Cardio Flashcards
What are the most common cardiac problems? (5)
- Myocardial infarction
- Angina
- HR abnormalities e.g atrial fibrillation
- Heart failure
- Heart valve disease e.g stenosis
What position should a patient be in for a cardiac exam?
Semi supine - 45 degrees
What needs to be exposed for cardiac exam?
Chest
What are the end of bed observations that can be made in a cardiac exam? (7)
- Oxygen mass
- GTN sprays
- Walking aids
- Drip stand
- Nebuliser
- Urinary catheter
- Snacks
What features of a patient can be seen from their general appearance relevant to a cardio exam? (10)
- In pain?
- Unwell?
- Breathless?
- Obvious scars?
- Drips/inhalers/oxygen?
- Cyanosis?
- Pallor?
- Oedema?
- Down’s Syndrome?
- Marfan’s?
List the order for body areas to examine (16)
- Hands and nails
- Radial pulse
- Respiratory rate
- Collapsing pulse
- Radio-radial delay
- Radio-femoral delay
- Blood pressure and brachial pulse
- Neck
- Face
- Eyes
- Mouth
- Chest
- Arteries (renal, femoral, aorta)
- Spine base
- Lung bases
- Foot pulses (popliteal/posterior tibilal/dorsalis pedis)
- Feet and ankles
What is looked for on the hands with palms facing downwards? (4)
- Clubbing
- Splinter haemorrhages
- Capillary refill time
- Temperature
What are splinter haemorrhages a sign of? (2)
- Infective endocarditus
- Trauma
What is clubbing?
Loss of angle/Schamroth’s window between nail and nail bed
What is Schamroth’s window?
Diamond shaped window in healthy individual between nails back to back
How does one observe clubbing?
Ask patient to place nails of their index fingers back to back
What are the cardiac diseases associated with clubbing? (3)
- Endocarditis
- Cyanotic congenital heart disease
- Atrial myxoma - non cancerous tumour in upper L/R heart side
How do you check for capillary refill time?
Press down on patient fingernail for 5 secs and time for when blood returns
When does capillary refill time suggest abnormality?
Longer than 2 seconds
What can a long capillary refill time suggest?
Hypovolaemia
What can be seen with the palms facing upwards? (7)
- Osler’s nodes
- Janeway lesions
- Dupuytren’s contracture
- Colour/peripheral cyanosis
- Tar staining
- Xanthomata
- Palmar erythema
What is Dupenytren’s contracture?
Small hard nodules just over skin of palm (thickening of palmar fascia) - worsens over time until fingers can no longer straightened
What does Dupenytren’s contracture suggest? (7)
- Increased alcohol usage
- Liver cirrhosis
- Diabetes
- Trauma
- Increased age
- Smoking
- Family history
What are Osler’s nodes?
Painful red purple raised lumps with a pale centre at fingers and toes
What do Osler’s nodes suggest?
Infective endocarditis
What are Janeway lesions?
Rare non Painful, erythematous small maculopapular palm/sole lesions
What do Janeway lesions indicate?
Bacterial endocarditis
What is xanthomata in hands?
Raised yellow lesions (mostly on wrist tendons)
What does xanthomata suggest?
Hyperlipidaemia
What is the first pulse felt for in a cardio exam?
Radial pulse
What is assessed in radial pulse? (2)
- Rate
- Rhythm
What are the 3 types of rate rhythm?
- Regular
- Regularly irregular
- Irregularly irregular
What does an irregularly irregular rhythm suggest? (3)
- Atrial fibrillation
- Wandering atrial pacemaker
- Multifocal atrial tachycardia
What does regularly irregular rate rhythm suggest?
Sinus arrhythmia
How is collapsing pulse assessed?
- Ensure no shoulder pain
- Palpate radial pulse
- Raise arm above head briskly
- Pulse falls away from wrist after 30 secs
- Tapping impulse in arm muscle bulk
= positive sign
What is collapsing pulse also known was?
Water hammer pulse
What is collapsing pulse caused by?
Blood empties quickly from arm in diastole
What can collapsing pulse indicate in normal physiological states?
- Fever
- Pregnancy
What cardiac problems can collapsing pulse indicate? (5)
- Aortic regurgitation
- Patent ductus arteriosus
- Anaemia
- AV fistula
- Thyrotoxicosis
What is assessed in a brachial pulse? (2)
- Volume
- Character
What is radio-radio delay?
Inequality between 2 radial pulses
What does radio-radio delay suggest? (3)
- Aortic coarctation (congenital narrowing)
- Aortic aneurysm
- Thoracic inlet syndrome
What does radio-femoral delay suggest? (2)
- Aortic coarctation (congenital narrowing
- Aortic embolism/thrombosis
What is assessed in brachial pulse? (2)
- Volume
- Character
How do you measure blood pressure?
Make notes
What is narrow pulse pressure associated with?
Aortic stenosis
What is wide pulse pressure associated with?
Aortic regurgitation
What would you ideally carry out with blood pressure that you can’t due to time constraints?
Measure in both arms
What is assessed in the neck in a cardio exam? (2)
- Carotid pulse
- JVP
What is assessed in carotid pulse? (2)
- Character
- Volume
What does a slow rising character carotid pulse indicate?
Aortic stenosis
How should someone examine the cartoid?
- Auscultate for a bruit before palpating
- Theoretically palpation = dislodge plaque = stroke
What 2 things could a “bruit” on auscultating the carotid indicate?
- Clot
- Radiating murmur
How is JVP assessed? (5)
- Position patient reclined semi supine 45 degrees
- Turn patient head away from you
- Observe for JVP
- Measure JVP
- Hepatojugular reflux
Where would the JVP be observed?
Internal jugular - pulsation L side of neck behind sternocleidomastoid
How is JVP measured?
Number of centimetres vertically from sternal angle to upper border of pulsation
What should JVP be less than?
4cm high
What is JVP a proxy measure of?
Right atrial pressure
What does raised JVP indicate? (3)
- Fluid overload
- Right ventricular failure
- Tricuspid regurgitation
How is the hepatojugular reflux illicited?
- Apply pressure to liver
- Observe JVP for rise
- Sustained longer than 1-2 cardiac cycles + greater than 4cm rise = positive result
What is a positive hepatojugular reflux sign suggestive of? (2)
- Right sided heart failure
- Tricuspid regurgitation
What abnormal colours can be found in the face? (2)
- Pallor
- Malar (high cheek) flush
What is malar flush a sign of?
Mitral stenosis
What signs can be found in the eyes? (3)
- Conjunctival pallor
- Corneal arcus
- Xanthelasma
How can conjunctival pallor be assessed?
Ask patient to pull down lower eyelid
What does conjunctival pallor indicate?
Anaemia
What does corneal arcus look like?
Yellowish/grey ring surrounding iris/peripheral cornea
What does corneal arcus indicate?
Hypercholesterolaemia
What is xanthelasma?
Yellow raised lesons/deposits around eyelids
What does xanthelasma indicate?
Hypercholesterolaemia
What can fundoscopy find? (2)
- Diabetic retinopathy
- Hypertensive retinopathy
What is retinopathy?
Damage to retina
What is assessed in the mouth? (3)
- Central cyanosis
- Angular stomatitis
- High arched palate
What indicates central cyanosis in the mouth?
- Patient sticks out tongue
- Bluish discolouration of lips/tongue
What is angular stomatitis?
Inflammation of the corners of the mouth
What does angular stomatitis indicate?
Iron deficiency
What does a high arched palate indicate? (2)
- Risk of aortic aneurysm/dissection
- Marfan syndrome
How should the patient position themselves to view scars on the chest?
Hands on hips
What scars should be looked for on inspection of the chest? (4)
- Midline sternotomy
- Lateral thoractomy
- Clavicular
- Left midaxillary line
What surgeries leave a midline sternotomy scar? (4)
- Open heart surgery
- Valve replacement
- Cardiac transplant
- Coronary artery bypass graft (CABG)
What surgeries leave a lateral thoractomy?
Minimally invasive valve surgery
Where is the lateral thoractomy scar found?
Under axilla
What do clavicular scars indicate?
Pacemaker
What do scars in the left midaxillary line indicate?
Subcutaneous implantable cardioverter defibrillator (ICD)
What do chest wall deformities indicate? (2)
- Pectus excavatum
- Pectus carinatum
What do visible pulsations of the apex beat indicate? (2)
- Ventricular hypertrophy
- Hypertension
What is palpated for in a cardio exam? (3)
- Apex beat
- Thrills
- Heaves
How is an apex beat palpated for? (3)
- Lean patient to left side
- 5th intercostal space
- Midclavicular line
What does lateral displacement of the apex beat suggest?
Cardiomegaly
What do heaves indicate?
Right ventricular hypertrophy
How are heaves palpated for? (3)
- Place heel of hand parallel to the left sternal edge
- Fingers vertical
- Feel hand lifted in systole
How are thrills palpated for? (3)
- Palpable vibration
- Across each heart valve
- Place hand flat horizontally across chest wall
What are thrills caused by?
Turbulent blood flow through a heart valve
What areas of the chest are auscultated for? (5)
- Carotid pulse
- Mitral area
- Tricuspid area
- Pulmonary area
- Aortic area
Where is the mitral area of the chest ausculated for? (2)
- 5th intercostal space
- Mid clavicular line
Where is the tricuspid area of the chest ausculated for? (2)
- 4th intercostal space
- Left sternal edge
Where is the pulmonary area of the chest ausculated for? (2)
- 2nd intercostal space
- Left sternal edge
Where is the aortic area of the chest ausculated for? (2)
- 2nd intercostal space
- Right sternal edge
What heart sounds are listened for? (4)
- S1
- S2
- Silence between S1 and S2
- Murmurs
What does S1 indicate? (2)
- Tricuspid and mitral valve closing
- Ventricular systole
What does S2 indicate? (2)
- Pulmonary valve and aortic valve closure
- Systole end
What does the silence between S1 and S2 indicate? (2)
- Diastole
- Ventricular filling
List the order of areas auscultated in a cardio exam (6)
- All 4 valves with diaphragm (+palpate carotid)
- Roll patient over to left: apex with bell (Mitral stenosis)
- Carotids with held breath (bruits+aortic stenosis)
- Breathe all way out + hold breath (aortic regurgitatin)
- Lung bases
How/what are the carotids auscultated for? (2)
- Auscultate with patient holding breath
- Aortic stenosis/bruits
How/what is the aortic regurgitation auscultated for?
- Full expiration
- Hold breath
- Left sternal edge
- Aortic regurgitation
How/what is mitral stenosis further auscultated for? (4)
- With bell
- Roll patient over onto left lateral side
- During expiration
- Radiates to axilla
Why is the murmur of aortic regurgitation louder on expiration?
Increased venous return
What does a murmur heard in the mitral area indicate?
Mitral stenosis
How is aortic regurgitation listened for? (4)
- Breathe all the way out and hold breath
- Listen over left sternal edge
- Blowing diastolic sound
- Radiates to carotids
What are listened for in lung bases in a cardio exam?
Crackles on inspiration
What do crackles in lung bases indicate in a cardio exam? (2)
- Pulmonary oedema (e.g. secondary to left ventricular failure)
- If no fluid overload: chronic lung diseases
Why is the spine base palpated in a cardio exam?
Sacral oedema
What does oedema indicate?
Right ventricular failure
What arteries are auscultated for bruits? (3)
- Renal artery
- Femoral artery
- Aorta
What is a bruit?
Turbulent blood flow
Where is the renal artery auscultated for?
Inferior to and either side of umbilicus
What pathologies are looked for in a patients feet and ankles in a cardio exam? (4)
- Ischaemia
- Venous disease
- Peripheral oedema
- Palpate foot pulses
What are the signs of ischaemia in a patient’s feet and ankles in a cardio exam? (3)
- Blue toes and feet
- Hair loss on leg front
- Ulcers
What are the signs of venous disease in a patient’s feet and ankles in a cardio exam? (3)
- Ulcers
- Dilated large and small veins
- Brown pigmentation from haemosidesin deposits
What finger is used to palpate peripheral oedema?
Index middle finger
What foot pulses are palpated for? (2)
- Dorsalis pedis
- Posterior tibial
- Popliteal
What further exams could be carried out after a cardio exam? (5)
- Full peripheral vascular examination
- 12-lead ECG
- Dipstick urine
- Bedside capillary blood glucose – diabetes
- Fundoscopy
How is the dorsalis pedis palpated for? (3)
- Plantar flexion to find extensor tendon of the great toe
- Lateral to this
- At level of navicular bone
How is the posterior tibial palpated for?
Behind and below medial malleolus
How is the popliteal palpated for? (4)
- Flex knee
- Thumbs on tibial tuberosity
- Curl your fingers into the popliteal fossa
- Compress the popliteal artery against the tibia
How can a murmur be checked for being a systolic murmur?
Palpate carotid at same time, see if starts with pulse
