ABSTRACT
CARDIOVASCULAR SYSTEM Mr Stoker is a 55-year-old gentleman who has presented to the accident and emergency department complaining of chest pain. Please examine his cardiovascular system.
Introduces self and seeks permission to examine Confirms patient’s name and age Asks patient if he is currently in any pain
Positions patient at 45° with chest exposed Examines hands for clubbing, signs of infective endocarditis, pallor, peripheral cyanosis and capillary refill Assesses radial and carotid pulses (rate, rhythm, character) Offers a blood pressure measurement Inspects head for signs of clinical anaemia, cyanosis, xanthelasma, corneal arcus and malar flush Inspects for a raised JVP Inspects chest for scars and visible apex beat Palpates chest for nature and site of the apex beat, and for any heaves or thrills Auscultates praecordium in all four areas with patient appropriately positioned Auscultates in the left axilla for radiation, and the carotids for radiation/bruits Auscultates the lung bases Palpates the peripheral pulses Feels for sacral and ankle oedema
Cleans hands by washing or using alcohol gel
Fluency of examination Competence in presenting findings, summarizing and forming differential diagnoses
KEY Whilst assessing the radial pulse, palpate both at the same time and comment on whether there is any radio-radial delay. Also check to see whether the pulse is slow rising or collapsing and if it is regular. It is worth inspecting carefully for scars, as these will give you clues to the diagnosis: a median sternotomy scar with vein harvest scars on the legs is suggestive of a coronary artery bypass graft; a median sternotomy scar alone and a lateral thoracotomy scar are suggestive of valvular replacement.
