Cardio Flashcards
What does cyanosis indicate?
= a bluish discolouration of the skin due to poor circulation (e.g. peripheral vasoconstriction secondary to hypovolaemia) or inadequate oxygenation of the blood (e.g. right-to-left cardiac shunting).
What does SOB indicate?
underlying cardiovascular (e.g. congestive heart failure, pericarditis) or respiratory disease (e.g. pneumonia, pulmonary embolism
What does pallor indicate?
= a pale colour of the skin that can suggest underlying anaemia (e.g. haemorrhage, chronic disease) or poor perfusion (e.g. congestive cardiac failure).
It should be noted that a healthy individual may have a pale complexion that mimics pallor, however, pathological causes should be ruled out
What is Malar flush?
plum-red discolouration of the cheeks associated with mitral stenosis.
What does oedema indicate?
typically presents with swelling of the limbs (e.g. pedal oedema) or abdomen (i.e. ascites). There are many causes of oedema, but in the context of a cardiovascular examination OSCE station, congestive heart failure is the most likely culprit
Medical paraphernalia to look for
Medical equipment: note any oxygen delivery devices, ECG leads, medications (e.g. glyceryl trinitrate spray), catheters (note volume/colour of urine) and intravenous access.
Mobility aids: items such as wheelchairs and walking aids give an indication of the patient’s current mobility status.
Pillows: patients with congestive heart failure typically suffer from orthopnoea, preventing them from being able to lie flat. As a result, they often use multiple pillows to prop themselves up.
Vital signs: charts on which vital signs are recorded will give an indication of the patient’s current clinical status and how their physiological parameters have changed over time.
Fluid balance: fluid balance charts will give an indication of the patient’s current fluid status which may be relevant if a patient appears fluid overloaded or dehydrated.
Prescriptions: prescribing charts or personal prescriptions can provide useful information about the patient’s recent medications.
Colour inspection of hands
pallor suggests poor peripheral perfusion (e.g. congestive heart failure) and cyanosis may indicate underlying hypoxaemia
Tar staining in hands
caused by smoking, a significant risk factor for cardiovascular disease (e.g. coronary artery disease, hypertension).
Xanthomata in hands
raised yellow cholesterol-rich deposits that are often noted on the palm, tendons of the wrist and elbow. Xanthomata are associated with hyperlipidaemia (typically familial hypercholesterolaemia), another important risk factor for cardiovascular disease (e.g. coronary artery disease, hypertension)
Arachnodactyly
(‘spider fingers’): fingers and toes are abnormally long and slender, in comparison to the palm of the hand and arch of the foot. Arachnodactyly is a feature of Marfan’s syndrome, which is associated with mitral/aortic valve prolapse and aortic dissection
Finger clubbing
= uniform soft tissue swelling of the terminal phalanx of a digit with subsequent loss of the normal angle between the nail and the nail bed.
Associated with several underlying disease processes, but those most likely to appear include congenital cyanotic heart disease, infective endocarditis and atrial myxoma (very rare)
Hand signs associated with infective endocarditis
Splinter haemorrhages: a longitudinal, red-brown haemorrhage under a nail that looks like a wood splinter. Causes include local trauma, infective endocarditis, sepsis, vasculitis and psoriatic nail disease.
Janeway lesions: non-tender, haemorrhagic lesions that occur on the thenar and hypothenar eminences of the palms (and soles). Janeway lesions are typically associated with infective endocarditis.
Osler’s nodes: red-purple, slightly raised, tender lumps, often with a pale centre, typically found on the fingers or toes. They are typically associated with infective endocarditis
Capillary refill time - how to do it and interpretation
Apply five seconds of pressure to the distal phalanx of one of a patient’s fingers and then release.
In healthy individuals, the initial pallor of the area you compressed should return to its normal colour in less than two seconds.
A CRT that is greater than two seconds suggests poor peripheral perfusion (e.g. hypovolaemia, congestive heart failure) and the need to assess central capillary refill time.
Causes of radio-radial delay
Subclavian artery stenosis (e.g. compression by a cervical rib)
Aortic dissection
Aortic coarctation
Collapsing pulse - how to do it
A collapsing pulse is a forceful pulse that rapidly increases and subsequently collapses. It is also sometimes referred to as a ‘water hammer pulse’.
(while lifting arm, palpate radial and brachial pulse and may feel tapping)
Causes of 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)
Pulse character assessment
Normal
Slow-rising (associated with aortic stenosis)
Bounding (associated with aortic regurgitation as well as CO2 retention)
Thready (associated with intravascular hypovolaemia in conditions such as sepsis)
Blood pressure abnormalities
Hypertension: blood pressure of greater than or equal to 140/90 mmHg if under 80 years old or greater than or equal to 150/90 mmHg if you’re over 80 years old.
Hypotension: blood pressure of less than 90/60 mmHg.
Narrow pulse pressure: less than 25 mmHg of difference between the systolic and diastolic blood pressure. Causes include aortic stenosis, congestive heart failure and cardiac tamponade.
Wide pulse pressure: more than 100 mmHg of difference between systolic and diastolic blood pressure. Causes include aortic regurgitation and aortic dissection.
Difference between arms: more than 20 mmHg difference in blood pressure between each arm is abnormal and may suggest aortic dissection.
Causes of raised JVP
Right-sided heart failure: commonly caused by left-sided heart failure. Pulmonary hypertension is another cause of right-sided heart failure, often occurring due to chronic obstructive pulmonary disease or interstitial lung disease.#
Tricuspid regurgitation: causes include infective endocarditis and rheumatic heart disease.
Constrictive pericarditis: often idiopathic, but rheumatoid arthritis and tuberculosis are also possible underlying causes.
Hepatojugular reflux
A positive hepatojugular reflux result suggests the right ventricle is unable to accommodate an increased venous return, but it is not diagnostic of any specific condition. The following conditions frequently produce a positive hepatojugular reflux test:
Constrictive pericarditis
Right ventricular failure
Left ventricular failure
Restrictive cardiomyopathy
Conjunctival pallor
underlying anaemia
Corneal arcus
a hazy white, grey or blue opaque ring located in the peripheral cornea, typically occurring in patients over the age of 60. In older patients, the condition is considered benign, however, its presence in patients under the age of 50 suggests underlying hypercholesterolaemia
Xanthelasma eyes
yellow, raised cholesterol-rich deposits around the eyes associated with hypercholesterolaemia
Kayser-Fleischer rings
dark rings that encircle the iris associated with Wilson’s disease. The disease involves abnormal copper processing by the liver, resulting in accumulation and deposition in various tissues (including the heart where it can cause cardiomyopathy
Central cyanosis
bluish discolouration of the lips and/or the tongue associated with hypoxaemia (e.g. a right to left cardiac shunt)
Angular stomatitis
a common inflammatory condition affecting the corners of the mouth. It has a wide range of causes including iron deficiency
High arched palate
= feature of Marfan’s
associated with mitral/aortic valve prolapse and aortic dissection
Dental hygiene
poor dental hygiene = risk factor for infective endocarditis
Pectus excavatum
a caved-in or sunken appearance of the chest
Pectus carinatum
protrusion of the sternum and ribs
Visible pulsations on chest
forceful apex beat may be visible secondary to underlying ventricular hypertrophy
Midline/median sternotomy scar
located in midline of thorax
used for cardiac valve replacement and CABG
Anterolateral thoracotomy scar
located between lateral border of sternum and mid-axillary line at 4th or 5th intercostal space
used for minimally invasive cardiac valve surgery
Infraclavicular scar
used for pacemaker insertion
(inspect/palpate for pacemaker)
Left mid-axillary scar
used for insertion of ICD
Displaced apex beat
(not in 5th intercostal space MCL)
ventricular hypertrophy
Parasternal heave
= precordial impulse that can be palpated using heel of hand parallel to left sternal edge (fingers vertical)
associated with right ventricular hypertrophy
Thrills
= palpable vibrations caused by turbulent blood flow through a valve (ie palpable murmur)
use flats of finger and palm over each valve
Mitral valve location
5th intercostal space MCL
Tricuspid valve location
4th or 5th intercostal space lower left sternal edge
Pulmonary valve location
2nd intercostal space left sternal edge
Aortic valve location
2nd intercostal space right sternal edge
Aortic stenosis
Ejection systolic murmur at 2nd ICS RSE
radiation to carotids
loudest on expiration
Aortic regurgitation
Early diastolic murmur heart at 2nd ICS RSE
accentuation: listen at the lower left sternal border with the patient sat forward during expiration
Mitral regurgitation
pansystolic murmur at apex
accentuation: roll patient on left and listen during expiration, radiation into axilla
Mitral stenosis
mid-diastolic murmur over apex
accentuation: patient on left side and listen during expiration
Posterior chest wall (cardio)
3 things
inspect for scars or deformities (eg. posterolateral thoracotomy scar for previous lung surgery)
Auscultate:
coarse crackles = pulmonary oedema (LVF)
absent air entry = pleural effusion (LVF)
palpate for sacral edema
Legs (cardio)
Inspect and palpate for pitting oedema (RVF)
Inspect for saphenous vein harvesting (CABG)
To complete cardio exam
Take full history
?resp/abdo exam
Measure BP (hypertension, aortic dissection)
Peripheral vascular exam
ECG (arrhythmias/MI)
Urine dip (proteinuria or haematuria associated with htn)
Capillary blood glucose (dm)
Fundoscopy (papilloedema htn)
