Cardio exam

Question 1

things to ask

Answer 1

• rate and rhythm and volume for pulse

- find carotid pulse - comment on character and volume

Question 2

where is the radial pulse located

Answer 2

The location is just lateral to the tendon of flexor carpi radialis and medial to the radial styloid process.

Question 3

what things are you looking for on inspection

Answer 3

i. Patient well or unwell? Are they short of breath at rest? Obvious cyanosis? Pallor? Sweating? Are they cachexic? Peripheral oedema? Any chest deformity – pectus excavatum/carinatum? Obvious scars?

Question 4

what is normal rate

Answer 4

normal=60-100. Low=bradycardia, high=tachycardia

Question 5

what is the cause of bradycardia

Answer 5

hypothyroidism, β-blockers, heart block

Question 6

what is the cause of tachycardia

Answer 6

hyperthyroidism, anxiety, β2-agonists (salbutamol etc), hypovolaemia

Question 7

what is irregular rhythm

Answer 7

1. Sinus arrhythmia – Normal and physiological. The heart speeds up with inspiration, and slows down with expiration. Can be quite pronounced in younger patients.
2. Irregularly irregular – atrial fibrillation
3. Regularly irregular – rate is not regular there is a pattern to the irregularity. For example second degree heart blocks resulting in intermittently non-conducting P waves, resulting in skipped beats.
4. Ventricular ectopic beats

Question 8

where is the JVP

Answer 8

a. Have patient look slightly to the left and look between the two heads of the sternocleidomastoid muscle

Question 9

why is JVP measured from the sternal angle

Answer 9

b. The JVP is measured from the sternal angle, because the right atria lies about 5cm below this point.

Question 10

what is the normal JVP

Answer 10

• it is 3cm or less

Question 11

what do you do to make the JVP rise

Answer 11

• hepatojulglar reflex - apply pressure over the liver

- it should rise 2cm

Question 12

how do you differentiated the JVP from the carotid

Answer 12

i. JVP has 2 pulsations, carotid has 1
ii. JVP is obliterated on palptation (therefore it cannot be palptated), the carotid can be palpated
iii. Hepatojugular reflex augments JVP, doesn’t augment carotid
iv. JVP moves with respiration, carotid does not. JVP decreases with deep inspiration, increases with full expiration.

Question 13

where is the apex beat

Answer 13

5th intercostal space, midclavicular line

Question 14

how do you measure JVP

Answer 14

How to measure the height of the JVP:
o Draw a line perpendicular to the angle of Louis
o Measure the angle between that line and the highest point the JVP
is visible with the patient at 45°

Question 15

what is the cause of JVP failure

Answer 15

Right-sided heart failure
o Pulmonary hypertension (e.g. due to pulmonary obstructive
disease)

Question 16

what other examinations would you do

Answer 16

ECG
blood pressure
respiratory examination

Question 17

why do you listen to the carotid pulse at the same time as asculatation

Answer 17

The heart sound you hear when you first feel the pulse is S1, and when the pulse disappears is S2.

Question 18

what is clubbing

Answer 18

this is the loss of the angle of the nail bed and finger - which is the hyponychial angle

Question 19

how do you check for clubbing

Answer 19

Patients are often asked to put the nail beds of similar fingers together to look for a ‘diamond’ (‘Schamroth’s sign) if there is uncertainty. Usually clubbing is obvious.

Question 20

what does conjunctival rim pallor make more likely

Answer 20

A finding of Conjunctival Rim Pallor makes it 16.7 times more likely that the Hb is <11g/dL

Question 21

what does a conjunctival rim pallor positive sign mean

Answer 21

It is positive if the conjunctival rim (r in the picture) is the same colour as the more proximal conjunctiva (p)

Question 22

where does the internal jugular vein enter the neck

Answer 22

 Internal jugular vein enters the neck between the two heads of SCM.

Question 23

where does the carotid artery run

Answer 23

the carotid artery runs down the side of the thyroid cartilage just between trachea and SCM slightly under the SCM

Question 24

why is the level of JVP important

Answer 24

it represents the preload on the heart (right arterial pressure) as it empties into it

Question 25

what does it mean if you cannot see the JVP

Answer 25

healthy or hypovolaemic

Question 26

what does it mean if you can see the JVP

Answer 26

heart failure

Question 27

how do you elicit the JVP

Answer 27

o Lie patient flatter, look for pulse entering the neck
o Hepatojugular reflex
o Filling and then emptying external jugula

Question 28

what can caused a displaced apex beat

Answer 28

• this might be due to an enlarged heart

- if the heart is being pushed or pulled to the side by lung pathology

Question 29

what happens when there are irregular cardiac contractions

Answer 29

When there are irregular cardiac contractions, some will be out of time with complete ventricular filling, and so may not propagate into an arterial pulse wave. Therefore, the radial pulse rate is likely to be lower than the auscultatory heart rate

Question 30

what should heart rate be taken from when considering rate control

Answer 30

Heart rate when considering Rate Control should, therefore, be taken from the heart via auscultation or ECG, not arterial pulse rate

Question 31

heart rate in atrial fibrillation should always…

Answer 31

Heart rate in AF should always be measured over a prolonged period – the error rate is lowest the longer you time over (60 seconds is wise)