Cardiac Exam Flashcards
First thing to do in cardiovascular exam
- general inspection from 5 feet away:
a) distressed?
b) body habitus ( size an shape of the person - refer to the person’s bmi i.e. they have a very high bmi rather than they are morbidly obese)
c) well vs. unwell appearance (combo of skin colour,, level of distress, breathing pattern, level of consciousness, body habitus, facial expression ect) - well nourished
- well perfused
After general inspection hat comes next
Vitals
- BP
- HR
- RR
- O2 sat
- pulsus paradoxus
Pulsus paradoxus
A decrease in systolic pressure during inspiration and/or an increase in systolic pressure during expiration
-when difference in systolic pressures is greater than 10 mmHg it is considered abnormal
When does pulsus paradoxus occur
Occurs with:
a) cardiac tamponade
b) severe volume depletion
c) severe asthma
Things to check for on the hands/wrists/fingers
1) Clubbing
2) Cyanosis (peripheral)
3) Capillary refill
4) Radial and brachial pulses
5) Splinter haemrrhage
6) Janeway lesions
7) Osler’s nodes
8) Raynaud’s phenomenon
Clubbing
- a bulbous swelling of the soft tissue at the nail base
- loss of normal angle between the nail an the proximal nail fold (angle inreases to 180 +)
- nail bed feels spongy or floating
Mechanism of clubbing
-still not completely known
Conditions that cause clubbing
X
Signs of bacterial endocarditis
- splinter haemorrhages
- janeway’s lesions
- osler’s nodes
Splinter haemorrhage
X
Janeway’s lesions
X
Osler’s nodes
X
Reynaus phenommenon
Vasoconstriction in the fingers
Capillary refill
The tine reqiured for finger nail to return to the pink colour after it has been squeeze
- normal is < 2 seconds (brisk)
- abnormally long times usually indicate poor circulation (a number of causes)
Things to note on examination of the radial pulse
1) Amplitude of the pulse = the size or strength of the pulse
2) Upstroke- how quickly the pulse reaches it maximum
3) Rate = frequency of pulse
4) Rhythm = description of regularity of pulse
Technique for palpation of an artery
- gently (too much pressure will occlude the artery an the pulse will be absent)
- use to figers
Things to inspect on legs
1) Pedal oedema
2) Pulses (femoral, popliteal, dorsalis pedis, posterior tibialis)
3) temperature
4) Signs of chronic poor circulation (loss of hair, discoloration, ulcers)
5) Achilles tendon xanthomata
Achilles tendon xanthoma
- disfiguring cholesterol deposits
- appreciable by palpation and visualization of the achilles tendon
- sign seen in familial hypercholesterolemia
Things to exam in eyes
Eyes:
- corneal arcus
- xanthalosma
- fundoscopic exam
- colour of conjunctiva (pale or pink)
Corneal arcus
- a gray color arc or circle that is superimposed on the outer edge of the iris (colored part of the eye)
- can be a sign of high cholesterol (also common in elderly = arcus senilus where is not representative of cholesterol level)
Xantholasma
- fatty deposits in the skin that surround the eye
- sign of high cholesterol
Importance of fundoscopic exam
Is the only place in the body where we can directly see arteries and veins
Things to exam in mouth
1) Petechia (petechiae)
2) Dentition
3) Central cyanosis
Signs/ Cause of petechiae of oral mucosa
- red/purple spot
- cause by minor haemorrage (broken capillary vessel)
- occurs with bacterial endocarditis
Dental pathology - importance
May alert the examiner to the risk for endocarditis
Central cyanosis
-cyanosis of the oral mucosa (not the lips which can appear cyanotic in a patient who is cold)
Things to examine in the neck
1) Accessory muscle use
2) Carotid auscultation
3) Carotid palpation
4) JVP inspection
5) Thyroid gland
Order of examination of the carotid + why
Carotid auscultaation should precede palpation because if there is a bruit then atherosclerotic stenosis might be present and if so then a plaque could be dislodged by palpation
Things to comment on during inspection of carotid pulse
- Amplitude
- Upstroke
- Rate
- Rhythm
Pulsus parvus and tardive-define + causes
Small weak pulse
-upstroke may feel slowed an the peak prolonge
Causes
1) decreased stroke volume (i.e. heart failure, hypovolemia, severe aortic stenosis)
2) Increased peripheral resistance (exposure to cold, severe heart failure)
Waterhammer pulse
- a large, bounding pulse
-the rise and fall are rapid, the peak is brief
Causes:
1) Increased stroke volume decreased peripheral resistance or both (anemia, hyperthyroidism, aortic regurg, arteriovenous fistulas , PDA)
2) Increased stroke volume because of slow heart rate (bradycardia) and cmlpete heart block
3) Decreased compliance of aortic walls (aging, artherosclerosis)
Inspection of JVP- things to note (vs. carotid)
- Biphasic vs. monophasic
- Changes with position vs. does not
- Increase with AJR vs. does not
- Changes with respiration vs. does not
- Non-palpable vs. palpable
- Obliterable vs. not
JVP changes with position
Drops as the patient becomes more upright
JVP changes with increase in AJR
Height increases with increase in pressure
JVP changes with respiration
Height of pulsations fall with inspiration
Signs of respiratory distress
- use of accessory muscles
ex: sternocleidomastoid
Inspection of the back
- Percuss the lungs
- Auscultate the lungs
- Sacral oedema
Things to note when auscultating/percussing lungs
- equal air entry bilaterally
- no adventitious sounds heard (crackles, wheezes)
What do crackles indicate
Pulmonary oedema
Pulmonary fibrosis
What do wheezes indicate
Early interstial oedema
Asthma/COPD
When does sacral oedema frequently develop
In persons who have been lying down for a long time
Examination of the chest -general
- Inspect
- Palpate
- Percuss/ausculate lungs
- Ausculate heart
things to inspect on the chest
- Cardiac pulsations
- Scars and pacemakers
- Pectus excavatum, pectus carinatum
Cardiac pulsations to observe
- Apex beat
- Visible lifts
- Pulmonary artery pulsations (visible in severe hypertension)
- Valve positions
Pectus excavatums
Hollowed chest
Pectus carinatum
Protrusion of sternum and ribs (due to overgrowth of cartilage causing sternum to protrude forward)
Things to palpate on chest
1) Apex
2) Right ventricular heave
3) Pulmonary artery
4) 4 valve areas for thrills
Apex
-most lateral position Note -size (how many interspaces) -mono vs. bi vs. triphsic - duration (sustained or not)
