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U tm ateO SC Eseries CVSExaminaionandVias DeliveDr. Shahriar GhadiriDisclaimer BIDA SW teaching is led by students with supervision of junior doctors and consultants across the UK. These teachings are created to support students’ learning but should not replace your local Medical School teaching material.Learning Outcomes Review Review the basic principles of CVS history taking and examination Common stigmata of cardiovascular disease and be Recognize able to provide differential diagnosis for cardiorespiratory presentations Recognise abnormalities and be able to understand Apply the underlying cause and manage accordingly. CVS examination • WIIPPPE • Look • Feel • Listen https://www.ebay.co.uk/itm/304359732335 WIIPPPE • Wash your hands • Introduce yourself • Identify pt • Permission (Purpose of exam) • Pain • Position • Exposure https://www.facebook.com/Haejinuae/posts/park-hae-jins-breath-taking-upper-body-exposure-on-forest/474711556534962/CVS examination General inspection - LOOK • Bedside: • Medication: GTN spray, Warfarin booklet, O2 • Monitoring: Glucometer, Fluid balance chart (+/-) • Mobility aid: Frame, Walking stick • Patient: (Expose chest, hands, legs and face) • Distress, Cyanotic, Pallor, Oedema • Obvious scar, Murmur • Syndromic features (Marfanoid, Down’s, Turner) CVS examination Hands • Nail • Check perfusion: • Dorsal • Look for peripheral cyanosis • Palmar • Temperature • Capillary refill: Press for 5 seconds then release (>2 seconds is classed as hypoperfusion) https://app.bitemedicine.com/osce-cpsa/osce-cardiology/examinations-cardiovascular-examination CVS examination Hands • Splinter haemorrhage: What’s a splinter? • Clubbing: loss of Schamroth's window Cardiac causes: • Chronic hypoxia: Cyanotic heart disease, Eisenmenger’ssyndrome • Infectiveendocarditis • Janeway lesions (Septic emboli deposition) Painless • Osler (Immune complex deposition) – Painful (ouch ouch osler’s) https://www.grepmed.com/images/3834/differential-clubbing-causes-nails-diagnosis CVS examination Wrist and Arm • Brachial pulse: • Bruising/AV Fistula • Volume, Character • Radial pulse • Blood pressure: • Rate, Rhythm, Character • Hyper/Hypotensive • Arm pressure discrepancy • Collapsing pulse • Pulse pressure • Radio-radial delay https://medagghealthcare.com/av-fistula/ https://ehealth.kcl.ac.uk/tel/virtual-patients/S2Y2-VA/VA-AdamSmith-Syncope/examination-extras.htmlhttps://www.clinicianrevision.com/courses/cardiology/lessons/cardiovascular-examination/topic/pulse-character/ https://www.anchorpumps.com/blog/what-causes-water-hammer-how-to-eliminate-it/CVS examination Neck • Jugular venous pressure (JVP) • Hepatojugular reflux • Vertical distance between the top of the • (transient rise = normal; sustained rise = angle (≤3cm in healthy people). RVF) • In a competent heart, increase liver pressure should not cause increased JVP • Causes (PQRST): • Pulmonary hypertension/PE/PS/pericardial • Carotid pulse (One at the time!!) effusion • Auscultate: Rule out bruit before • Quantity of fluid i.e. overload palpation • RVF • SVC obstruction • Tamponade/TR • Palpation: Volume, Character CVS examination Head • Face • Mouth • Malar flush – MS • Central cyanosis under tongue • Poor dental hygiene (IE risk) • High-arched palate (Marfan syndrome) • Eyes • Pallor (anaemia)/haemorrhages (IE) • Corneal arcus • Xanthelasma https://www.healthline.com/health/malar-rash https://www.ualberta.ca/airway-research/resources.html CVS examination Chest - FEEL • Chest deformities (pectus excavatum/carinatum) • Apex beat • May be displaced in: cardiomegaly e.g. • Scars due to aortic regurgitation or mitral • Anterolateral thoracotomy regurgitation. • Midline sternotomy • Infraclavicular • Left mid-axillary scar • Heaves • Devices (pacemaker, ICD, loop recorder) • Abnormally large beating of heart – NOT vibration • Palm on left sternal edge, suggests RVH • Thrills • A Palpable murmur – feels like vibration • Feel auscultation points with your fingertips for a vibration. https://medlineplus.gov/ency/presentations/100040_5.htm CVS examination RILE Auscultation • Right sided: Exacerbated on inspiration • Left sided: Exacerbated on expiration • “I auscultated a grade ___ ejection/pan systolic murmur heard loudest in the ___ region which was accentuated by positioning the patient in the ___ position on expiration and radiated to the ___. In summary, this is consistent with ___.” https://medizzy.com/feed/1996087 https://arhcardio.blogspot.com/2016/05/making-sense-of-murmurs-levine-scale.html?m=1 CVS examination Back and Leg Inspect, Percuss and auscultate lungbases: • Leg Inspection: • Stony dull percussion: pleural effusion • Peripheralvasculature:shiny skin, hair loss, • Fine crackles: pulmonary oedema ulcers, smelly, gangrene (arterial disease), • Sacral oedema varicose veins, scars (saphenous vein harvest). • Pittingoedema http://www.southsudanmedicaljournal.com/archive/may-2018/how-to-assess-for-bilateral-pitting-oedema.htmlCase 1 Positive findings: • Multiple bruises • Midline sternotomy scar with no associated graft scars on the arms or legs • On auscultation, a metallic 2nd heart sound • A systolic murmur • Character: ejection systolic • Region: loudest over the aortic region • Augmentation: end-expiration with the patient sitting forward • Radiation: none • No peripheral stigmata of IE • What is the most likely diagnosis based on these findings?Case 1 Why do you think patient has had a valve replacement? • Chronic valvular dysfunction: aortic stenosis, aortic regurgitation • Acute valvular dysfunction regurgitation: aortic dissection, infective endocarditis Factors to consider when deciding on valve replacement in aortic stenosis? • Severe stenosis and symptomatic • Severe stenosis and asymptomatic and one of: • Heart failure • Symptomatic on exercise testing • Mild-moderate disease managed conservatively (Stall in AS, Operate AR Regardless)Case 2 Positive findings: Tar staining Irregularly irregular pulse Auscultation • End systolic murmur with a mid systolic click • Loudest at the mitral region • Exacerbated on patient lying on their L side and on held expiration • Radiation to axilla • Bibasal crepitations • What is the most likely diagnosis based on these findings? Case 2 What are the causes for this pathology? • Acute: • Infective endocarditis • Rupture of papillary muscle (e.g. post MI) • Chronic • Ischaemic injury to L ventricle → dilated MV annulus • Calcification of MV annulus • Rheumatic heart disease • Marfan’s, ED, Ebstein anomaly https://www.tumblr.com/mcatmemoranda/185569087576/ec-ejection-click-mc-mid-systolic-click-osRefrences 1. Oxford Medical Education (2018) Cardiovascular examination, Oxford Medical Education. Available at: https://oxfordmedicaleducation.com/clinical-examinations/cardiovascular-examination/ (Accessed:04 May 2024). 2. Le, Tao; Bhushan, Vikas;and Sochat, Matthew. First Aid for the USMLE Step 1 2021. New York: McGraw-Hill Education, 2021. 3. Innes,J.A.,Dover, A.R. and Fairhurst, K. (eds.)(2018) Macleod's Clinical Examination (14th ed.). 14th edn.London:Elsevier. 4. Dr Lewis Potter·Cardiovascular examination·September 29, 2010·Last updated:April 11 (2024) Cardiovascular Examination - OSCE Guide, Geeky Medics. Available at: https://geekymedics.com/cardiovascular-examination-2/(Accessed:04 May 2024). 5. OSCES: Cardiology & Respiratory Examinations (part 1) (no date) BiteMedicine. Available at: https://www.bitemedicine.com/watch/osce- masterclass-examinations(Accessed:04 May 2024).FOR FEEDBACK AND QUERIES: Email @ info@bidasw.com