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1. General Inspection
a. Laboured respiration
b. Cachetic (malignancy, severe cardiac failure)
c. Syndromes- marfans, Down’s, Turners
d. Pectus excavatum
2. Vital Signs
Neck
Carotid character
Anacratic (small volume, slow uptake, notched upstroke) -> aortic
stenosis
Plateau (slow upstroke) -> aortic stenosis
Bisferiens – AR and AS (anacratic and collapsing)
Collapsing -> AR, hyperdynamic circulation, PDA, atherosclerotic
aorta
Small volume -> AS, pericardial effusion
Alternans -> alternating strong-weak beats – LVF
Jerky -> hypertrophic cardiomyopathy
JVP
If more than 3cm -> right heart filling pressure is raised
Causes of elevated central venous pressure
Right ventricular failure
Tricuspid stenosis or regurg
Pericardial effusion/pericarditis
SVC obstruction
Hyperdynamic circulation
JVP character
Dominant a wave -> TS, pulmonary stenosis, pulmonary
hypertension
Cannon a wave – caused by atrial contraction against closed
tricuspid valve -> complete heart block, ventricular tachy with
retrograde atrial contraction
Dominant V wave – TR
X descent –
exaggerated -> tamponade, pericarditis
absent – AF
Y descent
Sharp – severe TR, constrictive pericarditis
Slow – TS, right atrial myxoma
Hepatojugular reflex -> push for 15sec over liver -> JVP will
normally decrease unless severe right sided ventricular failure
7. Praedcordium
Inspection
- scars
- pectus excavatum
- Kyphoscoliosis
- Pacemaker
- Visible apex beat/thrills/heaves
Palpation
- apex beat: palpate with finger tips, most lateral and inferior point at
which the fingers are displaced with each beat
o causes of a displaced apex beat: enlargement, chest wall
deformity, pleural and pulmonary disease
- Character of apex beat
o Pressure loaded- AS, HTN
o Volume loaded (thrusting), displaced, diffuse, non-
sustained- MR, dilated cardiomyopathy
o Dyskinetic