CVS examination for Internal medicine

Cardiovascular examination

Examine the patient lying down at a 45 degree angle. Exposure of the chest(take off the shirt if possible)


Begin Examination by inspection of the general condition of the patient

“The patient is lying comfortably at a 45 degree angle. He appear ?alert, ?concious, ?not in any immediate pain or in any respiratory distress(describe what you see, don’t memorise script). Count the respiratory rate.###IMPORTANT

Examine the fingers for signs of clubbing, peripheral cyanosis, splinter hemorrhages, and Osler nodes.
Examine the hands and look for Janeway lesion.
Check the pulse for rate, rhythm and regularity. Compare the radial radial pulse (indicate subclavian artery stenosis due to aneurysm), and radio-femoral delay(indicate coarctation of aorta).--> Some doctors say radial radial delay is due to coarctation of aorta, but my logic and my findings find no reason to support such claims. No literature said that radial radial delay is due to coartation. If you find one, please let me and others know

Check for collapsing pulse which indicate aortic regurgitation,arteriovenous fistula, Patent ductus arteriosus, arteriosclerotic aorta or hyperdynamic circulation due to anaemia, pregnancy, thyrotoxicosis etc.(Remember all the pulse character such as plateu pulse, pulsus bisferiens, pulsus alternans, pulsus paradoxus and what they indicate)

Examine the face for flushing or grayish discoloration (mitral facies) suggestive of mitral stenosis.
Examine the eyes and periorbital area looking for corneal arcus and xanthelasma.
Check for jaundice and anaemia.
Examine the mouth for hydration, central cyanosis and oral hygiene.
Next, examine the neck for JVP
Use the right external jugular vein, look for sustained increase on inspiration which indicate constrictive pericarditis or cor pulmonale(Kussmaul’s sign)
Hepatojugular refluxà when abdomen is compressed, JVP elevate for less than 4 second in normal person. If elevated more than 4 second, indicate heart failure.
Use torch light at an angle, look at the shadow produced.(Datin Norella style)
If cannot detect, it is not elevated and hence normal.
** Difference between JVP and Carotid pulse should be fingertips by now J

Now examine the precordium. Look for scars from previous CABG or other thoracic surgery. Look for any visible pulsations.
Next, palpate the apex beat. Feel for the character(e.g. tapping in mitral stenosis), position and regularity of the apex beat.

Once apex beat is felt, proceed to palpation of the tricuspid area. Feel for thrills and heaves( Once felt will never forget, dun worryJ). Proceed to pulmonary and aortic area feeling for the same thing.

Percussion is not significant in CVS examination except for estimation of the heart border, which is rarely done.

Auscultation for heart sounds.
Begin at the apex using the bell of the stethoscope. Listen for low frequency murmur. If murmur is soft, ask the patient to lean to the left and listen for accentuation of the murmur.
Still using the bell, listen at the mitral area, listen for pansystolic murmurs which radiate to the axilla.( Mitral regurgutation)
Listen at the pulmonary and aortic area. Any murmur end diastolic murmur indicative of aortic or pulmonary regurgitation should be heard. Accentuated by sitting the patient up, deep breath and hold in mid expiration while listening to the murmur.
If a ejecion systolic murmur is heard, listen to the carotid artery for carotid bruit.

** in atrial fibrillation, pulse deficit can be elicited by counting the number of auscultated apex beat and radial pulse in a period of time. Any difference between apex beat and radial pulse of more than 10 indicate deficient pulseà atrial fibrillation.

Lastly, examine the leg for pedal edema. Examine the ankles and Achilles tendon for tendon xanthomata.

***I wanted to upload this, actually its in Words format, but being the Buta IT person that i am i dont know how.