CVS EXAMINATION

1. SPEE (45)
2. Observe carefully for
a. tachypnea,
b. Cyanosis, jaundice, anaemia, lymphadenopathy, and oedema. Xanthelesma (± arcus senilis) must
alert you to a diagnosis of coronary heart disease.
c. “spot diagnoses” that are associated with heart diseases:
i. malar flush,
ii. Turner’s,
iii. Noonan’s,
iv. Down’s and
v. Marfan’s syndromes.
vi. Presence of titilbation (head-nodding) and Corrigan’s sign in the neck will greatly help in
the diagnosis of aortic incompetence.
vii. Myxoedema facies may alert you to a diagnosis of pericardial effusion.
3. Examination of the hands
a. Look for anaemia and cyanosis in the nails.
b. Infective endocarditis is supported when you detect clubbing, splinter haemorrhage (common)
and Osler’s nodes or Janeway lesions (rare).
c. Xanthomata on the dorsum of the hand will support a diagnosis of type II hyperlipidaemia and
coronary artery disease.
d. Nicotine-stain in the finger can alert you to the presence of coronary artery disease.
4. Examination of the pulse:
a. Radial pulse
i. rate (count 60 seconds rather than 15 seconds X 4: you may miss ectopics coming later),
ii. rhythm (regular or irregular), atrial fibrillation (irregularly irregular pulse)
iii. volume, and the
iv. character (particularly looking for collapsing pulse)
b. radial-radial
c. Radial-femoral lag is looked for as a routine to detect the presence of coarctation of aorta.
5. Examination of eyes:
a. Jaundice (severe CCF, hepatic congestion
b. Pallor
c. Xanthelesma (hyperlipidemia)
6. Examine the oral cavity.
a. Inspect the tongue for central cyanosis.
b. A large tongue (macroglossia) may give a clue to amyloidosis of the heart.
c. Poor dental state should alert you to the possibility of infective endocarditis.
d. Enlarged tonsils may point to a diagnosis of rheumatic carditis.
e. A high-arched palate is a feature of Marfan’s syndrome.
7. Examine the internal jugular vein (JVP) in the neck carefully to determine the height.
a. Turn the patient’s face slightly away and look for a pulsation in the neck (bottom, left). If present,
determine if it is arterial or venous.
 i. JVP vs arterial pulse
1. Visible but not palpable
2. +ve hepatojugular reflux
3. Double wave form (flicker twice with each cardiac cycle)
4. +ve occlusion test
b. If it is a venous, measure its height at the sternal angle with the help of 2 rulers always keeping
your eyes at the level of the horizontal ruler (bottom, right). When the height is more than 3 cm
above the sternal angle, the JVP is raised. JVP raised in:
i. RV failure
ii. Tricuspid stenosis or regurgitation
iii. Volume overload
iv. Pericardial effusion
v. SVC obstruction
8. Examination of the praecordium.
a. Inspect for scars (midline sternotomy or mitral valvotomy scar below the breast), deformity, site
of pulsation of the apex beat.
b. Palpate :
i. Apex beat. Count down the correct number of interspaces. The normal position is the 5th
intercostal space, 1 cm medial to the mid-clavicular line. Note the character of the apex
beat (a forceful beat is consistent with left ventricular hypertrophy). Double apical
impulse is seen in hypertrophic cardiomyopathy.
ii. A left parastenal heave is caused by right ventricular hypertrophy and a large left atrium
(mitral stenosis).
iii. Mitral/tricuspid area and aortic/pulmonary area looking for thrills.
c. Auscultation
i. Mitral area (kat apex beat)
1. Diaphragm
a. Tarik nafas > tahan > mitral regurgitation
b. look for radiation to the axilla
2. Bell
a. left lateral position, > expiration> mitral stenosis.
ii. Tricuspid area
iii. Aortic areas
1. Expiration > aortic stenosis
2. Sit the patient up and with him leaning forward > expiration > aortic
regurgitation
3. Always time the murmur against the right carotid pulse with your left thumb.
iv. Carotid (bell)
1. Tarik nafas> tahan> Bruit + radiation of aortic stenosis
9. BACK.
a. Inspection – scar, deformity
b. Palpation - Check for sacral oedema
c. Percuss - the lungs for pleural effusion (stony dullness)
d. Auscultate - the bases for signs of CCF
10. LOWER LIMB
a. Pitting edema:
i. CCF
ii. Liver cirrhosis
iii. Nephritic syndrome
11. Finally tell the examiner you would like to do the following:
a. Take the blood pressure
b. Ask to see the temperature chart, urine analysis and fundi (particularly if you suspect infective
endocarditis)
12. If you have completed your examination and auscultated but found nothing obvious, DON’T PANIC (as
most student invariably do) and lapse into a state of incoherence or acute mutism! Ask to reexamine and
consider the following:
a. Mitral stenosis - exercise the patient with sit-ups and examine again in the left lateral position
b. ASD – listen carefully for fixed splitting of the 2nd HS in the pulmonary area
c. Mitral valve prolapse and hypertrophic cardiomyopathy – perform the Valsalva manoeuvre
(louder) or squatting (softer)
d. Pericardial effusion (look at the face again for features of uraemia and myxoedema)
e. Hypertensive heart disease
f. Dextrocardia
13. Finally,if you are really desperate for a diagnosis, the commonest “examination” cause of a cyanosed CVS
patient is Fallot’s tetralogy (in a child) and Eisenmenger’s syndrome (in an adult). Try your LUCK!

MURMUR Causes
Pansystolic Mitral Regurgitation
Tricuspid Regurgitation
Ejection systolic Aortic Stenosis
(midsystolic)
Pulmonary Stenosis
Early diastolic Aortic Regurgitation
Mid-diastolic Mitral Stenosis