Clinical Skills II

Instructional Book

Cardiovascular System

Clinical Skills Center

Faculty of Medicine
Pelita Harapan University
Karawaci Tangerang
Semester III
2017
The book was adapted from INTRODUCTION TO CLINICAL MEDICINE 3,
MELBOURNE MEDICAL SCHOOL, THE UNIVERSITY OF
MELBOURNE; with permission from University of Melbourne
Week I Cyanosis

Red blood cells provide oxygen to body tissues. Most of the time, almost all blood cells carry
a full supply of oxygen. These blood cells are bright red, and the skin has a pinkish or red
hue. Blood that has lost its oxygen is dark bluish-red. People whose blood is low in oxygen
tend to have a bluish color to their skin, called cyanosis. So cyanosis is a bluish color of the
skin or mucous membranes, due to excessive concentration of deoxyhemoglobin in the blood
caused by deoxygenation. When oxygen levels have dropped only a small amount, cyanosis
may be hard to detect, about 3-5 g/dL of reduced hemoglobin is required for cyanosis to be
apparent.

Cyanosis can be seen as two main types: Central (around the core, lips, and tongue) and
Peripheral (only the extremities or fingers).In dark-skinned people, cyanosis may be easier
to see in the mucus membranes (lips, gums, around the eyes) and nails. Central cyanosis is
often due to a circulatory (congenital heart disease: Tetralogy Fallot, Right to left shunts in
heart or great vessels, heart failure, etc) or ventilatory problem that leads to poor blood
oxygenation in the lungs. It develops when arterial saturation drops to 85% or 75% (in
dark-skinned individuals). All factors contributing to central cyanosis can also cause
peripheral cyanosis to appear. However peripheral cyanosis can be observed without any
heart or lung failures. A blood clot that blocks the blood supply to a leg, foot, hand, or arm
can cause peripheral cyanosis.

A patient or family member may detect that the cyanosis is more intense in the feet than in
the hands. This differential cyanosis suggests a right to left shunt through a patent ductus
arteriosus in a patient with Eisenmenger physiology. Patients with a large ductus develop
progressive pulmonary vascular disease, and pressure overload of the right ventricle occurs.
As soon as pulmonary pressure exceeds aortic pressure, shunt reversal (right-to-left shunt)
occurs. The upper extremity remains pink because the brachiocephalic trunk, left common
carotid trunk and the left subclavian trunk is given off proximal to the PDA.

Retardation of Growth and Development

Children with severe cardiac malformations frequently exhibit retardation of growth and
development, with height and weight near or below the third percentile or weight 20
percentile points below the mean percentile for height.

Growth retardation is most severe among children with overt cyanosis and those with large
left to right shunts that cause heart failure. Heart failure tends to cause a greater reduction of
weight than of height, correlates with the severity of hypoxemia.

Other factors contribute to growth retardation, including insufficient caloric intake, dyspnoe,
frequent infection, psychological disturbances, malabsorption, and hypermetabolism.
The basic cardiovascular examination

View the audio-visual segment that demonstrates the basic physical examination of
the cardiovascular system.

1. Preparing the patient

Start by explaining to the patient the reason for the examination and what it will involve.
Avoid using medical jargon.

Ask the patient to undress to their underwear. Where possible, provide a gown or sheet.
Leave the patient covered for as long as possible during the examination4. When you are
ready to examine the chest, ask the patient to lower the gown or sheet. Provide assistance if
you think it is required, but always ask the patient first. Check that the patient is comfortable
and ready to proceed.

Position the patient on the bed or examination couch with their head and neck comfortably
supported by a pillow and with their chest at an angle of 450. This may not be possible,
however, if the patient is too ill to sit up.

2. Hand hygiene
Wash your hands or apply an alcohol hand rub before commencing the examination.

3. General inspection

While you are preparing the patient for the examination, make a discreet general
inspection. Take note of the patients general mental state, alertness and respiratory effort.
You may notice features such as use of supplemental oxygen.

4. Inspection of the hands

Examine the patients hands. You may notice nicotine stains or clubbing. Examine the
palmar creases for evidence of anaemia.

5. Measurement of the radial pulse

Measure the radial pulse at the wrist. Press on the radial artery just proximal to the wrist with
the pads of your index and middle fingers. Count for 15 seconds and multiply by 4 to
obtain the number of beats per minute. A normal pulse rate is between 60 to100. Take note of
whether the rhythm of the pulse is regular or irregular.

6. Examination of the head and neck

Examine the conjunctivae for anaemia. Look at the lips and tongue for evidence of cyanosis.

7. Examination of the jugular venous pulse (JVP )

Examine the jugular venous pulse (JVP). Use natural light to do this if possible. The right-
sided JVP is conventionally inspected but if it is not visible, inspect on the left side. Do not
rotate the head to look for the JVP as it will tense the sternocleidomastoid muscle.

The internal jugular vein is best for examining the cardiac wave form as it is in a straight line
with the right atrium, although the external jugular vein is usually easier to see than the
internal jugular vein. The external jugular vein is sometimes used to measure the height of
the JVP but be aware that it can be falsely elevated due to external pressure. Measure the
height of the JVP vertically, relative to the sternal angle. A measurement greater than 3cm
indicates raised pressure in the right-side of the heart.

8. Examination of the carotid artery pulse

Palpate the carotid artery pulse on both sides. Be sure not to feel both carotid pulses at the
same time.

9. Inspection of the chest

Inspect the praecordium for scars. In a thin person, you may see pulsations such as the apex
beat .
10. Palpation of the chest
Palpate the apex beat which is usually found in the fifth intercostal space in the mid-
clavicular line. The anterior axillary line (AAL) and the mid-axillary line (MAL) are also
markers for the horizontal position of the apex beat. When examining a female, you may
need to use the back of your left hand to move the breast upwards in order to palpate the apex
beat.

11. Auscultation of the heart

Listen to the heart first using the bell of the stethoscope, which is better for low-pitched
sounds such as heart sounds. Auscultate at the apex, lower left sternal edge, upper left
sternal edge and upper right sternal edge. Take time to appreciate the quality of the heart
sounds. It may help to simultaneously palpate the carotid pulse so you can accurately time
the heart sounds. Then listen with the diaphragm which is better for higher pitched sounds
such as murmurs. You are not expected to identify murmurs at this stage of the course.

12. Examination of the posterior chest

Listen at the lung bases for the crepitations of heart failure.
13. Examination of the lower limbs.
Look for signs of peripheral edema. This is best felt by palpating behind the medial
malleous.

Palpate the dorsalis pedis and posterior tibial pulses. The dorsalis pedis pulse is palpated on
the dorsum of the foot. By placing the extensor hallicus longus tendon on a stretch, you may
find this pulse easier to palpate. The posterior tibial pulse is felt behind the medial malleous.

14. Completing the examination

Inform the patient that the examination is complete and that they can get dressed. Offer
assistance if necessary.
Week II - Syncope

Syncope is defined as the sudden loss of consciousness and postural tone due to insufficient
blood supply to the brain2. It may be described by the patient as passing out or having a
blackout, a spell or a funny turn. Although recovery is usually rapid and complete, an
episode of syncope can cause physical injury and be very distressing for the patient.

Many causes of syncope, such as vasovagal episodes (fainting), are benign. These must be
differentiated, however, from cardiovascular aetiologies, which are associated with an
increased risk of sudden death. Cardiac syncope can be caused by arrhythmias, such as
tachycardias and bradycardias, as well as organic heart disease, such as aortic stenosis or
myocardial ischemia.

A careful history is important to clarify whether the person actually lost consciousness
rather than had an episode of light-headedness, dizziness or vertigo. It is also important to
differentiate syncope from an epileptic seizure. A witness account will be critical for
obtaining information about the period when the patient was unconscious.

Be sure to find out about what the patient noticed prior to the loss of consciousness
(prodromal symptoms) as well as the context in which it occurred. Precipitating factors
should be sought, especially in the case of recurrent episodes. When you have gained more
medical knowledge, you will be able to ask specific questions in order to determine the cause
of the syncope.

Case Study 3.08

Julie Davidson, a 55-year old office worker, has had

an episode of syncope. She is being interviewed by
cardiologist Dr Neil Strathmore.

Watch the interview and record the features of Ms

Davidsons presenting problem. Discuss the
information that you obtained with your tutor.
The measurement of blood pressure

Blood pressure is the pressure of blood in the arteries as it is pumped around the body by the
heart. It varies throughout the day and is influenced by factors such as exercise, anxiety and
caffeine intake.

The measurement of blood pressure is a key component of the physical examination. The
instrument that is usually used to measure blood pressure in the clinical setting is called a
sphygmomanometer. View the audio-visual segment that demonstrates the measurement of
blood pressure.

1. Prepare the patient

Start by explaining to the patient that you are going to measure his or her blood pressure.
Ideally, the patient will be relaxed and sitting or lying in a quiet environment. Make sure the
patients upper arm is uncovered.

2. Hand hygiene
It is important to wash your hands or apply an alcohol hand rub before commencing the
examination.

3. Select the appropriate sized cuff

The length of the inflatable bladder needs to be approximately 80% of the circumference of
the arm and the width about 40%7. The reading will be artificially elevated if the cuff is too
small and the opposite if the cuff is too big. Normal and large-sized cuffs are available in most
clinical settings.

4. Apply the cuff

Establish the position of the brachial pulse by palpation. This will usually be located towards
the medial aspect of the antecubital fossa. Wrap the deflated cuff firmly around the patients
upper arm with the arrow pointing to the brachial artery. The lower border of the cuff should
be about 2 3 cm above the brachial artery pulsation. Ensure that the cuff is at the level of the
heart, regardless of the position of the patient.

5. Estimate the systolic blood pressure using palpation

Turn the valve of the bulb to the closed position. This allows air to enter and remain within the
bladder. Palpate the radial pulse while inflating the cuff until the pulse disappears. Note this
value, since it gives an approximate estimation of the systolic blood pressure. Open the valve
to deflate the cuff completely and then wait 30 seconds. You can also do this manoeuvre using
the brachial pulse.

6. Inflate the cuff with your stethoscope over the brachial pulse
Insert the ear pieces of your stethoscope into your ears, angled away from your head. Gently
tap on the diaphragm of your stethoscope to ensure that it is set correctly. The bell of the
stethoscope can also be used to measure blood pressure and may provide a better sound but
the diaphragm is usually easier to use.

Place the diaphragm over the brachial pulse. Hold it in position with your right hand. Do not
press too hard as this may cause distortion of the artery. At the same time, support the
patients right elbow, also with your right hand. Make sure the patients arm is slightly bent at
the elbow and is relaxed; if it is tense, this may elevate the blood pressure. Again, ensure that
the arm is held so that the cuff is at the level of the heart. Use your left hand to inflate the cuff
to about 30 mmHg above the palpated reading.

7. Listen for the auscultatory sounds

Slowly deflate the cuff at a rate of 23 mmHg per beat, watching the pressure and listening
for the appearance and disappearance of the auscultatory sounds. When the cuff pressure is
above the systolic pressure of the heart, the blood flow in the brachial artery is occluded and
no sounds are heard.

As the cuff is deflated to just below the systolic pressure, blood flows through the artery
during systole but stops flowing during diastole. The turbulence that is produced causes the
sounds that you can hear with your stethoscope (Phase I). These sounds continue as you deflate
the cuff but may change in quality (Phase II and III). Just before the diastolic pressure is
reached, the sounds become muffled (Phase IV).

When the cuff pressure falls below the diastolic blood pressure, the sounds disappear as
there is no longer any restriction to blood flow in the artery (Phase V). Deflate the cuff rapidly
to zero and remove the cuff.

8. Record the result

The systolic blood pressure is the pressure at which the auscultatory sounds are first heard.
The diastolic blood pressure is taken as the pressure at which the sounds disappear (Phase
V). Sometimes the sounds remain muffled until zero, in which case the appearance of the
Phase IV auscultatory sounds are used for the diastolic reading.
Week 3 - Palpitations

A palpitation is defined as an abnormal awareness of the heart beat. A person might notice
that the heart skips a beat or has an irregular rhythm, is beating faster or slower than normal,
or has had a stronger contraction than usual.

Most people notice their heart beat every now and then. This may especially occur in the
context of being anxious, exercising or drinking coffee. Abnormal palpitations, however,
may be due to problems such as heart disease, an overactive thyroid gland, anaemia or
psychiatric conditions. Palpitations that are episodic and have a sudden onset tend to be more
noticeable than chronic palpitations.

Patients describe palpitations in a variety of ways. They may use words such as pounding,
thumping, fluttering and flopping. They may also report that they feel the heart skipping beats
or stopping. Be careful to find out exactly what the patient is experiencing.

Case Study 3.07

Julie Davidson, 55, has developed a problem with

palpitations. She has been referred by her general
practitioner to Dr Neil Strathmore, a cardiologist.

Watch the interview and write down the cardinal

features of her presenting problem. Identify
any features that might suggest a serious underlying
cause.
Week IV - Chest pain due to myocardial ischemia

Chest pain is a common symptom and the list of possible causes is very long. Some of these
are serious and potentially life-threatening, while others are minor in nature.

Myocardial ischemia is the most common serious cause of chest pain. It occurs when there is
insufficient oxygenated blood flowing to the heart muscle because of an imbalance of supply
and demand. The most frequent cause of myocardial ischemia is the narrowing of one or
more of the coronary arteries due to atherosclerosis. A careful history focussing on the
cardinal features is an important first step in trying to determine if a patient has chest pain
due to myocardial ischemia.

Angina is the term used to describe reversible myocardial ischemia. Angina typically presents
as diffuse central chest pain, often radiating to the arms (usually the left) and also to the neck,
lower jaw and upper abdomen. It is usually described as a heavy pain or pressure that lasts
a matter of minutes. Physical exertion, which increases oxygen demand, is a classic
precipitating factor. Angina is relieved by rest or by specific anti-angina drugs such as
nitroglycerin. Angina may be associated with dyspnea, nausea or sweating. Prolonged angina
pain (> 20 minutes) suggests myocardial infarction. This occurs when the ischemia is severe
enough to cause permanent heart muscle damage (necrosis).

When interviewing a patient who you think might have ischaemic chest pain, it is important
to enquire about the presence of risk factors for coronary artery disease (CAD). These
include smoking, high blood pressure (hypertension), high cholesterol (hyperlipidaemia),
diabetes and family history. The patients age and gender also need to be taken into account.

Calf pain due to intermittent claudication

Atherosclerosis can cause narrowing of other blood vessels throughout the body apart from
the coronary arteries. When it affects the peripheral arteries, it can cause ischaemic pain in
the legs. This is typically experienced as a cramping feeling in the calves which occurs when
the patient walks and subsides with rest. This type of pain is called intermittent claudication
which is derived from the Latin word for limp. Its severity is measured by the distance that
the patient can walk before developing the pain. The risk factors that favour the development
of peripheral artery disease are similar to those that lead to the development of coronary
artery disease.

Case Study 3.06

Bob Ainsworth, a 68-year old retired cabinet maker, has wors-

ening intermittent claudication in his left leg. He has returned to
the Vascular Surgery Clinic for review. He is talking with medical
student Tess McClure.

Watch the interview and write down the cardinal features of his
presenting problem. Discuss these with your tutor.
Consultation skills

During clinical skills, the concept of managing an interview was discussed using the
technique of sign-posting as an illustration. There are other techniques that can help you to
effectively and efficiently gather information about the patients presenting problem.

Re-directing the interview

The patient may have volunteered a number of pieces of information in their opening
statement. It may not be possible to explore all of these at once and you may wish to return to
a specific item later on. To do this, you will need to re-direct the interview. It is helpful to
sign-post this change of direction to the patient by restating or paraphrasing the part of the
original statement that you want to follow up. It also indicates to the patient that you have
been listening carefully to what they have been saying. Tess McClure used this technique
during her interview with Bob Ainsworth:

BOB AINSWORTH: Its not like I smoke as much as I used to. Im only on about 10 or 15
a day. I cut down a lot after I retired from work a few years ago.
TESS MCCLURE: a few years ago, uh huh Now you said earlier that it has started
to wake you up at night. Can you tell me something about that?
BOB AINSWORTH: Ive been getting pain but its not in my calf when its at night
its in my foot instead the left one at night past couple of weeks. Its a
burning pain

Helping the patient stay relevant

It is important to be economical with your time during a medical interview. To do this, you
may need to help the patient stay focussed on the main issues. This may involve tactfully
interrupting at a suitable point and redirecting the interview to a more relevant topic3. Tess
McClure used this technique during her interview with Bob Ainsworth:

MR AINSWORTH: Ive always had a terrier of some sort. They make very
good watchdogs but prone to a bit of deafness pauses for breath
TESS MCCLURE: Thats interesting to know about, Mr Ainsworth now I wonder
if you could tell me a bit more about the pain in your leg?
MR AINSWORTH: Oh the pain? Oh, yes, it is like a cramp. Comes on when I
walk
Week V Edema

This tutorial introduces edema, a common symptom that involves the accumulation of
fluid in the interstitial space between cells. It also provides an opportunity for you to revisit
the symptom dyspnea. Congestive heart failure is one of the most common causes of dyspnea
and edema.

The bodys water is compartmentalised into intracellular water, which comprises about two
thirds of the total, and extracellular water, which comprises the other third. Extracellular
water is further compartmentalised into plasma (or intravascular fluid) and interstitial fluid.
Capillary walls allow small amounts of fluid to cross from the intravascular space into the
interstitium so oxygen and nutrients can be transported to cells for metabolism. This fluid is
returned to the intravascular space through the lymphatic drainage system. The distribution
of fluid between the intravascular space and the interstitium is maintained by the
permeability of capillary walls as well as the balance between osmotic and hydrostatic
pressures across these walls (known as the Starling equation).

Edema is the accumulation of fluid in the interstitial space between cells. There are three
main mechanisms by which edema can occur. Firstly, it can occur if there is an increase in
hydrostatic pressure within capillaries due to extra fluid or obstruction of venous return to the
heart. The most common cause of edema due to this mechanism is congestive heart failure.
Fluid accumulates in the venous circulation because the heart muscle cannot pump enough
blood into the arterial system during systole. It can also occur if there is obstruction of a
vein, such as in deep vein thrombosis.

Secondly, edema can occur if there is a decrease in oncotic pressure. Normally, proteins
help to hold water inside blood vessels. If there is reduction in blood proteins, fluid will leak
into the interstitial space. This can occur if there is decreased production of protein, such as
in cirrhosis of the liver, or if there is increased loss through the kidneys or bowels. Thirdly,
edema can occur if the capillary membrane is more permeable than usual. Increased
permeability can occur in the setting of inflammation or allergic conditions, such as
anaphylaxis. Another type of edema is when there is obstruction of lymphatic drainage so
that fluid is prevented from returning to the vascular space from the interstitium. This is
called lymphedema.

Characterising edema as a symptom

When characterising edema as a presenting symptom, it is important to establish the site as this
can help point to the underlying cause. Edema due to volume overload, as in heart failure,
will first be noticed in the lower limbs due to the effect of gravity. Unilateral leg swelling
raises the possibility of deep vein thrombosis. Generalised edema is likely to be due to
increased capillary permeability. The patient may report that pressure applied over edema,
such as from ribbed socks, causes indentation of the skin. This causes pitting, which can
also be elicited on physical examination.

As with any other symptom, find out about the severity, time course, context and aggravating
and relieving factors. Many patients with edema of the lower limbs will report that it is worse
towards the end of the day but is relieved by resting with the feet up. Asking about associated
features will help to establish the diagnosis. For example, the presence of edema of the legs
associated with dyspnea on exertion and orthopnoea suggests that the patient has heart failure.

Two symptoms as the presenting problem

It is not uncommon for a patient to present with two or more symptoms at once. On one hand,
this may present a pattern that readily leads you to a diagnosis. On the other hand, the
symptoms may be unrelated. At this stage of your medical training, it is best to characterise
each symptom separately but be sure to find out how they relate to each other.

Case Study 3.05

Mr James Nicholls, a 66-year old retired plumber, has a

history of myocardial infarction and heart failure. He has
come to see his general practitioner with dyspnea and
edema. Mr Nicholls is being interviewed by Sarah Blake,
a first year medical student.

Watch the interview and write down the cardinal features of his

presenting problems
REFERENCE

1. INTRODUCTION TO CLINICAL MEDICINE 3, MELBOURNE MEDICAL

SCHOOL,THE UNIVERSITY OF MELBOURNE, Melbourne.