1
CVD STATION
FULL EXAMINATION RUN-THROUGH
- Note: the CPSA emphasises a focused examination, you will likely not need to
do a full CV examination but a focused one which will be guided by the pt history
and presentation.
- During our CPSA, many were caught off guard because the briefing led
us to expect a CVD station. However, the patient presented with an
acute-on-chronic arterial ulcer, requiring us to perform a PAD
examination instead. Be aware that this is a potential scenario.
Introduction - I will now be conducting an examination of your heart which
will require you at some point to remove your top (+/or bra).
- Explain examination: It will involve me looking at your
hands, face and chest. I will be tapping around your chest
and listening with my stethoscope.
- Would you like a chaperone for this examination? Would that
be ok with you?
Some examiners prefer candidates to explain their thought process
during the examination, including the signs they are looking for. If
you feel confident and your university has indicated that this is
common practice, you can begin the exam by saying something
like:
"Would it be alright if I talk through the examination with the
examiner? This will involve using some medical terminology."
PPE Wash hands and equipment (stethoscope)
I consistently wore gloves, even though it wasn't entirely clear
whether they were required.
End of the Position the patient at 45 degrees and expose them from the waist
bed up
I am looking at general appearance of the patient (do they appear
breathless, are they on any oxygen/fluids/medication/catheter etc,
are they gasping for breath (tachypnoea), do they appear
distressed/in pain, any signs of central cyanosis), walking aids,
adjuncts (e.g., IV lines, catheter, infusions etc.)
- You will need to tailor the investigation based on the
patient's characteristics, making the end-of-bed
observation crucial.
- Don’t forget always be systematic in your approach and
examine from the right hand side of the bed
Hands I’d like to have a look at your hands, things to look for:
, 2
1. Temperature (compare both sides) – cold hands are a sign of
poor cardiac output / Raynaud’s / PVD
2. Cap refil (<2 seconds)
3. Signs of peripheral cyanosis
4. Tar staining – modifiable RF for CVD
5. Xanthomata aka cholesterol deposition – modifiable RF
6. Endocarditis specific: Osler’s nodes (tender nodules in
fingertips), Janeway lesions (macules on the back of the
hand/palm)
Nails - Clubbing: could I please ask you to place the nails of your
index fingers back to back
- Koilonychia – sign of anaemia
- Splinter haemorrhage/s – indicative of infective
endocarditis
Wrist - Pulse: Radial pulse (measure for 30 seconds x 2 to get the
BPM), I always do radial-radial delay (particularly in the
acute scenario to rule of aortic dissection as a differential)
- You could describe the radial pulse: I can see that your
pulse is regular / irregular / irregularly irregular / low rising /
bounding etc.
Could do collapsing pulse (if you suspect aortic regurg)
- Ensure the absence of shoulder pain prior to the test
- I rarely do that – will depend on the history and
presentation of the patient
, 3
Arm Mention obs – I will now be taking some basic observations (BP,
temp, RR etc)
- In the context of the CPSA this is usually provided to you if
you mention it during the course of your examination (aka
patient time)
Neck - I am now looking at the carotid pulse (looking for
exacerbated pulsation aka Corrigan’s sign = aortic
stenosis)
- Tip: You should never palpate both carotid arteries at the
same time because doing so can significantly reduce blood
flow to the brain, potentially causing the patient to faint or
lose consciousness. Compressing both carotids
simultaneously can interrupt the oxygen supply to the brain,
leading to a dangerous drop in cerebral perfusion.
JVP Patient lying at 45 degrees and looking towards their left – the
right internal jugular vein is preferred for assessment as it is a
more direct reflection of right atrial pressure due to the straight
anatomical connection with the SVC and the R atrium.
Signs
- Kusmauls sign – JVP rises on inspiration (present in
cardiac tamponade, constrictive pericarditis)
- Raised JVP – sign of fluid overload
- Canon waves – large a wave (sign of complete heart block)
Face I am looking for signs of malar flush (redness around the cheeks -
indicative of mitral stenosis)
Xanthomata around the eyes, palms and/or tendons – sign of
hyperlipidaemia (modifiable RF)
Eyes - Xanthelasma in the skin in the inner eyelid
- Conjunctival pallor – a sign of anaemia
- Corneal arcus (ring around the cornea) – age related +
associated with hyperlipidaemia
- Proptosis – in patients with Grave’s disease which is often
associated with atrial fibrillation
Niche:
- You can mention that you would complete your
examination by doing a fundoscopy for Hypertensive
retinopathy (in pts with a Hx of hypertension), Roth spots (if
you suspect infective endocarditis)
Mouth If I could ask you to open your mouth for me, please
, 4
- Looking for hydration status, dentition (RF for infective
endocarditis) signs of central cyanosis, pale mucous
membranes (signs of anaemia)
- Angular cheilitis (cuts at the edge of the lips ; sign of iron
deficiency anaemia)
Chest and precordium
Ask patient to remove top (+ bra)
Inspection I am looking from the side of the bed for any surgical scars
(medial sternotomy and lateral thoracotomy)
Palpation Palpate the chest wall for the following:
- Apex beat (warn the patient that you will be feeling
under the left breast to feel for the apex beat) – feel at
5th IC space mid-clavicular line
- Heaves (hypertrophy)
- Thrills (palpable murmur)
Auscultation 4 valve areas (always whilst palpating the carotid pulse)
*More on murmurs later*
The rest
Back Examine the back
Auscultate lung bases
Look for sacral oedema (sign of fluid overload and heart
failure)
CVD STATION
FULL EXAMINATION RUN-THROUGH
- Note: the CPSA emphasises a focused examination, you will likely not need to
do a full CV examination but a focused one which will be guided by the pt history
and presentation.
- During our CPSA, many were caught off guard because the briefing led
us to expect a CVD station. However, the patient presented with an
acute-on-chronic arterial ulcer, requiring us to perform a PAD
examination instead. Be aware that this is a potential scenario.
Introduction - I will now be conducting an examination of your heart which
will require you at some point to remove your top (+/or bra).
- Explain examination: It will involve me looking at your
hands, face and chest. I will be tapping around your chest
and listening with my stethoscope.
- Would you like a chaperone for this examination? Would that
be ok with you?
Some examiners prefer candidates to explain their thought process
during the examination, including the signs they are looking for. If
you feel confident and your university has indicated that this is
common practice, you can begin the exam by saying something
like:
"Would it be alright if I talk through the examination with the
examiner? This will involve using some medical terminology."
PPE Wash hands and equipment (stethoscope)
I consistently wore gloves, even though it wasn't entirely clear
whether they were required.
End of the Position the patient at 45 degrees and expose them from the waist
bed up
I am looking at general appearance of the patient (do they appear
breathless, are they on any oxygen/fluids/medication/catheter etc,
are they gasping for breath (tachypnoea), do they appear
distressed/in pain, any signs of central cyanosis), walking aids,
adjuncts (e.g., IV lines, catheter, infusions etc.)
- You will need to tailor the investigation based on the
patient's characteristics, making the end-of-bed
observation crucial.
- Don’t forget always be systematic in your approach and
examine from the right hand side of the bed
Hands I’d like to have a look at your hands, things to look for:
, 2
1. Temperature (compare both sides) – cold hands are a sign of
poor cardiac output / Raynaud’s / PVD
2. Cap refil (<2 seconds)
3. Signs of peripheral cyanosis
4. Tar staining – modifiable RF for CVD
5. Xanthomata aka cholesterol deposition – modifiable RF
6. Endocarditis specific: Osler’s nodes (tender nodules in
fingertips), Janeway lesions (macules on the back of the
hand/palm)
Nails - Clubbing: could I please ask you to place the nails of your
index fingers back to back
- Koilonychia – sign of anaemia
- Splinter haemorrhage/s – indicative of infective
endocarditis
Wrist - Pulse: Radial pulse (measure for 30 seconds x 2 to get the
BPM), I always do radial-radial delay (particularly in the
acute scenario to rule of aortic dissection as a differential)
- You could describe the radial pulse: I can see that your
pulse is regular / irregular / irregularly irregular / low rising /
bounding etc.
Could do collapsing pulse (if you suspect aortic regurg)
- Ensure the absence of shoulder pain prior to the test
- I rarely do that – will depend on the history and
presentation of the patient
, 3
Arm Mention obs – I will now be taking some basic observations (BP,
temp, RR etc)
- In the context of the CPSA this is usually provided to you if
you mention it during the course of your examination (aka
patient time)
Neck - I am now looking at the carotid pulse (looking for
exacerbated pulsation aka Corrigan’s sign = aortic
stenosis)
- Tip: You should never palpate both carotid arteries at the
same time because doing so can significantly reduce blood
flow to the brain, potentially causing the patient to faint or
lose consciousness. Compressing both carotids
simultaneously can interrupt the oxygen supply to the brain,
leading to a dangerous drop in cerebral perfusion.
JVP Patient lying at 45 degrees and looking towards their left – the
right internal jugular vein is preferred for assessment as it is a
more direct reflection of right atrial pressure due to the straight
anatomical connection with the SVC and the R atrium.
Signs
- Kusmauls sign – JVP rises on inspiration (present in
cardiac tamponade, constrictive pericarditis)
- Raised JVP – sign of fluid overload
- Canon waves – large a wave (sign of complete heart block)
Face I am looking for signs of malar flush (redness around the cheeks -
indicative of mitral stenosis)
Xanthomata around the eyes, palms and/or tendons – sign of
hyperlipidaemia (modifiable RF)
Eyes - Xanthelasma in the skin in the inner eyelid
- Conjunctival pallor – a sign of anaemia
- Corneal arcus (ring around the cornea) – age related +
associated with hyperlipidaemia
- Proptosis – in patients with Grave’s disease which is often
associated with atrial fibrillation
Niche:
- You can mention that you would complete your
examination by doing a fundoscopy for Hypertensive
retinopathy (in pts with a Hx of hypertension), Roth spots (if
you suspect infective endocarditis)
Mouth If I could ask you to open your mouth for me, please
, 4
- Looking for hydration status, dentition (RF for infective
endocarditis) signs of central cyanosis, pale mucous
membranes (signs of anaemia)
- Angular cheilitis (cuts at the edge of the lips ; sign of iron
deficiency anaemia)
Chest and precordium
Ask patient to remove top (+ bra)
Inspection I am looking from the side of the bed for any surgical scars
(medial sternotomy and lateral thoracotomy)
Palpation Palpate the chest wall for the following:
- Apex beat (warn the patient that you will be feeling
under the left breast to feel for the apex beat) – feel at
5th IC space mid-clavicular line
- Heaves (hypertrophy)
- Thrills (palpable murmur)
Auscultation 4 valve areas (always whilst palpating the carotid pulse)
*More on murmurs later*
The rest
Back Examine the back
Auscultate lung bases
Look for sacral oedema (sign of fluid overload and heart
failure)
