Cardiovascular and respiratory medicine
Station 12 Blood pressure measurement 27
Causes of secondary hypertension:
– high glucocorticoids, e.g. Cushing’s
– high mineralocorticoids, e.g. Conn’s
– high growth hormone, e.g. acromegaly
– pre-eclampsia (+ oedema and proteinuria)
– NSAIDs, steroids, oestrogen, illicit drugs
Complications of hypertension:
• Cerebrovascular accident (haemorrhage or
Investigations in hypertension:
• Assessing for a possible secondary cause.
• Assessing for complications/end-organ
damage (see above) e.g. fundoscopy, ECG,
blood tests such as urea and electrolytes.
Figure 5. Positioning of the cuff and head
• Introduce yourself to the patient.
• Confirm his name and date of birth.
• Explain the examination and obtain his consent.
• Position him at 45 degrees, and ask him to remove his top(s).
• Ensure that he is comfortable.
• From the end of the couch, observe the patient’s general appearance (age, state of health,
nutritional status, and any other obvious signs). Is he breathless or cyanosed? Is he coughing?
Does he have the malar flush of mitral stenosis?
• Observe the patient’s surroundings, looking in particular for items such as a nitrate spray, an
oxygen mask, ECG electrodes, and IV lines and infusions.
• Inspect the chest for any scars and the precordium for any abnormal pulsation. A median
or replacement of the mitral valve. Do not miss a pacemaker if it is there!
Inspection and examination of the hands
– temperature: feel with the back of your hand
– colour, in particular the blue of peripheral cyanosis and the orange of nicotine stains
– nail bed capillary refill time: press the nail for 5 seconds; it should refill within 2 seconds
– any presence of clubbing (endocarditis, cyanotic congenital heart disease)
– any presence of Osler nodes and Janeway lesions (subacute infective endocarditis)
– any presence of splinter haemorrhages (subacute infective endocarditis)
– any presence of koilonychia or ‘spoon nails’ (iron deficiency)
• Determine the rate, rhythm, volume, and character of the radial pulse. A regularly irregular
rhythm suggests second degree heart block, whereas an irregularly irregular rhythm suggests
atrial fibrillation or multiple ectopics.
• Raise the patient’s arm above his head to assess for a collapsing/water hammer pulse (aortic
regurgitation). Ask the patient whether he has any shoulder pain first.
• Simultaneously take the pulse in both armsto exclude radio-radial delay (aortic arch aneurysm).
Indicate that you would also exclude radio-femoral delay (coarctation of the aorta).
• Indicate that you would like to record the blood pressure (see Station 12). A wide pulse pressure
is typically seen in aortic regurgitation; a narrow pulse pressure in aortic stenosis.
Cardiovascular and respiratory medicine
Station 13 Cardiovascular examination 29
Inspection and examination of the head and neck
• Inspect the eyes, looking for peri-orbital xanthelasma and corneal arcus, both of which indicate
• Gently retract an eyelid and ask the patient to look up. Inspect the conjunctivusfor pallor, which
• Ask the patient to open his mouth, and look for signs of central cyanosis, dehydration, poor
dental hygiene (subacute bacterial endocarditis), and a high arched palate (Marfan’ssyndrome).
• Palpate the carotid artery and assess its volume and character. A slow-rising pulse is suggestive
of aortic stenosis, a collapsing pulse of aortic regurgitation. Never palpate both carotid arteries
• Assess the jugular venous pressure (see Figure 6) and, if possible, the jugular venous pulse form:
ask the patient to turn his head slightly to one side, and look at the internal vein medial to the
clavicular head of sternocleidomastoid. Assuming that the patient is reclining at 45 degrees,
the vertical height of the jugular distension from the angle of Louis (sternal angle) should be
no greater than 4 cm: if it is greater than 4cm, this suggests right heart failure, fluid overload,
Ask the patient if he has any chest pain.
– impalpable: obesity, dextrocardia, situs inversus…
– displaced, suggesting volume overload (mitral or aortic regurgitation)
– heaving, suggesting pressure overload and left ventricular hypertrophy (aortic stenosis)
– ‘tapping’, suggesting mitral stenosis
• Place the flat of your hands over either side of the sternum and feel for any heaves and thrills.
Heaves result from right ventricular hypertrophy (cor pulmonale) and thrills from transmitted
30 Station 13 Cardiovascular examination
right second intercostal space near the sternum
left second intercostal space near the sternum
left third, fourth, and fifth intercostal spaces near the sternum
– mitral area (use the stethoscope’s bell)
left fifth intercostal space in the mid-clavicular line
• Manoeuvres and points to remember:
– ask the patient to turn onto his left side and to hold his breath at end-expiration. Using the
stethoscope’s bell, listen in the mitral area for the mid-diastolic murmur of mitral stenosis
– listen over the carotid arteries for any bruits and the radiation of the murmur of aortic
– listen in the left axilla for the radiation of the murmur of mitral regurgitation
For any murmur, determine its location and radiation, and its duration (early, mid, late, ‘pan’ or
throughout) and timing (diastolic, systolic) in relation to the cardiac cycle. This is best done by
Figure 7. Auscultation points.
Cardiovascular and respiratory medicine
Station 13 Cardiovascular examination 31
III Murmur of moderate intensity that is immediately audible
IV Murmur of loud intensity with a palpable thrill
V As above, murmur audible with only stethoscope rim on chest wall
VI As above, murmur audible even as stethoscope is lifted from chest wall
Table 5. Common conditions associated with murmurs
Aortic stenosis Slow-rising pulse, heaving cardiac apex, ejection/early-systolic murmur best
heard in the aortic area and radiating to the carotids and cardiac apex
Mitral regurgitation Displaced thrusting cardiac apex, pan-systolic murmur best heard in the
mitral area and radiating to the axilla, patient may be in atrial fibrillation
Aortic regurgitation Collapsing pulse, thrusting cardiac apex, diastolic murmur best heard at the
Mitral valve prolapse Mid-systolic click, late-systolic murmur best heard in the mitral area
RILE: Right-sided murmurs are heard loudest on Inspiration whereas Left-sided murmurs are heard
• Percuss and auscultate the chest, especially at the bases of the lungs. Heart failure can cause
pulmonary oedema and pleural effusions.
• Palpate the abdomen to exclude ascites and/or hepatomegaly.
• Check for the presence of an aortic aneurysm.
• Ballot the kidneys and listen for any renal artery bruits.
Examination of the ankles and legs
• Inspect the legs for scars that might be indicative of vein harvesting for a CABG.
• Palpate for the ‘pitting’ oedema of cardiac failure: check for pain and then press for 5 seconds
on the patient’s legs. If oedema is present, assess how far it extends. In some cases, it may
extend all the way up to the sacrum or even the torso (‘anasarca’).
• Assess the temperature of the feet, and check the posterior tibial and dorsalis pedis pulses in
32 Station 13 Cardiovascular examination
• Indicate that you would look at the observation chart, dipstick the urine, examine the retina
with an ophthalmoscope (for hypertensive changes and the Roth’s spots of subacute infective
• Cover the patient up and ensure that he is comfortable.
• Summarise your findings and offer a differential diagnosis.
Conditions most likely to come up in a cardiovascular examination station
• Median sternotomy scar, with or without scar on the lower leg (vein harvesting).
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