending on the valve. If it is one click corresponding to the first heart sound it is a mitral valve; if it corresponds to the second heart sound it is an aortic valve. Listen carefully for murmurs, either flow murmurs or murmurs indicating valve failure.
Listen to the right heart valves over the tricuspid and pulmonary areas
Finish your examination by assessing cardiovascular functional status – listening to the lung bases for crackles of left ventricular failure, and feel the ankles for the pretibial oedema of right ventricular failure.
Check the legs for vein graft harvest scars, and the skin for bruises perhaps indicating warfarin use.
Ask to see the observation chart and ECG
Thank the patient, wash your hands, and turn to the examiner, stethoscope held behind your back to prevent fidgeting and present your findings.