Cardiovascular checklist

WIPPER and the intro

• Introduce yourself and shake hands
• Washing of hands and appropriate hand hygiene
• Asking for permission
• Ensuring the room’s privacy
• Ensuring the environmental warmth and good lighting conditions
• Asking for appropriate exposure (from the waist and above)
• Asking the patient to be in the appropriate position (semi-sitting at 45 degrees in bed)
• Relocating to the right side of the patient
• Asking for a chaperon
• “I have all of my equipment’s”

General look of the patient

• Consciousness, alertness and orientation of the patient to time, place and person (After asking the 3 questions)
• Comment on the patient’s position and comfort
• Comment on the patient’s external devices status (No oxygen masks, nebulizers etc.)
• Comment on respiratory rate (Not tachypneic), respiratory distress
• Comment on cyanosis
• Comment on edema

Vital Signs

• Make sure you know the 6 vital signs

Hands - Inspection

Starting with the hand

• No cyanosis
• No pallor
• No palmar erythema
• No petechial rash
• No Xanthomata (Hyper-lipidemia)
• No Janeway lesions (painless, thenar region) (Infective endocarditis)
• No Osler’s nodes (painful, tip of fingers) (Infective endocarditis)
• No tar staining
• No IV drug abuse signs

Moving on to the nails

• No finger clubbing
• No splinter hemorrhages (Infective endocarditis)

End this section by examining for tremor

• Examine for fine tremor

Hands - Palpation

• Check hands’ temperature, dry/sweatiness
• Check Capillary refill (<2 seconds is a normal capillary refill time)

Check pulses bilaterally, details below
All pulses are done with 2 fingers, except for radial;

Radial pulse

• Radial pulse; using 3 fingers, lateral to flexor carpi radialis, after 1 minute (do 15sec), comment on the rate, rhythm, volume, character and compressibility.
• Check both radial pulses simultaneously to assess “Radio-radial delay”, a sign for aortic dissection
• Check radial and femoral pulses simultaneously to assess “Radio-femoral delay”, a sign for aortic coarctation (ONLY MENTION)
• Calculate pulse deficit, we don’t do this during exams (mention it), but a difference of +10 BPM is abnormal (Associated with atrial fibrillation)
• Now ask the patient about shoulder pain first, if none is present, elevate hand above level of patient’s head while checking the radial pulse, to check for “Collapsing pulse” (Aortic regurgitation)
• Don’t forget to comment your findings, mention the HR measured, regular rhythm, normal volume, normal character, compressible, no radio-radial/radio-femoral delays, no pulse deficit, no collapsing pulse.

Brachial pulse

• Using 2 fingers, assess the brachial pulse medial to the biceps tendon in antecubital fossa. (Bilaterally)
• Mention rate, rhythm, volume, character and compressibility

Carotid pulse

• Using 2 fingers, gently assess the carotid pulse anterior to sternocleidomastoid near the jaw.
• Bilaterally, but never feel both sides at the same time as that might trigger vasovagal attack, comment on rate, rhythm, volume, character and compressibility
• Ask the patient to hold his breath, and auscultate for the bruit
• Comment on the bruit

Femoral (mention only), posterior tibial and dorsalis pedis are done in PVS. We do them if the station was a focused pulses station

Face

• Check eyelids for xanthelasmata (Hyper-lipidemia)
• Check iris for corneal arcus (Hyper-lipidema)
• Check conjunctiva for pallor and petechial hemorrhage (Infective endocarditis)
• Mention that you need fundoscopy to check for roth spots (Infective endocarditis), or HTN/DM changes
• Check for malar flush on cheeks (Mitral valve stenosis)
• Check for any signs of central cyanosis (Under the tongue), peripheral cyanosis (On the lips)

JVP Examination

As JVP is very important and might be a full station on its own, make sure you’re ready for it.

Inspection

• Rest the patient’s head on a pillow (Make sure its rested, we need a relaxed sternocleidomastoid), ask him to turn his head slightly to the left, using a torch, try to find JVP pulsation.
• Comment, double peaked, inward pulsating JVP

Palpation

• After doing the usuals for any palpation, try to palpate it

JVP is normally impalpable, so make this comment and move on

• Compress the root of the neck, JVP should disappear, comment that it disappeared after compressing root of the neck
• Ask the patient to lie flat → Increased JVP (comment)
• Ask the patient to sit straight → Decreased JVP (comment)
• Ask the patient to take a deep inspiration → Decreased JVP (comment)
• Check abdominojugular reflux, press (while gradually increasing pressure) on the Rt upper quadrant for 30 seconds (don’t do full 30 of course), on a positive test (normally positive), JVP increases (comment whether positive or negative reflux)

Measuring JVP

• Use a ruler, put it on the sternal angle (Straight with the ground not patient’s body), assess using a straight object that’s put on the highest pulsation you see of the JVP, measure on the ruler and add 5cm and comment on the measured JVP (Normally it’s <9cmH20)

Precordium Examination

Inspection

From the foot of the bed;

• First ask the patient to take a deep breath
• Comment “Symmetrical chest with no visible deformities, bilateral movement of chest with respiration”

From the right side of the pt;

• Check for scars, make sure you know what scars mean;
  1. Midsternotomy is for CABG
     
  2. Left submammary is for mitral valvotomy
     
  3. Infraclavicular is for pacemakers
     And mention no scars
• Mention no swellings, visible masses, dilated veins.
• Mention normal hair distribution
• Using the torch, mention afterwards that you see no visible pulsation/no visible apex beat

Palpation

• Do the usuals for palpation
• Generally palpate the chest, don’t miss any point, use your whole hand
• Comment no palpable masses, no tenderness

Apex beat

• Try to find it using your whole hand
• Try to find it using 2 fingers (roll the patient to the left side if you couldn’t find it)
• Locate it → which intercostal space, is it midclavicular?
• Comment; gently tapping apex beat, located in the 5th intercostal space, midclavicular line.

Heaves

• Using your hand’s heel, ask the patient to expire and hold his breath, assess both right ventricular heave (lower left sternal angle), and left ventricular heave (apex, hence “apical heave”)
• Comment! No right or left ventricular heaves

Thrills

• Using your flat fingers; not the tips nor the base, check for thrills in 4 locations; apex, parasternal, right and left second intercostals.
• Comment! No thrills

Auscultation

Auscultation spots

Differentiate S1/S2 by feeling carotid pulse while auscultating the patient

• First, with the diaphragm, 4 valvular spots and 2 radiation spots
  • 4 Valvular spots, mitral, tricuspid, aortic and pulmonary
  • 1 Carotid, for radiation of aortic stenosis
  • 1 Left axilla, for radiation of mitral regurgitation
• Second, with the bell, 4 spots
  • 4 Valvular spots (some only use the bell for mitral and tricuspid, you’ll not be penalized for more spots anyway)
• Last, finish with 2 maneuvers
  • Aortic regurgitation, using the diaphragm, ask the patient to sit straight and then lean forward, examine (aortic area), and Erb’s area.
  • Mitral stenosis, using the bell, ask the patient to roll to his left side and then put the bell on the apex.
  • Comment on the whole auscultation; “Normal S1,S2, no S3,S4, normal physiological splitting of S2, no murmurs, no added sounds like opening snap, ejection click or friction rub”

Ending the station

• I will auscultate lung bases for crackles (Heart failure - Pulmonary edema)
• I will examine the abdomen for ascites; hepatomegaly, sacral edema
• I will examine lower limb for edema, ulcers, pulses