Cardiac Examination Deep Dive - Clinical Skills Explained - Dr Gill

[Music] thank you hello and welcome back to the channel you enjoy myself Dr James Gill for other clinical skills video today we're going to do the Deep dive on the cardiovascular examination so we're going to go through each step what we're looking for and why we're doing those particular tests so to start off with our cardiovascular system obviously we need to gain consent hello my name's Dr Gill I've been asked to do a cardiovascular examination of yourself before we go any further please confirm your name and date of birth at Thomas I'll be 2nd January 2000. thank you this is going to involve your lying back and letting us have a look at your hands getting you to take off your shirt then we're going to have a look at your neck I'm also going to place my hands on your chest listen there with the stethoscope and also look at your feed is that okay and before we start do you have any problems that you're aware of with your heart no super so at the start it's important to give it get an idea how the patient is feeling at that moment in time before you go on with your examination so as we've got the patient lying on the bed we want to have a look at them to see if we can see any obvious distress are they looking uncomfortable do they appear short of breath your respiratory rate is a really good tell for how the patient is physiologically so if you've got a problem with your heart if there's a problem with your blood pressure if you've got a big infection you're unlikely to be able to sit there with a normal respiratory rate even if everything else seems to be all right we also want to have a look around the patient to see if we can see any paraphernalia aspirin bottles oxygen cylinders anything that might indicate what's going on with the patient having assessed the patient appears to be calm and at rest want to have a look over here at the hands so if you put your hands up for me please so in terms of looking over the fingers what are we looking for so we're looking to see if there's any spooning of the fingernails I we've got indents suggesting we've got iron deficiency anemia we're looking to see if we can see any tar staining that might indicate someone who's smoking I want to press over the fingertips to see what the capillary refill is like other things that we might see on nails themselves would be at splinter hemorrhages now these little black dots are indicative of endocarditis but don't um worry too much about them because most people will actually have them because the Communist cause is not endocarditis but it's actually micro traumas so just digging in the garden hitting your hand for example or if you're like me and bite your nails I've got a few at the moment so if you could put your fingers together like so for me and we're putting the fingernails together we can see Shamrock's window and we know there's no signs of clubbing from a cardiovascular perspective clubbing would be indicative of bacteria endocarditis and any of this cyanotic heart conditions such as tetralogy a flot for example turn your hands over for me staying with that concept of a septic emboli we're going to look for Janeway lesions which are painless lesions on the Thena and hypothena Eminence or have we got any oslo's nodes which are painful swellings these are septic embol I have again lodged in the tissues and the bacteria there rather than killing off the um the the tissue around it as we see with splinter hemorrhages we've actually got peripheral proliferation of the bacteria resulting in swelling and pain and infection there now here we can see a couple of spots on his fingers how long have these been there forever so we're not going to worry too much about those in terms of whether or not they could be Janeway lesions they don't certainly fit that the other thing we're looking for on the hand is the um the Palmer creases we can see we've got normal coloration to the Palmar creases if there's a power there so the Palm increases look pale it might indicate the presence of an anemia the other thing that we want to have a look for on the The Palms and the hands is tendons xanthoma so yellow deposits running along the tendons which are associated with hypercholesterolemia having locked over the hands we then want to check both pulses at the same time now when we check the radial pulse we're checking for the rate and Rhythm so how fast is the pulse going and is it um coming through regularly so for example one two one two or is it irregular so there's no pattern to the beat if we find that we want to get an ECG to clarify more information about the what that rhythm is now I'm taking both hands at the same time because I'm feeling for a radial radial delay I want to feel both pulses coming through at the same time we then need to move up the arm to check at the antecubital fossa here we're checking for the brachial pulse now we want to check at this point because that's going to let us feel the character of the pulse so it's just a strong pulse it's the bounding pulse or a weak and thready pulse so we may have a bounding pulse if we've got problems with the thyroid causing a hyperthyroidism or if the patient for example has heart failure or maybe has had a myocardial infarction in the past resulting in a weak pulse we'd feel that here at the brachial pulse now we can't take that from the radial pulse because that's a smaller bore artery we need to be going higher up it is also possible to check for the character at the carotids but in many patients I prefer to do that on the brachial because it's less uncomfortable for them similarly there's a theoretical risk that if someone had plaques and issues with the Carotid you could potentially throw off a clot but I think that's incredibly unlikely staying with the arm we need to have a look at the pulse in a different way and we're going to check for a collapsing pulse so do you have any problems with your shoulder so I'm going to grip the patient's arm tightly making sure that I can feel the radial pulse and I'm then going to lift the pulse up straight and I want to see if the pulse is staying in the same place or does it feel like it's moving down the arm what we're looking for there is if we have an aortic regurgitation we're increasing the column of blood against that faulty valve and that faulty valve prolapses backwards meaning the pulse Falls backwards down the hand now there's something called a water hammer pulse this is a kind of a Victorian toy um and again it feels like a pulse is changing in this small glass children's toy same sensation is what people describe um the collapsing pulse is feeling like but I've never really played with a water hammer so I can't quite confirm what that is uh what that would feel like but it's definitely something that if you end up in a Victorian toy shop to have a go with and see how it feels carry on up the arm so stay in nice straight lines we're going to have a look at the face so if you take your glasses off for me and if you lean back and I'm just going to lift your eyelids down and look up for me and we're looking at the um the conjunctiva to see if there's any evidence of Palo which might again go along with an anemia suggesting maybe the heart is having to work harder if you look down for me and we're looking at the sclera I can't see any yellow yellowing there now there is some debate whether or not that should be included in a cardiovascular assessment however there's no such thing as never in medicine you could get a hemolytic anemia whereby the blood is being broken down which will cause raised levels of bilirubin would potentially affect the cardiovascular system and we'd see that as a potential jaundice in the eyes we also need to have a look around the eyes themselves so we want to see if there's any evidence of xanthal asthma so cholesterol deposits around the eyelids or underneath the eye this is this is incredibly important from a cardiovascular perspective as if you can see that it means the patient has incredibly high levels of cholesterol and probably it's going to be something in the family maybe familial hypercholesterolemia which is going to put them at a significant risk of cardiovascular events such as myocardial infarction the other thing that we need to be looking at the eyes for is for corneal arcus so we're looking around the eye to see if we can see a a yellow or whitish colored ring now that can be due to two things again it might indicate a raised level of cholesterol because those could be lipid deposits however we will also see those in patients as their age where it has a slightly different name called senile arcus and actually there are some movies where with some aged movie stars if you have a close look when they're getting their close-ups you can see that one of the people you notice on particularly is Sylvester Stallone so going from the eyes we then need to have a look at the mouth I'm starting off with the lips I'm saying can I see any blue tinging to the lips so indicative potentially of peripheral cyanosis but it also might correlate with central cyanosis which we'd have to look out for in a moment so if you open your mouth boy please and stick your tongue out please and looking at the tongue I can't see any smoothness there's no power to it there's no loss of there's no changes in color and also I can't see any problems the corners of the mouth but put your tongue to the top of your mouth and I'm having a look at the blood vessels under the mouth thank you you can relax those blood vessels aren't blue so even if we had seen some blueness to the lips which as I say we might be able to describe as a peripheral cyanosis if there was blueness under the tongue then we say that that will be central cyanosis and we know that there's a problem with the oxygenation of the blood whether or not that's a problem with the respiratory system where the blood can't be oxygenated or there's a problem with the heart for example tetralogy of Fallout where you have mixing of the oxygenated and deoxygenated blood so we're not getting sufficient oxygenation from that perspective we wouldn't be able to tell but it would certainly mean some more for us to pay attention to shortly so having looked at the eyes and at the mouth we then need to go on to look at the neck so we are going to have a look at the jvp but before we do that we need to check the lymph node of the head and neck so I'm just going to stand behind you if that's okay and I'm going to put my hands on your neck from behind and I'm going to see if I can find any lumps and bumps to your neck is that okay so so stand behind the patient and we're going to start off under the chin checking the submental lymph nodes moving along to the the angle of the jaw the submandibular to the angle of the jaw checking the um tantilla lymph node we're going in front of the ears to the pre-auricular and behind the ears the postericular if you just lean forward for me we're checking the back of the neck and back of the head check for the occipital nose and hit that position we can then move on to the neck itself checking for um any deep and superficial cervical chain lymph nodes and then backwards for me and just making sure there's nothing there I'm covering over the base of the ribs so there's no problems there so we're going to carry on to have a look at your neck if we want to have a look to see if we can see the jugular venous pulsation and in terms of doing that if you turn your head to the looks that way for me I'm looking at the Sterner collider mastoid heads and I'm just moving the T-shirt down ever so slightly to look at the base of the neck it's very important that you appropriately expose the patient when necessary if you can have a look to the base of the neck adequately then I would say it's reasonable to keep the patient's t-shirt on at this point however if that's not possible then obviously ask him to disrope will be entirely appropriate but keep in mind at all times what is the level of comfort for your patients and whether or not you would want to be exposed at that point as well so having a look I can see the two heads at the standard collider mastoid muscle and the jvp is normally located between the two heads here just above the clavicle in a lot of patients we're not going to be able to see um that jvp straight away because it's a much more subtle pulse than the carotids and I can see what appears to be the carotopulse slightly uh medially compared to the jvp so one way I can compare the two is simply by touch the Carotid pulse should be palpable whereas the jvp should be impalpable when I press on it I can't feel it we can also look at the waveform the um the corrosive pulse should beat in time one two one two with the pulse however the jvp has a two separate waveforms so it would not necessarily match the pulse there is however one final way that we can confirm that and that's with the hepata jugular reflux for this we will ask the patient to take their t-shirt off so if you take your T-shirt off please put that down here so looking at where we've found the jvp we want we draw an imaginary line from the maneuveral external angle which is which is in line with the second rib vertically upwards and we come across to see where we can feel that pulsation as long as that is intersecting with this imagine ruler at less than four to five centimeters we know there isn't a problem however if we're having difficulty seeing it as I said we might want to do an additional test and that's the hepatogular reflux so we look at the patient's abdomen we see if we can see an emphasis of scars any evidence that there may have been an operation to this area I can't I can see one small scar here but nothing to worry me here do you have any pain to the upper abdomen brilliant so what we're going to do we'll get you to turn your head that way and I'm going to push down into your stomach and I'm going to watch your neck as we do so so one two three and and relax and it's a quite sharp short sharp movement and in doing that that push puts pressure on the liver results in increased black back flow up through the vessels so we're getting that blood going up the jvp and we see that rise as well so here it wasn't very easy to see the jvp but by doing the hepatogular reflux we saw it rise up from where it was hiding just at the edge of the clavicle and we know that everything is normal however if we did have a patient that had something causing increased pressure at the atrium for example they had pericarditis or hyperinflated lungs with COPD or if they'd had an atrial maxoma anything that's affecting the atrium there could result in the jvp having risen so high up we can't see it with the patient sat here we might if it's gone up inside the skull see their earlobe waggling at the back the other thing we could do to check in that situation is if you could sit forwards for me I'm just going to lie you flat so here we can see the jvp just pulsing away nicely at the base of the neck and one of the other things that you can tell to confirm the jvp is that it will in draw when the patient has their first inspiration so if you take a deep breath in for me and relax so we can see that jvp disappearing in as we breathe in so here we can see the jvp pulsing away nicely at the base of the neck and if we get the patient to take a deep breath in we'll see the jvp in draw as we do so with the change in pressure around the chest so take a deep breath in please so that in drawing of breath has changed the pressure in the chest particularly around the right atrium so we've resulted in a reduction in pressure around the atrium causing the jvp to be pulled back just to reiterate that once more take another deep breath for me memories no way so and after having seen that jvp we're just going to switch it back up again having looked at the neck then we need when you come back down thinking about pressures to check our blood pressure so we're going to take our manual swig and we want to check that it's the right size for the patient so we're going to do that by checking the size of the cuff against the patient's arm and we want to make sure the cuff is approximately 40s which we're just on the right side of here it's very important that our cuff is not too small because that will cause a falsely elevated blood pressure so for example if you have a patient with a large BMI if you're using pulse a blood pressure cuff which is too small you'll falsely read their blood pressure so it's vitally important for accurate medicine to make sure we're using the correct information the correct kit so we're going to put the uh the uh we're going to put this figment gauge on and I'm going to do this manually first so I'm going to hold on to the pulse and I'm going to increase the pressure okay and the pulse has disappeared at about 100 beats 100 millimeters Mercury now the reason why we need to do it twice first manually and then with the stethoscope is because it's possible in some patients normally the elderly about 20 of patients will have what's called a systolic uh blood pressure lag so what I mean by that is when we listen to uh the uh the pulse sounds the cart off noises with the stethoscope we may actually get the first quarter of noise being only there for a brief moment and then disappearing and it's possible that you may miss that first sound before it then reappears which can mean we're going to give a falsely low blood pressure however we would be able to feel it throughout so we know roughly where we should be finding out systolic in our patient here around about a hundred so we should be able to expect to hear that first sound then and then disappear when we're going to find the diastolic so we're moving over to the diaphragm putting that in over the brachial artery tying up the valve and increasing the pressure so I'm going to go 20 millimeters higher than we were originally okay and then slowly letting it out so we've got a good first sound at 100. and then it comes back at 60. and then it disappears at 60. so we're quite happy with that blood pressure and we take things off again okay having done our basic starts the cardiovascular assessment we then need to focus onto the chest so the first thing we want to do is find the apex beat so the apex beat is the most lateral position of the heart with inside the chest where essentially the the apex of the heart will touch against the chest wall and in young or thin patients you may be actually be able to see this location so possibly I can see a small movement to the skin over here but we need to confirm we're looking the right place and the way that we do that is we find the maneuverable sternal angle so this is the interface between the sternum and the maneuverum and that lines up with the second rib so we then want to count down to the fifth intercostal space so from the second rib there's the second rib space third rib space fourth rib space fifth rib space and we're going to move along and round so when the mid cavicular line and I'm going to place the flat of our hand over that and I can feel the apex beat exactly where I thought I could see it and where I can feel it with my fingers now we may have a patient who perhaps has a smaller heart maybe they've got an increased body habitus and we can't feel it here in which case we get the patient to roll over onto their left side and come back for me in doing so that causes the heart to move over in the chest hopefully coming closer to the wall so we can feel that impulse there now the reason why that's important is we may find that the the Apex beta shifted from that fifth intercostal space mid-cavicular line that can happen for example in left ventricular hypertrophy there are other conditions so for example with cardiomyopathies where we may get a baggy heart and that may change the Apex speed to a much more diffuse character so it's less easily to determine exactly where it is as opposed to that nice tap against the chest wall there carrying on with our palpation because our standard approach would be inspection palpation percussion and auscultation we want to place our hands flat on the patient's chest wall so I'm going to put the flat of my hand across the left side of the chest and I'm trying to feel if my heart hand is pushed off the chest wall which will be indicative of a cardiac heave again associated with left ventricular hypertrophy these large size of the heart literally moving the chest wall forwards we want to do a similar and you can place your hands either side of the sternum and there I'm feeling for a thrill which is a palpable murmur so when we do find a murmur using our stethoscope we need to be able to grade it zero being its only detectable by the most esteemed Physicians and professors all the way to grade six not only is it audible outside the patient's chest but it can be felt as well and an example of that might be the click of a metallic valve or potentially an incredibly serious aortic stenosis with that coarse jet of blood so having not found any abnormalities on our inspection the chest wall we then need to get our stethoscope and here we're going to keep in mind that there are two modes on the electronic stethoscope but there are two ways of using a regular stethoscope whether or not that's the diaphragm or the Bell we're going to start off with the diaphragm first listening over the four regions of the heart the reason why we start with the diaphragm is it's going to attenuate most sounds so whilst we're doing that I'm going to hold the pulse at the same time and I'm listening over the aortic region which is over the second intercostal space to the right sternal Edge then over the pulmonary region which is second intercostal space left pulmonary Edge coming down to the tricuspid region which is uh the lower left sternal border and then finally going around to listen over the Apex which is the fifth intercostal space mid-cavicular line and we're going to change over then to using the Bell which again we're going to listen over the Apex to see if we can hear any changes and as well over the left lower external border so the reason why we need to change what we're what we're using in terms of using the uh the Bell because that allows us to pick up much lower frequency sounds with the diaphragm the large size of it means that all sounds are collected and Amplified by the very thin membrane of the diaphragm but that will mean that low frequency sounds are lost in that somewhat by comparison when we move over to the Bell the low frequency sounds are collected by the concave nature of the Bell so I Amplified over the higher frequency sounds so it allows us to be able to hear something such as mitral stenosis more easily so when we're listening for the heart sounds we need to listen for S1 the first heart sound and S2 the second heart sound now the first heart sound is caused by the mitral and tricuspid valve closing and they're autocompulmonary valve opening conversely the second is the inverse the mitron tricuspid opening and the aortic and Pulmonary closing easiest way of learning this is not to memorize it but to think what's going on in the heart so S1 the start of the cardiac cycle is The ventricle squeezing together in order to do that we've got to close the mitral and tricuspid valve otherwise blood's going to go the wrong way and we want to open the pulmonary and aortic valves to send blood to the lungs and the body conversely when we're looking at S2 in diastole the heart is relaxed thus we close the pulmonary and aortic valves and the mitral and tricuspid open so if you think about what's going on with the cardiac cycle you should know what your S1 and S2 sounds are similarly with that we can tell what we're going to hear from a diastolic an isystolic in terms of our murmurs so our systolic murmurs are going to be aortic stenosis and mitral regurgitation ASMR because the in S1 the cut the heart is Contracting so forcing blood out through the open aortic uh valve if there's narrowing we're going to hear that aortic stenosis Brewery so shooting that blood out conversely at that point the mitral valve should be closing to stop blood going out to the body in which case we'd expect nothing to be there but if there was it would be the mitral valve regurgitating so again we have a systolic murmur there conversely with our S2 where we're in diastole the heart is relaxing now we're talking about aortic regurgitation and mitral stenosis so arms here we've got the aortic valve falling back on itself allowing blood to flow the wrong way and we've got mitral stenosis so narrowing of that heart valve causing again a brewery or jet as that blood is force of that narrowed opening the other moment that we need to listen for again going to the diaphragm is the mitral regurgitation so here we're looking in the mid auxiliary line again holding the pulse and we're just going to listen directly over here to see if we can hear a systolic murmur there are however a couple of special Maneuvers that we need to do so putting the stethoscope back in checking onto the pulse onto the bell of the diaphragm and if you could roll over to your left side for me and we're listening again over the Apex speed to see if we can hear the murmur of mitral stenosis okay and if you could sit up for me now we're then going to listen for the Burma of aortic regurgitation so again I'm going to take the Pulse and I'm going to listen to the lower left sternal border note that is not what we've previously described as the aortic region we're going to take a deep breath in and breathing together deep breath out and hold it and breathe normally so whilst you're in that position ideally you want to hear one or two beats going through so you can get your ear in position by having the patient breathing out as they're doing so we're changing the pressures in the chest worsening the regurgitation on their uh the aortic valve increasing the sound volume partially because we've also got less lung in the way the reason why we're listening in a different position is the auscultation sites do not align with the heart valves they align with the movement of blood so it's the direction in which the sound will be traveling and for aortic regurgitation it's traveling in the opposite direction to that which we'll be looking at for aortic stenosis hence we're listening to the opposite part of the chest now there's another special test that we need to do for aortic stenosis so again taking the pulse if you could turn your head that way for me and we're going to place place the stethoscope on the patient's throat lightly get them to take a deep breath in and hold it and breathe normally for me and we're listening for a couple of Beats because here we're saying if the aortic stenosis Brewery is traveling up the neck so again keeping in mind that breweries are to do with the flow of blood and thus sound transmission so we'll move in different directions having not heard any abnormalities to the chest we then need to look at some of the other large vessels so for that we need to again lie the patient flat with the patient lying flat we then need to confirm again do you have any pain or discomfort to your stomach so we're going to check for our any evidence of a triple A so an aortic abdominal aneurysm and then we're going to listen to see if we can find evidence of renal Brewers so we're just going to press down over the stomach either side of the umbilicus and I'm pressing quite hard because the aorta is a retroperitoneal organ and I can feel the pulse coming through my hands but it's not an expansile pulse it's not pushing my hands away we're going to take the stethoscope again with the diaphragm we're going to listen just over the umbilicus okay and I can't hear any evidence of breweries here and then we're going to listen laterally by about two three centimeters and Superior again here we're trying to find any evidence of breweries that might indicate a renal aneurysms renal artery aneurysms and again on the opposite side so there's no problems at that point so we also need to check for a radial femoral DeLay So if you can just pull the top of your trousers down for me okay and we're going to hold on to the radial pulse and we're going to feel over the femoral pulse at the top of the leg and again I can feel that the pulse is coming through at my fingers and on the thermal pulse at the same time we're going to do the same to the opposite side and again I've confirmed that we've got an intact uh pulse there so we've got no errors of concern there so if you pull your browser for me moving down the bed we want to have a look at the legs so we're seeing if there's any evidence of a peripheral edema so I'm going to press with three fingers for 10 seconds and then we're going to have a look and I can't see any imprints at all suggesting there's no peripheral edema again there's none here we can also assess the feet for the same features that we'd look for in the hands given that it's the same tissue so we're likely to get a duplication of anything there as well as having look visually over the feet we need to check for the peripheral vasculature so we're going to press in to the medial malleoli and we're trying to find the posterior tibial pulse the easiest way to find that is starting off over the medial malleoli and just dropping back into the dip behind it and then we're going to bring our hands round and we're going to check for the dorsalis pedis and we're going to press just a lateral to the extender tendon on the second toe and we should be able to feel uh the Silas pedis pulse coming through nice and strongly there we can go one step further just to confirm archipelara refill which is under two seconds on both feet to complete our examination if I just get you to sit up please and we're going to have a quick listen to the patient's chest so if we Cross Your Arms over your chest please and if you take a deep breath in for me and out in and out deep breath in and out deep breath in and out deep breath in and out and in and out and in and out that out so we're listening all the way down to the lung basis to see if we can see any evidence of pulmonary edema which might associate with heart failure similarly in the same way that we've looked at the feet we're going to press to the base of the back to see if there's any evidence of sacral edema pressing with the three fingers with 10 millimeters of mercury which we can determine because the fingertips will have gone white with pressure and again there's no indent here so we thank the patients provide them with their shirt back and do you have any questions to myself at this moment no super so thank you so that completes our cardiovascular examination we've gone through all the steps that are required for a standard medical school asking there are additional information that you can find checking the video here on more detail for the cardiac murmurs if that's some that's of interest to you if you could like the video it certainly tells YouTube that we're here and subscribing to the channel will let you interact with us more and help us guide where we're going to do future videos with that thank you for watching take care and we'll see in the next one cheerio [Music] foreign

Channel: Dr James Gill

Views: 252,984

Keywords: ASMR, Cardiac murmurs explained, Cardiology Explained, Cardiology OSCE Guide, Clinical Examination, Clinical Examination ASMR, Dr Gill, OSCE guide, cardiac examinations, cardiac osce, cardiac physical examination, cardiology clinical examination, cardiology examination, cardiology examination explained, cardiology examination osce, cardiology osce, cardiothoracic examination, cardiovascular examinations, clinical examination of cvs, heart sounds explained, osce revision guide

Id: dxUHp85M8kQ

Length: 36min 33sec (2193 seconds)

Published: Sun Mar 05 2023