How To Ace Your Cardiology Exam: A Step-by-step Guide

hello and welcome back to another medical Deep dive video my name is Dr James Gil and we're going to be looking at the cardiovascular system or specifically how to perform the examination now we've done quite well in completing uh the vast majority of the clinical examinations so far but we're going to try and expand that at the moment to look at um medical tests so for example doing blood pressure and things like that I'd be really grateful if you consider liking these videos and subscribing that way you'll get notifications when new ones are popping out and you'll help us be able to determine the direction of the channel going forwards so with that in mind let's go over the Deep dive for the cardiovascular examination what we're actually doing with our stethoscopes and what we're going to be hearing when we have a listen to Bob well perhaps not Bob himself he doesn't really do much but you get the idea what we're going to be doing so in terms of starting off the examination um suppose we should probably go for a bit of Basics really the heart is often described as a pump that is technically true but it's not quite accurate the heart is comprised of two pumps we've got the left side of the heart comprising of the atrium and the left ventricle pushing blood out to the body then we've got the right right side of the heart comprising the right atrium and the right ventricle pushing blood out to the lungs where it's going to get oxygenated and that's realistically where the whole blue and red when it comes to blood vessels um and just how we draw or color the heart comes from the red side in inverted commas is the left side taking oxygenated blood out the body and the blue side the veins um that's the uh right side taking deoxygenated blood from the body and pushing it out to the lungs within the heart are four very important structures we've got the tricuspid valve we've got the mital valve we've got the pulmonary valve and the aortic valve and they control the flow of blood around the heart and similarly when these um structures these valves run into a problem that's when we tend to get pathology that we are going to hear with regard to m murmur of the heart and that's going to be one of the crucial things that in a cardiac clinical examination we're going to be looking to pick up now we've already done a video looking at some of the major murmur um I think that should pop up here if you want to have a look at that but we're not going to dwell an awful lot on those today we've already touched on that after all but we are going to look at what it is that you're doing for the examination and how you're picking these sounds up up now the different valves will affect the heart in different ways should they throw a problem the tricuspid and Pulmonary valves they're going to affect the right side of the heart and in the same way that we've said that the right side of the heart is do with veins it's to do with deoxygenated blood it's blood coming back from the body then we'd expect a right-sided heart problem to cause us peripheral issues so we're going to have problems where we're getting swelling of the ankles we're getting poor sucking of the blood back up from the body into the heart we'll have issues with perhaps congestion of the liver and we may see dilated veins potentially by comparison the left side of the heart that will be affected by issues with the mital and the aortic valve and as we've also said where the left side of the heart is dealing with the arterial um system so the red oxygenated blood if there's an issue here it's going to feed backwards into causing problems with the lungs so we're going to get decongestion in the chest we're going to get pulmonary hypertension and that's going to have significant issues with not necessarily oxygenating the blood because that's a lung function but getting the oxygenated blood out to the body so we're likely to have chest pain we're likely to have shortness of of breath these patients are likely going to have reduced exercise tolerance so the important thing with regard to this is that we'll appreciate symptoms such as chest pain such as ankle swelling that the patient might complain about that are going to help us begin to form our differential diagnosis but when we're doing our examination we're going to pick up on the clinical signs that will help us to solidify our hypothesis or perhaps reject it and come up with alternative differentials the information we've gathered from the U the history will connect with the clinical signs that we'll find during our examination so we may find things like seeing the patient sh of breath we may see them with swirl and ankles before we start the indepth examination and that's going to give us a bit of a pointer to say well actually we've got symptoms here that are talking about heart failure and we can see signs here before we've actually begun the formal examination that's suggesting actually this patient might have heart failure so alt together we're constantly working to try and refute or prove our differentials that we've collected from the history and I think as we say that it's probably a good opportunity to start our examination so we're going to have a look as suggested there at the patient from the end of the bed and we want to get a good idea how the patient looks do they look calm do they look at rest do they look short of breath have they struggled to get into your clinical room or perhaps onto the couch keeping in mind that our examination starts from our first contact with the patient often going to greet them at the door as they walk from the waiting room using our um Vision in this way can be really really key to getting an effective examination because we're going to be able to plan or should I say perhaps uh we're going to put mental reminders for ourselves I can see this thing I'm going to need to double check what clinical signs I might be able to find because of that early uh thing that's peaked your awareness so once we've done our uh end of the bed inspection we want to get the patient to um lie on our bed at 45° and then we're going to start off by having a look at their hands now I'm a big fan of looking at the hands because there's a plethora of um clinical signs that are going to pop up here now remembering that signs are the things that we see versus the symptoms the patients complain about we really need to focus down on the cardiovascular signs that can pop up in the hand so in terms of looking for clubbing we need to get the patient to put their fingers together and we're going to look for something called shamro window can we see a diamond between uh the fingertips now clubbing is a very important sign to look for generally during a clinical examination but the fact that it's only present for a very rare cardiovascular issues bacterial endocarditis which we'll talk a little bit more about in a moment CTIC uh congenital heart disease and also problems with um a tumor in the Atrius an atrial meoma does mean that from a cardiovascular perspective it's a relatively poor um yield sign now we're still going to look for it because it's important to appreciate that patients don't come in nice little packaged boxes with one condition for each patient often a patient can have multiple things hence why if someone has detected um a clubbing on a patient we need to keep in mind what other things could be going on and that's why we all the while building towards our our hypothesis rather than saying this is what's going on because I've seen this one sign so as well as looking for clubbing um we talked about bacterial endocarditis we may see splinter hemorrhages now splinter hemorrhages are longitudinal um black black marks on the fingernails due to bacterial endocarditis so what happens there is this infection in the heart causes well literally pockets of bacteria to grow on the surface of the heart perhaps on the valves and as these nasty areas of infection get bigger they can actually get broken off by the passage of the blood that means they're going to fly through the body to then Lodge in the capillaries where they can't get through and when they Lodge in the capillaries of the fingertips we see these longitudinal splinters because this septic EMB has um blocked the capillary and has caused the um death of the tissue around it giving that black mark on the fingertips now from my perspective splinter hemorrhages are always a slightly entertaining clinical sign because the commonest cause of them is not bacterial carditis it's actually straightforward trauma so for example someone's done DIY at home someone's banged their hand all of these are going to cause splinter hemorrhages and for myself I have a bad habit of chewing my finger fingernails and as a result it's quite common that I will have the Splinter Hemorrhage or so but when we're teaching clinical skills for the first years there's always a couple of students get a little bit anxious when they find splinter hemorrhages on themselves when we're raising this topic for the first time now there are other clinical signs in the hand that can suggest we have bacterial endocarditis in the same way that we've had blockages the capillaries on the fingernail that we can see because the fingernail allows us this sort of window into the body there we can also get janway lesions which occur on the palms of the hands where again we're getting problems with emilii affecting the tissues and finally we can have osler's nodes where we get painful swellings normally to the pads or the fingertips where again the aseptic emili have lodged but now rather than just killing tissue they're actually resulting in their own infection in that area hence the redness the Emma the swelling and the pain we may also see when we're looking at the fingertips peripheral sinosis so blue tingers to the fingertips which can indicate a problem with the circulatory system so for example somebody's very cold such as when I was at a base camp I had peripheral sinosis there but we may also see this because the heart is not pumping effectively but not everything we're going to look for in the hand is purely due to um a structural problem with the heart we can also see konia or Colonia here we've got spoon-shaped uh nails or a depression uh on the nail which is due to iron deficiency anemia now that's important from a cardiovascular perspective because well if you've not got enough blood it's going to make you shorter breath it's also going to make your heart work harder putting you at greater risk of things like heart failure andina or potentially even a heart attack other things that we want to keep in mind when doing the cardiovascular examination and looking at the fingertips will be tar staining because as we know smoking is a very highrisk activity for both respiratory but also cardiovascular health again we can have another sign that crosses over when we've talked uh about the abdominal examination we've highlighted looking for Palma EMA so red Palms now this is often due to problems with the liver however it can also be seen in cardiovascular disease or cardiovascular disorders should I say more specifically so polycythemia Rua so high level of red blood cell can cause this um Palma athema similarly we can also get it with thyrotoxicosis now I'm sure somebody is going to say well thyrotoxicosis that's an endocrine problem that's a thyroid issue isn't it yes absolutely however the thyroid has a direct impact on the heart and if your thyroid is running an overdrive if we've got thyroid toxicosis or hyperthyroidism we're at risk of a very dangerous atrial fibrillation or perhaps even um straightforward cardiac failure so it's very important that we keep in mind how the different systems will interact so the thyroid is perhaps one of the most crucial pieces of the body because of how this little area will cause huge effects in terms of the rate the Rhythm the character of the pulse but also an effect on the nature of the very heartbeat itself something else that we may see in the hand or particular The Palms or maybe the uh ligaments coming from that will be tendon zanoma so yellow deposits of cholesterol are in the tissue now obviously if we getting deposits of cholesterol that's probably going to be a worrying factor and it is suggestive of something called hyper cholesterolemia that somebody's cholesterol levels are so high that this um yellow deposit this cholesterol is depositing out of the blood onto the tissues and I've actually seen this in several patients and it's a real shot over the bow to myself as a clinician that I need to pay significant attention to this patient now that may not be because they have a problem today but it does mean that I have work to do to try to address their cholesterol levels to make sure we don't put them at untreated risk for um furring up of the arteries so aoma and cholesterol deposition there now once we've had a look over the hands because I'm a bare very simple brain I like to stay in a straight line for my examinations so I'm going to go from the hands up the arm to the face and then down looking at the chest having gone from the hands we want to check the pulse so we want to take two fingers we can find flexor carpi radialis and using two fingers we'll go in just laterally to um the flex a tendon there and we should be able to find the radial artery beating nicely away try that on yourselves now if you can't find it one effective way can be to flick your wrist backwards that will bring the artery closer to the surface and also help you um see the tendon to put your fingers uh by the side of it now at this point I would argue that we should be checking the pulse in both wrists at the same time now that allows us to check for something called a radial radial delay which is due to literally blood not hitting both arms at the same time there is something narrowing uh one of the blood vessels um meaning we have that increased resistance or a delay this is often due to coact of the aorta and felt at the wrist rather than one one one pulse coming through we're likely to get one two one two because we have that clear delay now from my perspective I would argue that um we should check both pulses at the same time anyway well simply it doubles your chance of finding the pulse straight away which if you're a medical student in a high stress examination where you're you know trying to pass your clinical skills course the more things that you can do to help improve your likelihood of getting the marks the better surely when we do find the pulse we want to look at three features or comp went on three features of the pulse we want to be able to describe the rate the beats per minute how fast is the heart going and the simplest way to do that is just counting beats over 15 seconds and then timesing by four that should give us a ballpark figure for where the patient's pulse is at the moment and we understand that we should be expecting a pulse between 60 and 95 with under 50 being considered to be a radic cardia and greater than 100 being a tachicardia the two other things that we need to look for in the pulse will be the Rhythm and the character but we'll go through the Rhythm first because we need to be higher up the arm than uh the radial artery for that when we talk about Rhythm essentially we're looking at coordination of the heart contraction so we should be expecting the pulse to come through one two one two or ldb ldb as the heart heart valves close in time we can also describe the pulse as irregular and there are two subclassifications for that we can have an irregularly irregular Rhythm or a regularly irregular Rhythm so one of the things we can do is we can ask the patient if they say they're feeling palpitations to tap out the order of the pulse um on the table now if we have an irregularly irregular pulse it's just random there's nothing to it the patient would often struggle to say this is what my pulse feels like because it's literally all over the place and that is commonly seen with atrial fibrillation this can mean that um these pulses can often be so weak that the heart will contract but a pulse can't actually be felt being transmitted all the way down to the radial artery this can be one of the reasons why an automated uh blood pressure monitor often can't calculate a blood pressure in um patients with AF which is why it's still a core skill that students are able to take a manual blood pressure and you can see how to do that over here the other form of irregular pulse is an irregular regular rhythm so what do we mean by that perhaps the pulse will be one two one two one one two one two one and that would repeat so so we're we're going to get a dropped beat and the same thing is going to happen rhythmically so our regularly irregular Rhythm and that will be seen for example in second deegree heart block which is why at the end of the cardiovascular examination we want to make sure that we're doing an ECG so we can get an electrical trace of the heart and see how the um the electrics of the heart are working now you'll be able to see um here the uh video we've done on how to perform an ECG and when I can get round to it I'll also be filming another video that I'll eventually have pop up here explaining what the trace uh lines on an ECG actually mean and what we're looking for just going to have to wait a little bit for that the final bit of information that we need to get about the um pulse is the character now we need to move further up the arm to U the anticubital foser to a larger bore artery to calculate or to get information on the character essentially with the character what we're meaning is how does the pulse feel is it a strong pulse is it a a bounding pulse is it a very weak or thread pulse and we're going to do that by um placing two fingers just medial to the bicep tendon and if we're having difficulty finding that pulse we can get the patient to just try and contract their bicep slightly which will make the bicep tendon pop up and then we can again put our fingers just medial to it and there we're going to be able to describe how we feel that strength of the pulse so one cause of a bounding pulse might be seen in carbon monoxide poisoning or a thready pulse being in hypothyroidism our bounding pulse could also be seen in thyrotoxicosis keeping in mind that the thyroid is the accelerator for the body so the harder the thyroid is working the harder everything else will be and that's definitely going to be affecting the heart another form of pulse character that we're going to need to look for is a collapsing pulse now this is due to a problem with atic regation the um atic valve is unable to remain closed with the increased pressure allowing blood to flow back giving us this water hammer pulse so we need to make sure the patient doesn't have any problems to their shoulder we're going to grasp um their radial pulse with our hands and then raise the arm up as we raise the arm up we cause an increased column of pressure making it more likely that the damaged aortic valve will not be able to hold against that pressure and thus will regurgitate and the way we'll feel that is rather than the pulse tapping regularly at the radius we'll actually feel tap and the pulse will drop down ever so slightly and we can see that when we look at a pulse pressure graph um the pulse sliding much further back down below what we'd expect to be um seen in a healthy individual when it comes to um listening for that aortic regurgitation over the heart we're going to be expecting to find a diastolic uh murmur there which will be heard loudest over the left sternal border and in expiration leaning forwards but we are somewhat getting the um the cart before the horse there because we've still got to carry on up the arm to the rest of the body so we've done our character at this point it would be appropriate to get our Vital Statistics so perform a blood pressure check on the patient now in terms of uh characterizing a the character of the pulse we can have a scoring from 0 to four all the way from no pulse zero all the way through to a bounding pulse which would be the most significant that we see at 4 so what could be causes of a practically imp palpable or zero character pulse so that would be cardiac tanard if we got mital stenosis or perhaps even in heart failure but it's probably worthwhile to highlight that the character of the pulse is actually a very subjective uh clinical sign so realistically um it's something that we're going to be using as a broad brush stroke tool so in terms of doing the blood blood pressure it's going to be best if we have the patient lying back at 45° with their arms and legs uncrossed we can uh do a blood pressure sat up um in a chair but given that we're going to be doing a whole examination here it's probably better to have the patient uh uh take position on the couch particularly because once we've done um the uh blood pressure we need to then carry on to have a look at the face and it's going to be much more effective if the patient is uh able to lean back and relaxed so that we can have a look at the eyes in terms of the eyes we want to have a pull the um lower lid down to see if there's any signs of a conjunctival palor so this would go along with iron deficiency anemia and we may have already had um a wink that we're likely to find some other clinical signs if we'd found coil earlier on when looking at the fingers we also want to have a look around the um eyes themselves to see if there are any yellow deposits so um xanthelasma um of corn of um colesterol deposition and looking closely at the pupil we may see again cholesterol a white ring around the outside of the eye called corneal arcus now this is not only due to hyper cholesterolemia we will see the white ring in older people and we've discussed that in an abdominal examination it may be possible to see a golden or copper colored ring called a Kaiser fer ring you can have a look at the abdominal examination video later if you want to learn more about that moving down from the eyes we want to have a look at the patient face generally do they look flushed is there any signs of what we might call mital faces that might indicate a mital stenosis we then going to have a look at the tongue to see whether or not the patient appears to be well hydrated which we're definitely going to have a good um indication of because we've already done that blood pressure but we're also going to have a look in there to see underneath the tongue to see if there's any signs of central sinosis suggesting that we've got a problem with the heart or the lungs having looked over uh the mouth we're going to then move down to have a look at the neck and we've already got the patient positioned at 45° for uh their blood pressure check at this point we want to make sure the patient head is nicely relaxed on the couch and turned to face the left this will bring the sternal cider mastoid muscles uh into relief and here we're going to be looking to see what is occurring with the patient's jvp so we want to have a look between the uh heads of sternomastoid muscle to see if there is a pulse at all if it is visible we want to be able to calculate how high that is on the chest going from the maneuver sternal angle upwards a raised jvp can indicate problems with heart failure whereas a low jvp might indicate problems with hypovolemia so dehydration so perhaps somebody needing to be topped up a little bit now with that uh we can confirm the pulse that we've seen at the neck is that of the jvp because it should not be possible to feel it but also because we can do a hpat jugular reflex pushing in on the patient's abdomen which should cause the jvp to rise up by putting pressure on the liver that causes an increased pressure in the v in the Venus system which will in turn cause an increased pressure in the right atrium and then we'll see a rise in the jvp as we appreciate that the jvp is a monometer so it's a way of assessing the pressure in the right atrium here again there's another video for you on uh understanding the JV and also performing a jvp examination in more detail here for you so the jvp could be raised in heart failure it could be raised in simple fluid overloading it could be raised in pregnancy we may also see issues from pericarditis possibly anemia and also just straightforward bradicardia because the heart is having to work so much harder then and as we've mentioned before lots of systems will interact so in the same way that thyrotoxicosis could cause cause us to have a tachicardia it could cause us to have an irregularly regular heartbeat of atrial fibrillation it may cause us to have a bounding uh character and it may also cause a raised jvp this is one of the reasons why the thyroid is considered to be one of the you know most important um organs in the body because it has an effect everywhere with the patient undressed we then need to focus on the chest wall and here we want to see if there's any deformities so pcus excavatum or pcus carinatum where the chest is going in or perhaps out both of those can put pressure on the heart and cause other pathologies we also want to see if there are any dilated veins that might indicate that we've got a vascular issue resulting in the body trying to find alternative roots to send blood back to the heart this might be seen in an SV see obstruction as an example so we want to see if there are any um scars on the chest that might indicate the patient has perhaps had open heart surgery or maybe they've had a graft taken to uh improve their Plumbing elsewhere we also want to see whether or not there's any evidence of a pacemaker um normally seen near the left clavicle it's possible that we can also see visible pulsations in the chest wall so that may be because somebody has a left V ventricular hypertrophy the left side of the heart has grown so significantly or it could be that we've got a particularly slight person I know with myself that I can see my apex beat uh tapping against my chest wall through the skin on myself that's completely normal particularly for someone who engages in physical activity that's probably an effective point to say let's start off by looking at the apex beat so the apex beat should be found in the fifth intercostal space mid cicular line if we can't see it then we can place a hand flat on the chest in this area and hopefully we would be able to feel the um pulse where the heart is hitting the chest wall now we may find that that's not possible perhaps we've got dilated cardiomyopathy and thus we have a very diffuse beat perhaps the patient has a uh T they have a pnea thorax or they have a an affusion around the heart both of which would impact on the ability to feel that pulse could also be impacted if the patient is just a very large patient so in all of those cases we're going to keep our hand here to the side and roll the patient onto their left side that will cause the heart to flop down or Flop across and hopefully come closer to the chest wall hopefully meaning we'll be able to get a better feel for what's going on there if the apex beat has become display then we may expect to find a cardiac heave so we want to put our hand flat on the chest and here we're trying to feel for a forceful pulse coming through the chest wall again that's likely to be seen in um left ventricular hypertrophy so increased size of the heart we can Al we also need to assess for a thrill now it's I always find that interesting that medically we've chosen that term because obviously has other connotations and can sound quite strange if we say that to a patient without understanding what it is that we're meaning what we're actually feeling for there is a palpable murmur so we want to put our hands either side of the sternal border to see if we can feel a vibration coming through the chest from that uh murmur in the heart now this is very unusual and I've only felt this once it normally indicates a high degree uh murmur of quite some significance so having looked at the chest we've uh palpated the chest we know the position of the apex beat and we've checked for our heaves and thrills we then need to get out our stethoscopes and actually start listening to the heart so we want to listen over the uh the four valves over the aortic pulmonary mital and tricuspid area but it's very important we note that the regions that we're going to listen to are not where um the heart valves are anatomically this is where the heart valve sounds are radiating so in terms of listening over the heart valves we want to listen over to the aortic region so that's going to be the second intercostal Space by the right sternal border we want to listen to the pulmonary region so the second intercostal space on the left side of the sternum we want to listen to the mital region so that's going to be the fifth intercostal space in the midclavicular line we also want to listen to the tricuspid area that's at the left lower sternal border again it's crucial to highlight that these regions are not the anatomical locations of the valves but merely where their sound is radiating to when it comes to using our stethoscopes we need to appreciate that we have the Bell and the diaphragm to the stethoscope and that will allow us to hear different things in different ways so we have the Bell and the diaphragm to the stethoscope we want to listen with the diaphragm first the larger um part of the stethoscope and that will attenuate that will increase all sounds the one disadvantage of that it means that lower frequency sounds may not be heard as well with the diaphram and that's why on my electronic stethoscope I will press a button to move to the Bell or on an other stethoscope you'll rotate it round to engage the bell and we'll use the Bell to listen as well because it'll pick up higher frequency sounds and we'll use that to listen over the Apex and also over the mital area to attempt to pick up mitro stenosis when we're osculating the chest it's vitally important to make sure we're also checking the pulse at the same time because this will allow us to confirm what we're hearing and how that relates to uh the different beats so for example our S1 sound will correlate with the feeling of the radial pulse and in terms of um the oscilation we we are going to need to position the patient slightly for different areas So the patient's largely going to be examined at 45° however we will again get the patient to roll over to their left if we're wanting to listen to the mital area and if we were checking for aortic regurgitation we get the patient sit forwards but they're going to breathe in and they'll breathe out with us and we'll hold the stethoscope and we'll listen with the stethoscope when they're holding their breath in expiration because that will enhance the sound of an aortic regurgitation it's important that we breathe with the patient so that they know to restart breathing because we don't want to cause them any undue distress about holding their breath for longer than they need to because remember patients want to provide you with good information they want to be as helpful as they can when it comes to to oscilating the heart it's always worthwhile to make sure you have a mental checklist have you heard sounds one and two have you heard any extra sounds such as sounds three and four have there been any opening or closing clicks or snaps from the heart valves and obviously have you heard any murmur you can find uh a video here about the murmur specifically that we recorded a while ago that goes into much more depth on each of those moving away from the heart in the same way that we checked if there's any discomfort over the abdomen before we did the jvp we need to check whether or not there is any signs of an abdominal aortic aneurysm a AAA and we're going to do this by pressing both sides of the umbilicus with the flat of our hands quite deeply and it's important to warn the patient that there might be a little bit of discomfort because what we're trying to feel is an expansile pulse pulse that's pushing our hands apart and that might indicate we've got a dilation this major blood vessel in the abdomen moving on we want to check the pulses now sometimes people will want to have the femoral pulses checked if we are doing a specific peripheral ex um uh vascular examination however it's much easier just to start off at the feet and then come upwards the reason why we want to start off at the feet is well that we're talking about tubes if we can feel the pulse on the feet at the AC on the dorsum of the foot on the dorsalis pedis and on the side of the foot by the ankle at the posterior tibial and we know that the other pulses further up the leg in the poal fosser behind the knee and at the groin for the fal pulses will be intact if however we can't find either of the pulses on the feet then we want to carry on further up the um the body to find where we can detect the pulses we also want to check for peripheral odema which as we've highlighted might be seen in heart failure and we're going to do that by pressing on the inside of the tibia with three fingers and we're going to press so that our fingertips turn white that's quite crucial because that indicates that we're pressing with 10 mm of mercury which should be sufficient to push out any edema into the surrounding tissues and we'll leave an indent if there is fluid there we're going to complete our examination on the toes just by checking the capillary refill which should be under 2 seconds in a healthy individual with good um circulation we might also see signs of peripheral sinosis there as we'd look for in the hands as well as well as the edema on the legs we'd also want to check the patient's sacrum where we may have edema if we've got significant harm failure we also want to position the patient forwards so that we can have a listen to the lung bases where if we've got left-sided heart failure we're going to get pulmonary edema so crackles to the lung bases there so to wrap up our examination we want to do an ECG an electrical trace of the heart to investigate any arrhythmias we want to do a urine dip to see if there was evidence of protein uh in the urine we'd also want to check for hem IA which can be seen in vasculitis such as the Kawasakis we mentioned earlier we'd also want to uh uh we also might see hematuria blood and the urine from endocarditis checking the urine dip will also allow us to see if there's any protein in the urine which might indicate renal disease or perhaps hypertension I would also want to look for sugars there which might suggest diabetes other things that we might want to do to complete the examination is check a full blood C to see how much blood they'd actually got and also have a look at the back of the eyes if we hadn't done so before because we can get hypertensive retinopathy changes on the back of the eye there which might um be otherwise undetected and indicate an end organ damage from the blood pressure which is exceptionally important to then make sure we are controlling well that completes our Deep dive into the cardiovascular examination hopefully this has been useful to yourself please put any questions that you've got down below um and please if you could like the video because that will help the YouTube algorithm and that will hopefully mean that more people will get to see this similar if you could subscribe I think that uh would be useful for all of us I get to see um who's following but also it means that we get to interact more on the community's page here where I'm trying to build the channel to engage with yourselves that little bit more thank you very much for watching uh and we'll see you in the next one take care