Block 2 - Cardiovascular Flashcards
What are 8 common cardiovascular complaints?
- Chest pain/heaviness
- Dyspnoea
- Palpitations
- Syncope
- Intermittent claudication
- Erectile dysfunction
- Other symptoms
- For every system you want to elicit the red flag systemic symptoms such as fever, weight loss or night sweats.
What is the overall cardiovascular history protocol?
**Cardiovascular History Protocol
**1. Introduction
2. Presenting Symptoms
3. Past Medical History
4. Treatment / Medications
5. Allergies
6. Social History
7. Family History
How do you perform a CVS risk profile?
- What are the 5 most important factors?
- 2 others?
- 10 questions to ask?
CVS Risk Profile:
1. Age
2. Diabetes
3. Smoking
4. Hypertension
5. Hyperlipidaemia.
- FamHx - premature cardiovascular disease in 1st degree relative <60yrs
- Familial hypercholesterolaemia
What questions should you ask a patient about their past medical history in a cardiovascular history? (12)
- 8 Questions you should ask a patient with hypertension?
**Cardiovascular History - PMH
**
1. Hypertension?
2. Myocardial infarction?
3. Rheumatic fever?
5. STD?
6. Thyroid disease?
7. Recent dental work?
8. Diabetes?
9. Renal disease
10. Non-prescription and prescription drug use?
11. Smoking? = pack years
12. Alcohol? = No. of standard drinks/week
What questions should you ask a patient about their social history in a cardiovascular history? (4)
**Cardiovascular History - Social History
**
1. Occupation and occupational exposures
2. Diet and exercise
3. Living conditions - who lives at home, ability to perform ADLs
4. Financial issues.
What specific questions should you ask a patient presenting with chest pain/heaviness? (6)
Cardiovascular History - Chest pain or heaviness: SOCRATES
1. Location
2. Character
3. Exacerbating and relieving factors
4. Onset
5. Duration
6. Radiation.
Stable angina is reproducible and exertional.
Causes (differential diagnosis) of chest pain and typical features?
What specific questions should you ask a patient presenting with dyspnoea in a CVS history? (5)
**CVS History - Dyspnoea
**
1. Timing of onset
2. Severity
3. Duration of episode
4. Relieving and exacerbating factors
5. Patterns:
- Exertional - exercise tolerance compared with normal for patient. Has it changed recently?
- Orthopnoea – how many pillows do you sleep on? Has the number changed?
- Paroxysmal Nocturnal Dyspnoea- do you wake up short of breath at night?
What specific questions should you ask a patient presenting with dyspnoea in a CVS history? (5)
Swelling of ankles:
1. Timing?
2. Bilateral or unilateral ankle oedema?
2. Trauma? Bites or scratches?
3. Pattern - worse at end of day? in the morning?
4. Painful?
5. Other CVS symptoms?
Palpitations: differential diagnoses?
What specific questions should you ask a patient presenting with palpatations in a CVS history? (5)
Palpitations: (subjective awareness of heartbeat)
1. Rate
2. Regularity - do you notice your heart racing or beating irregularly?
3. Associated symptoms - Syncope? Anxiety? Sweating? SOB?
What specific questions should you ask a patient presenting with palpatations in a CVS history? (5)
Syncope: (transient loss of consciousness) Exertional syncope is an important sign of severity of aortic stenosis. Syncope without warning can be due to bradycardia and postural hypotension.
1. When? Where? How?
2. Exertional?
2. Head trauma?
3. How long did you lose conciousness for?
4. Pre-aura?
5. Other symptoms?
DIFFERENTIAL DIAGNOSIS OF SYNCOPE AND DIZZINESS?
Drugs associated with syncope?
6 Ps of peripheral vascular disease?
six Ps of peripheral vascular disease:
P ain
P allor
P ulselessness
P araesthesias
P erishingly cold P aralysed.
What specific questions should you ask a patient presenting with leg pain (claudication) in a CVS history? (11)
- Causes?
Leg pain: Calf pain (walking)- intermittent claudication.
Calf pain (at rest)- DVT or critical limb ischaemia
Overall cardiovascular examination protocol? (11)
CVS Exam Protocol
1. Introduction
2. Exposure and positioning
3. General Inspection
4. Hands & Upper Limbs - fingers/hands/wrists
5. Vitals
6. Head & Neck - Face, Eyes, Mouth, JVP, Carotids
7. Precordium - IPPA
8. Back - IPPA
9. Abdomen - IPPA
10. Lower Limbs - Inspect, Palpate
11. Bedside tests
What is involved in the Introduction of the CVS Exam?
**CVS Exam Protocol - Introduction
**1. Introduces self
2. Washes hands
3. Explains examination, obtains verbal consent.
4. Confirms name & Age
“Hi my name is Kitty and I’m a second year medical student at the university of Notre Dame. I’ve been asked to come and examine you for any heart problems you might have. This will involve me having a look at you hands, face, neck and chest and then a quick listen and feel of your chest as well. Does that all sound ok to you? It shouldn’t take too long but if you’re uncomfortable at any point we can stop.”
“Before we start please can I confirm your name and age? Is there anything I can do to make you more comfortable?”
CVS Exam - Exposure & positioning?
**CVS Exam - Exposure & positioning
Recumbent with upper body at 45 degrees. Exposed from head to symphysis pubis.
“Please can you hop onto the bed for me, i’ll just pop you back a little bit. And I will need you to be undressed from the waist up if thats ok? You can leave any underwear on.”
CVS Exam - General Inspection? (6)
**CVS Exam - General Inspection
**
1. General appearance: Well/ill/in pain, age, gender, weight (central or generalised obesity)
2. Dyspnoeic
3. Diaphoretic (Diaphoresis=sweating)
4. Pallor, cyanosis (peripheral, central)
5. Dysmorphic features.
6. Bedside clues – oxygen, walking stick, nitrolingual spray
CVS Exam - Hands & Upper Limbs? (10)
CVS Exam - Hands & Upper Limbs
1. Nicotine stains
2. Palmer crease pallor
3. Peripheral cyanosis
4. Nail clubbing
5. Nail splinter haemorrhages
6. Tendon xanthomata
7. Janeway lesions or osler nodes
7. Palpate: Radial artery - rate and rhythm.
8. Palpate: Carotid artery - volume and character of pulse.
9. Measure Blood Pressure: Measure in every patient. If appropriate ask patient to stand to check for postural hypotension (>15mmHg systolic BP)
CVS Exam - Head & Neck? (7)
**CVS Exam - Head & Neck
**
1. Face - Malar flush
2. Face - Xanthelasma
3. Eyes – conjunctival pallor (anaemia), jaundice,
4. Mouth - central cyanosis
5. Mouth - high arched palate if suspecting Marfan’s.
6. Jugular venous pressure: Position patient at 45 degrees. Should be <3cm from sternal angle
7. Auscultate (with diaphragm): over carotid artery for bruits (Ask patient to hold their breath). (This could be done following the precordium auscultation)
Causes of an elevated JVP?
CVS Exam - Precordium - Inspection? (5)
CVS Exam - Precordium - Inspection
1. Midline or other scars
2. Deformity
3. Pacemaker (left or Right upper pectoral region)
4. Visible pex beat
5. Other visible pulsations.
CVS Exam - Precordium - Palpation? (3)
**CVS Exam
**
Palpate
1. Thrills - place palm horizontally over each of the cardiac areas
2. Heaves - place hand vertically over each of the parasternal edges.
3. Palpate the apex beat (then locate it counting the ribs) - 5th intercostal space, MCL.
CVS Exam - Precordium - Auscultation? (5)
CVS Exam - Auscultation
1. Mitral area –> bell then with the diaphragm
2. Tricuspid area –> diaphragm
3. Pulmonary area –> diaphragm
4. Aortic area –> diaphragm
5. Carotids
(traditionally auscultation of the neck is done after the aortic area) (if the patient was already sitting reverse the order ‘Carotid - Aortic - pulmonary - Tricusped =- Mitral’ )
“Heart sound were dual with no added sounds or murmurs. There were no thrills or heaves. The apex beat was is a normal location (5th ICS, MCL) and of normal character.”
Signs & Symptoms of the 4 heart murmurs?
Timing of Cardiac murmurs?
CVS Exam - Back? (4)
CVS Exam - Back
1. Inspect for scars & deformities
2. Palpate for sacral odema at lower back
3. Percuss lung lobes - upper, middle, lower, axilla
4. Auscultate - lower lung lobes only - for crackles
CVS Exam - Abdomen? (3)
CVS Exam - Abdomen
1. Palpation: Liver tenderness, enlargement and pulsatility
2. Percussion: ascites
3. Auscultation (with diaphragm): aortic, renal and femoral bruits
CVS Exam - Lower limbs? (10)
CVS Exam - Lower limbs
1. Colour – compare colour, left with right, proximal with distal
2. Thinning of skin
3. Ulceration
4. Hair loss
5. Varicose veins
6. Peripheral cyanosis
7. Clubbing of toes
8. Palpate for temp - both sides
9. Palpate for pitting oedema
10. Palpate peripheral arteries - dorsalis pedis and posterior tibial arteries –> popliteal arteries –> femoral arteries
CVS Exam - 3 bedside tests?
CVS Exam - 3 Bedside Tests
1. ECG: 12 lead +/- rhythm strip.
2. Urinalysis: Glycosuria, proteinuria
3. Fundoscopy
Causes of nail clubbing?
Normal BP readings? Classificatons of Hypertension?
Peripheral Vascular Exam Protocol? (8)
Peripheral Vascular Exam Protocol
1. Introduction
2. Exposure & positioning
3. General Inspection
4. Extra-cranial vessels
5. Upper Limbs
6. Abdomen
7. Lower Limbs
8. Special Tests
Peripheral Vascular Exam Protocol - Introduction? (4)
Peripheral Vascular Exam Protocol - Introduction
1. Introduces Self
2. Washes hands
3. Explains procedure & gains consent
4. Confirms name & age
“Hi my name is Kitty, i’m a second year medical student from the university of notre dame and i’ve been asked to come and examine you for any problems with your blood vessels. This will involve me having a look and feel of your arms, abdomen and legs. Does that sound ok to you? It shouldn’t take long and if you’re uncomfortable at any point we can stop. Before we get started please can I confirm your name and age? Is there anything I can do to make you more comfortable?”
Peripheral Vascular Exam Protocol - Exposure and positioning?
Peripheral Vascular Exam Protocol - Exposure and positioning
Please can I get you to undress from the waist down but you can leave any underwear or shorts on and lie flat on the bed for me please.
Peripheral Vascular Exam - General Inspection? (8)
**Peripheral Vascular Exam - General Inspection **
1. Bed side clues - mobility aids, O2, etc.
2. Cyanosis
3. Pallor
4. Scars (clues to prevous surgical procedure bypass etc..)
5. Amputations
6. Gangrene
7. Necrosis
8. Ulceration (venous ulcers,arterial ulcers)
Peripheral Vascular Exam - Extra cranial vessels? (2)
Peripheral Vascular Exam - Extra cranial vessels
1. Auscultate: for carotid bruits on breath hold. (if present avoid palapation due to risk of emboli)
2. Palpate: carotid arteries - one side at a time.
Peripheral Vascular Exam - Upper limbs? (12)
Peripheral Vascular Exam - Upper limbs
1. Colour changes (erythema, pallor, cyanosis)
2. Trophic changes (thin shiny skin, hair loss)
3. Ulceration (venous ulcers,arterial ulcers)
4. Amputations, gangrene,necrosis (if not noted earlier)
5. Palpate: Skin temperature comparing both sides (use back of the hand)
6. Palpate: Capillary refill (should be < 2 seconds)
7. Palpate: Brachial artery at the elbow (antecubaital fossa)
8. Pulses: Radial (rate & rhythm), ulnar, Brachial (volume & charachter), axillary.
10. Perform Allen’s Test.
11. Radio-radial delay (when present may suggest AAA, pre-subclavian coartication of aorta, etc.)
12. Record BP in both arms (significant difference may suggest aortic aneurysm)
13. Feel for arteriovenous fistula (dialysis patients)
Peripheral Vascular Exam - Abdomen? (3)
Peripheral Vascular Exam - Abdomen
1. Inspect: for obvious pulsation
2. Palpate: to exclude abdominal aortic and iliac aneurysms (pulsatile AND expansile)
3. Auscultate (with diaphragm): for aortic (above the umbilicus), renal (either side of umbiliacus) and iliac arteries (RIF LIF)
Peripheral Vascular Exam - Lower Limbs - Inspection? (5)
Peripheral Vascular Exam - Lower Limbs - Inspection:
1. Scars (harvested vien for bypass)
2. Colour changes (erythema, pallor, cyanosis)
3. Trophic changes (thin shiny skin, hair loss)
4. Amputations - Gangrene,necrosis (if not noted earlier)
5. Ulceration (venous ulcers,arterial ulcers) including the areas between the digits and under the nails must not be forgotten also pressure areas especially the heel.
Peripheral Vascular Exam - Lower Limbs - Palpate? (4)
- 6 pulses?
Peripheral Vascular Exam - Lower Limbs - Palpate
1. Skin temperature comparing both sides (use back of the hand)
2. Capillary refill (should be < 2 seconds)
3. Pitting oedema.
4. Pulses:
1. Femoral
2. Radio-femoral delay. (when present may suggest the coarcitation of aorta especially in young hypertisive male,AAA,etc..),
3. Popliteal
4. Posterior tibial pulse - felt posterior to the medial malleolus
5. Dorsalis pedis pulse - felt on the top of the foot lateral to the extensor hallucis tendon
6. Lateral peroneal pulse - can occasionally be palpated anterior to the lateral malleolus.
Peripheral Vascular Exam - Lower Limbs - Auscultate? (2)
Auscultate (with diaphragm):
The groins for femoral bruits,popliteal fossa for popliteal artery bruits.
Peripheral Vascular Exam - Lower Limbs - Special Tests? (2)
Peripheral Vascular Exam - Lower Limbs - Special Tests
1. **Allen’s test **–> get pt to open and close fist several times then hold fist in tight grip. Occlude the radial and ulnar arteries with your thumbs for ~10seconds and release the radial artery. The blanched hand should reperfuse quickly. Repeat with the ulnar artery.
2. Buerger’s test
(In specialist vascular clinics, hand held doppler ultrasound insonation and arterial pressure measurements of the arteries at the ankle. Record ankle-bracial Index.)
CVS Exam - 3 bedside tests?
CVS Exam - 3 Bedside Tests
1. ECG: 12 lead +/- rhythm strip.
2. Urinalysis: Glycosuria, proteinuria
3. Fundoscopy
