Year 1 MBChB

Clinical Skills Session

Cardiovascular examinationReviewed & ratified by:

Dr V Taylor-Jones, Ms C Tierney

Cardiovascular Examination

Aims and Objectives

Aim: To be familiar with the elements of a cardiovascular examination.

o Lower limb pulseso Apex beat o Heart sounds

Objective: To understand the anatomy and physiology and apply it to the practical skill

Objective: To be able to locate and palpate lower limb pulses

Objective: To be able to locate and palpate the apex beat

Objective: To be able to listen and identify heart sounds 1 & 2

Theory and backgroundUnderpinning a cardiovascular examination is knowledge of anatomy & physiology together with applying the basics of the examination.

For the elements of a cardiovascular (CVS) examination you should consider

o Inspection, general and specific.o Palpation of pulses including lower and upper limbs, comparing right

and left and observing for a delay. Palpating apex beato Auscultation, heart sounds

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Patient safety

General inspection

Look at your patient and note or measure the following:

Their general demeanour;

o Are they showing any signs of breathlessness

o Are they sweating

o Are they showing signs of pain or discomfort

o Are they a normal colour, are they showing signs of

Cyanosis

Pallor

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Palpation - upper & lower limb pulsesAll peripheral pulses should be checked as you progress though the examination, comparing right to left.

Upper Limbs :

o Radial pulse o Brachial o Carotid

Lower Limbs : o Femoralo Poplitealo Tibialis posterioro Dorsalis Pedis

Describing the pulse

The pulse is described byo rhythmo rateo volume (Brachial/Carotid/Femoral)o character (Brachial/Carotid/Femoral)

o state of the vessel wall (Brachial/Carotid/Femoral)o Finger tips are used to feel the pulses; however, you may notice that the

thumb may be used, by specialists, for the carotids.Ensure hands are washed using the full Ayliffe technique prior to taking any pulse on a patient.

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The radial pulseThe radial pulse is located on the lateral aspect of the lower forearm just proximal to the wrist joint. Move fingertips medially the tips of your fingers drop into a groove, in which lies the artery. Examine the pulse by compressing the artery backwards against the bone, using the finger tips

Radio-radial delay

This is found by palpating for both radial pulses they should occur simultaneously.

A delay may indicate coarctation of the Aorta at a point before the subclavian artery, or an aortic aneurysm (also note volume of pulse as this may also be affected).

Carotid Pulse

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This is palpated 1-1.5 cm lateral of the midline in the neck at the upper level of the thyroid cartilage

Readily palpable at anterior border of sternocleidomastoid muscle

May be felt with finger tips or thumb, which are used to push posteriorly

Femoral artery

The femoral artery enters the upper leg by passing under the inguinal ligament. It enters the leg at the mid-inguinal point.The femoral artery is usually easily palpated with clean fingers and is an important point of access to the arterial system

Popliteal artery

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The popliteal artery is palpable in the popliteal fossa. The artery passes through the fossa slightly medially to laterally.

The popliteal artery can be palpated in about the midline of the fossa at the level of the femoral condyles, using clean fingers, the artery is best felt with knee in slight flexion.

Tibialis posterior artery

The tibialis posterior artery is found on the medial aspect of the ankle.

It is palpable, with clean fingers, at a position midway between the prominence of the medial malleolus and the prominence of the calcaneus.

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Dorsalis pedis 1

Dorsalis pedis is a continuation of the tibialis anterior

Tibialis anterior is often palpable, with clean hands, at the ankle joint in a mid-malleolar position, medial to the extensor hallucis longus tendon

Dorsalis pedis 2

The tendon crosses the artery laterally to medially. The dorsalis pedis artery can be palpated, with clean hands, on the dorsum of the foot, lateral to the extensor hallucis longus tendon.

The extensor hallucis longus tendon can be made visible by asking the patient to dorsiflex the great toe

Inspection of chest wall

Inspect the chest wall for;

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o Scarso Rasheso Lesions or bruisingo Pulsationo Respiratory rate, patterno Distended veins

Palpation of the apex beat

With the tip of each finger in the mid axillary line left lateral chest wall.

Place index, middle and ring finger into intercostal spaces starting at the axilla (which should approximate to the 4th, 5th and 6th intercostal spaces)

Gradually bring tips of fingers medially until one feels the beat (may only be a faint tapping)

Describe position in relation to intercostal spaces and vertical landmarks of the chest (e.g. mid-clavicular line, anterior axillary line, mid-axillary line)

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Apex beat is normally palpated within the 5th intercostal space at the mid-clavicular line.

The Apex beat is the point most laterally and inferiorly at which the heart beat can be felt.

The Patient should be at 45o (laying on back) or they may be asked to sit forward or to roll to the left slightly.

The apex beat is important to determine as it can indicate certain conditions, if the apex beat is not in the 5th intercostal space at the mid-clavicular line.

Location of the apex beat

Palpate down from the sternal notch to the raised sterno-manubrial joint (angle of Louis) situated approximately 5cms below sternal notch

With finger on the angle of Louis feel laterally on to the 2nd rib

The dip below the 2nd rib is the 2nd intercostal space

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Location of the apex beat

Walk your fingers over each rib counting each dip (intercostal space)

To initially identify intercostal spaces it is easier to start at the sternal edge counting downwards on the anterior chest wall then move laterally to the point you need to identify.

Revision of stethoscope

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Auscultation of heart sounds

When listening for heart sounds we are listening for the sounds produced when the valves close.

We listen over areas on the chest wall, to which the sounds are projected, NOT over the anatomical position of the valves.

We will also listen for additional sounds which may indicate cardiovascular conditions.

Sites for auscultation of heart sounds

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S1 1 st heart sounds (LUB)

Loudest at the apex and is mainly mitral valve closure it precedes systole and generates the sound “Lub” (low pitched, longer in duration than S2). It can be timed with the pulse.

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S2 2nd heart sounds (DUP)

This is loudest at left sternal edge in 2nd Intercostal space. It is the closure of aortic and pulmonary valves and creates the sound “dup” (higher pitched and shorter than S1). It precedes diastole

During inspiration delayed pulmonary valve closure may cause 2nd heart sound to split “dup-p”

Peer Feedback

Glossary

Aponeurosis – White fibrous tissue resembling a flattened tendon which anchors a muscle.

Coarctation of the aorta – congenital condition causing narrowing of the aorta

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03 Y1 CVS peer feedback.docx