CVS: Strip to the waist; 45 sitting upright
Use bed sheet to maintain patient’s dignity while examining other systems.
Look around bed for: medication, oxygen, insulin, chest leads, walking aids, medical-alert bracelet.
Does the patient look: well, breathless, well nourished. Any recognisable syndrome, how is the patient’s complexion?
Inspect dorsal and palmar aspects noting colour, skin texture, deformities and feel for temperature or sweating.
Look for tar-staining, finger clubbing, lipid deposits (xanthomata), palmar erythema, Dupryten’s, Osler’s nodes and Janeway lesions (Infective endocarditis).
Capillary refill (test on chest)
Nails: koilonychias (spoon-shaped nail in iron deficiency), onycholysis (destruction), Beau’s lines (chronic disease), Mee’s lines (renal failure), Muehrcke’s lines (hypoalbuminaemia), pitting (psoriasis/alopecia) and capillary nailbed pulsation (Quinke’s sign of aortic regurge).
‘I’m going to have a look at a vein in your neck. Can you relax your head and turn your head slightly to the left.’
With the patient slightly looking to the left observe JVP, shine light he bedside light or a pen torch to help highlight it
Note cm above angle of Louis (normal =3cm)
‘I’m now going to look at your eyes. Could you look up to the ceiling for me.’
Eyes: Looking for anaemia, jaundice, corneal arcus, Kayser-Fleischer rings (Cu deposits, Wilson's disease), xantholasma
Cheeks: Malar flush (mitral stenosis)
Mouth: Looking for central cyanosis, infection, palate for jaundice & Marfan’s.
Palpate radial pulses
‘I’m now going to take your pulse.’
Rate: Count for 15 secs and x4 (60-100 is normal)
Rhythm: regular, irregular
‘I’m going to raise your arm up.’
Raise arm for collapsing pulse while gripping wrist
Check with examiner if they would like you to check the BP
‘I’m going to take your blood pressure’
Position relaxed arm at level of heart
Palpate brachial artery
Inflate cuff till brachial pulse occluded for maximum inflation pressure then deflate. Wait 15-20 seconds.
Listen with diaphragm and inflate cuff then gradually deflate at rate of 2mmHg/second
Note B.P. to 2mmHg
‘I’m going to feel for the pulse in your neck. It may feel slightly uncomfortable’
Character & Volume: bounding pulses (CO2 retention, liver failure, sepsis), small volume (aortic stenosis, shock, pericardial effusions), collapsing (aortic incompetence, AV malformations, PDA), slow-rising (aortic stenosis), bisferiens (aortic stenosis or regurge), pulsus alternans ( strong then weak - LVF, AS, cardiomyopathy), pulsus paradoxus (systolic weakens with inspiration - severe asthma, pericardial constriction, tamponade).