Cardiac Examination Flashcards
What does malar flush indicate?
Mitral stenosis
What is malar flush?
Plum-red discolouration of the cheeks
What 5 major clinical signs are you looking for during end of the bed inspection?
- Cyanosis
- SOB
- Pallor
- Malar flush
- Oedema
What cardiac condition would oedema indicate?
Congestive heart failure
What is pedal oedema?
Swelling of the limbs
What 3 signs in the hands are associated with infective endocarditis?
- Splinter haemorrhages
- Janeway lesions
- Osler nodes
What 5 major signs are you examining for during general inspection of the hands?
- Colour
- Tar staining
- Finger clubbing
- Xanthomata
- Arachnodactyly
Major cardiac differential diagnosis for pallor of hands?
Congestive heart failure
What are xanthomata?
Raised yellow cholesterol-rich deposits that are often noted on the palm, tendons of the wrist and elbow
What do xanthomata indicate?
Hyperlipidaemia
Most common cause of hyperlipidaemia?
Familial hypercholesterolaemia - this is a risk factor for cardiovascular disease
What are arachnodactyly?
‘Spider fingers’ - fingers and toes are abnormally long and slender, in comparison to the palm of the hand and arch of the foot
What condition is arachnodactyly a feature of?
Marfans syndrome
What 2 cardiac defects is Marfans associated with?
- Mitral/aortic valve prolapse
2. Aortic dissection
3 most common cardiac causes of finger clubbing?
- Congenital cyanotic heart disease
- Infective endocarditis
- Atrial myxoma (very rare)
How do you assess for finger clubbing?
- Ask the patient to place the nails of their index fingers back to back.
- In a healthy individual, you should be able to observe a small diamond-shaped window (known as Schamroth’s window)
- When finger clubbing develops, this window is lost.
Differences between Osler’s nodes and Janeway lesions?
Oslers:
- Tender
- Red/purple
- Slightly raised
- Often pale centre
- Found on fingers or toes
Janeway:
- Non-tender
- Found on thenar and hypothenar eminences
How do you assess patient’s temperature?
Place the dorsal aspect of your hand onto the patient’s to assess temperature
What condition is cool and clammy hands associated with?
Acute coronary syndrome
What differential diagnosis would cool hands indicate?
Poor peripheral perfusion (e.g. congestive cardiac failure, acute coronary syndrome)
How do you assess capillary refill time?
Apply five seconds of pressure to the distal phalanx of one of a patient’s fingers and then release.
In healthy individuals, what is the normal CRT?
<2 seconds
What is the next step needed if the CRT is >2 seconds?
Need to assess central capillary refill time
What does a CRT >2 seconds indicate?
Poor peripheral perfusion (e.g. hypovolaemia, congestive heart failure)
For irregular heart rhythms, how long should you measure the pulse for?
60 seconds
What type of resting heart rate is typically seen in athletic individuals?
Bradycardia
Most common cause of irregular heart rhythm?
Atrial fibrillation
What is radio-radial delay?
Radio-radial delay describes a loss of synchronicity between the radial pulse on each arm, resulting in the pulses occurring at different times.
3 most common causes of radio-radial delay?
- Subclavian artery stenosis (e.g. compression by a cervical rib)
- Aortic dissection
- Aortic coarctation
What is a collapsing pulse?
A forceful pulse that rapidly increases and subsequently collapses.
3 most common causes of a collapsing pulse?
- Normal physiological states (e.g. fever, pregnancy)
- Cardiac lesions (e.g. aortic regurgitation, patent ductus arteriosus)
- High output states (e.g. anaemia, arteriovenous fistula, thyrotoxicosis)
What normal physiological states can cause a collapsing pulse?
Fever
Pregnancy
What high output states can cause a collapsing pulse?
Anaemia
Arteriovenous fistula
Thyrotoxicosis
What condition is a slow rising pulse associated with?
Aortic stenosis
What condition is a bounding pulse associated with?
Aortic regurgitation
Co2 retention
What condition is a thready pulse associated with?
Intravascular hypovolaemia e.g. sepsis
What blood pressure is defined as hypertension if under 80 years old?
> /= 140/90 mmHg
What blood pressure is defined as hypertension if over 80 years old?
> /= 150/90 mmHg
What blood pressure is defined as hypotension?
< 90/60 mmHg
What is a ‘narrow pulse pressure’ defined as?
Less than 25 mmHg of difference between the systolic and diastolic blood pressure
3 major causes of a narrow pulse pressure?
- Aortic stenosis
- Congestive heart failure
- Cardiac tamponade
What is a ‘wide pulse pressure’ defined as?
More than 100 mmHg of difference between systolic and diastolic blood pressure
2 major causes of a wide pulse pressure?
- Aortic regurgitation
2. Aortic dissection
A difference of more than 20 mmHg difference in blood pressure between each arm is abnormal and may suggest which cardiac abnormality?
Aortic dissection
Where is the carotid pulse located?
Between the larynx and the anterior border of the sternocleidomastoid muscle.
Prior to palpating the carotid artery, you need to auscultate the vessel. Why?
To rule out the presence of a bruit
What is a bruit?
A bruit is an audible vascular sound associated with turbulent blood flow.
What does the presence of a bruit indicate when auscultating the carotid artery?
Underlying carotid stenosis
Why is it essential to know if a bruit is present or not before palpating the carotid artery?
Carotid stenosis makes palpation of the vessel potentially dangerous due to the risk of dislodging a carotid plaque and causing an ischaemic stroke.
Be aware that at this point in the examination, the presence of a ‘carotid bruit’ may, in fact, be what?
A radiating cardiac murmur (e.g. aortic stenosis).
When palpating the carotid artery, why should the patient be positioned safely on the bed?
As there is a risk of inducing reflex bradycardia when palpating the carotid artery (potentially causing a syncopal episode)
What is there risk of inducing when palpating the carotid artery?
Reflex bradycardia (potentially causing a syncopal episode)
What does the jugular venous pressure (JVP) provides an indirect measure of? Why?
Central venous pressure
This is possible because the internal jugular vein (IJV) connects to the right atrium without any intervening valves, resulting in a continuous column of blood.
The presence of this continuous column of blood means that changes in right atrial pressure are reflected in the IJV (e.g. raised right atrial pressure results in distension of the IJV).
How would a raised right atrial pressure affect the IJV?
Would distend it
Position of patient’s head when measuring the JVP?
Ask the patient to turn their head slightly to the left.
How is the JVP measured?
Assess the vertical distance between the sternal angle and the top of the pulsation point of the IJV
In healthy individuals, what should the vertical distance between the sternal angle and the top of the pulsation point of the IJV be?
No greater than 3 cm
What does a raised JVP indicate the presence of?
Venous hypertension
What are the 3 major cardiac causes of a raised JVP?
- Right sided heart failure
- Tricuspid regurgitation
- Constrictive pericarditis
Name 2 causes of tricuspid regurgitation
Infective endocarditis
Rheumatic heart disease
What does the hepatojugular reflux test involve?
Application of pressure to the liver whilst observing for a sustained rise in JVP
In healthy individuals, how long should the IJV rise during the hepatojugular reflux test be?
The rise should last no longer than 1-2 cardiac cycles (it should then fall)
What is deemed a ‘positive result’ during the hepatojugular reflux test?
If the rise in JVP is sustained and equal to or greater than 4cm
Why should the hepatojugular reflux test only be carried out when deemed necessary?
Can be uncomfortable for patients
What does a positive hepatojugular reflux result suggest about the condition of the heart?
Suggests the right ventricle is unable to accommodate an increased venous return, but it is not diagnostic of any specific condition
Name 4 conditions that frequently produce a positive hepatojugular reflux test
- Constrictive pericarditis
- Right ventricular failure
- Left ventricular failure
- Restrictive cardiomyopathy
When inspecting the patient’s eyes, which 4 signs are you looking for?
- Conjunctival pallor
- Corneal arcus
- Xanthelasma
- Kayser-Fleischer rings
What condition would conjunctival pallor indicate?
Anaemia
What is corneal arcus?
A hazy white, grey or blue opaque ring located in the peripheral cornea
Who does corneal arcus typically occur in?
Patients over 60 (considered benign)
What would corneal arcus in patients under 50 suggest?
Underlying hypercholesterolaemia
What are xanthelasma?
Yellow, raised cholesterol-rich deposits around the eyes
What condition are xanthelasma associated with?
Hypercholesterolaemia
What are Kayser-Fleischer rings?
Dark rings that encircle the iris
What condition is Kayser-Fleischer rings associated with?
Wilson’s disease
What is Wilson’s disease?
Abnormal copper processing by the liver, resulting in accumulation and deposition in various tissues
How can Wilson’s disease affect the heart?
Cardiomyopathy (due to accumulation and deposition of copper)
When inspecting the patient’s mouth, which 4 signs are you looking for?
- Central cyanosis
- Angular stomatitis
- High arched palate
- Dental hygiene
How would central cyanosis present?
Bluish discolouration of the lips and/or the tongue
What is angular stomatitis?
A common inflammatory condition affecting the corners of the mouth
Which deficiency is one cause of angular stomatitis?
Iron deficiency
Which condition is a high arched palate a feature of?
Marfans
Which cardiac abnormalities is Marfans associated with?
- Mitral/aortic valve prolapse
2. Aortic dissection
What is poor dental hygiene a risk factor for?
Infective endocarditis
What is pectus excavatum?
a caved-in or sunken appearance of the chest
What is pectus carinatum?
a protrusion of the sternum and ribs
A forceful apex beat may be visible secondary to underlying…?
Ventricular hypertrophy
What would a median sternotomy scar indicate?
This surgical approach is used for cardiac valve replacement and coronary artery bypass grafts (CABG)
What would an anterolateral thoracotomy scar indicate?
This surgical approach is used for minimally invasive cardiac valve surgery.
Where is an anterolateral thoracotomy scar located?
Located between the lateral border of the sternum and the mid-axillary line at the 4th or 5th intercostal space.
What would an infraclavicular scar indicate?
This surgical approach is used for pacemaker insertion.
What would a left mid-axillary scar indicate?
this surgical approach is used for the insertion of a subcutaneous implantable cardioverter-defibrillator (ICD).
Which 3 things are you assessing when palpating the chest?
- Apex beat
- Heaves
- Thrills
How do you palpate the apex beat? Location?
Palpate the apex beat with your fingers placed horizontally across the chest.
5th intercostal space in the midclavicular line
What cardiac abnormality can cause displacement of the apex beat from its usual location?
Ventricular hypertrophy
What is a parasternal heave?
A parasternal heave is a precordial impulse that can be palpated.
Position of hand when palpating heaves?
Place the heel of your hand parallel to the left sternal edge (fingers vertical) to palpate for heaves.
How can you tell if heaves are present?
If heaves are present you should feel the heel of your hand being lifted with each systole.
Are parasternal heaves associated with right or left ventricular hypertrophy?
RIGHT ventricular hypertrophy
What is a thrill?
A thrill is a palpable vibration caused by turbulent blood flow through a heart valve (a thrill is a palpable murmur).
How do you assess for thrills?
You should assess for a thrill across each of the heart valves in turn.
To do this place your hand horizontally across the chest wall, with the flats of your fingers and palm over the valve to be assessed.
Location of the mitral valve?
5th intercostal space in the midclavicular line
Location of the tricuspid valve?
4th or 5th intercostal space at the lower left sternal edge
Location of the pulmonary valve?
2nd intercostal space at the left sternal edge
Location of the aortic valve?
2nd intercostal space at the right sternal edge
What is the first step during auscultation of the heart valves?
Palpate the carotid pulse to determine the first heart sound
Should you use the bell or diaphragm of the stethoscope when auscultating the heart valves?
Diaphragm and then repeat auscultation across the four valves with the bell
What type of sounds is the bell of the stethoscope is more effective at detecting?
Low frequency sounds
What type of sounds is the diaphragm of the stethoscope is more effective at detecting?
High frequency sounds
Would the bell or diaphragm be better at detecting the mid-diastolic murmur of mitral stenosis?
Bell (low frequency)
Would the bell or diaphragm be better at detecting the ejection systolic murmur of aortic stenosis?
Diaphragm (high frequency)
When auscultating the lung fields posteriorly, what would coarse crackles indicate?
Pulmonary oedema (associated with left ventricular failure)
What would stony dullness on percussion of the lung fields posteriorly suggest?
suggestive of an underlying pleural effusion (associated with left ventricular failure)
You should inspect the patient’s legs for evidence of saphenous vein harvesting. What would this indicate?
Performed as part of a coronary artery bypass graft
