Cardio exam Flashcards
things to ask
- rate and rhythm and volume for pulse
- find carotid pulse - comment on character and volume
where is the radial pulse located
The location is just lateral to the tendon of flexor carpi radialis and medial to the radial styloid process.
what things are you looking for on inspection
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?
what is normal rate
normal=60-100. Low=bradycardia, high=tachycardia
what is the cause of bradycardia
hypothyroidism, β-blockers, heart block
what is the cause of tachycardia
hyperthyroidism, anxiety, β2-agonists (salbutamol etc), hypovolaemia
what is irregular rhythm
- Sinus arrhythmia – Normal and physiological. The heart speeds up with inspiration, and slows down with expiration. Can be quite pronounced in younger patients.
- Irregularly irregular – atrial fibrillation
- 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.
- Ventricular ectopic beats
where is the JVP
a. Have patient look slightly to the left and look between the two heads of the sternocleidomastoid muscle
why is JVP measured from the sternal angle
b. The JVP is measured from the sternal angle, because the right atria lies about 5cm below this point.
what is the normal JVP
- it is 3cm or less
what do you do to make the JVP rise
- hepatojulglar reflex - apply pressure over the liver
- it should rise 2cm
how do you differentiated the JVP from the carotid
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.
where is the apex beat
5th intercostal space, midclavicular line
how do you measure JVP
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°
what is the cause of JVP failure
Right-sided heart failure
o Pulmonary hypertension (e.g. due to pulmonary obstructive
disease)
what other examinations would you do
ECG
blood pressure
respiratory examination
why do you listen to the carotid pulse at the same time as asculatation
The heart sound you hear when you first feel the pulse is S1, and when the pulse disappears is S2.
what is clubbing
this is the loss of the angle of the nail bed and finger - which is the hyponychial angle
how do you check for clubbing
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.
what does conjunctival rim pallor make more likely
A finding of Conjunctival Rim Pallor makes it 16.7 times more likely that the Hb is <11g/dL
what does a conjunctival rim pallor positive sign mean
It is positive if the conjunctival rim (r in the picture) is the same colour as the more proximal conjunctiva (p)
where does the internal jugular vein enter the neck
Internal jugular vein enters the neck between the two heads of SCM.
where does the carotid artery run
the carotid artery runs down the side of the thyroid cartilage just between trachea and SCM slightly under the SCM
why is the level of JVP important
it represents the preload on the heart (right arterial pressure) as it empties into it
what does it mean if you cannot see the JVP
healthy or hypovolaemic
what does it mean if you can see the JVP
heart failure
how do you elicit the JVP
o Lie patient flatter, look for pulse entering the neck
o Hepatojugular reflex
o Filling and then emptying external jugula
what can caused a displaced apex beat
- this might be due to an enlarged heart
- if the heart is being pushed or pulled to the side by lung pathology
what happens when there are irregular cardiac contractions
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
what should heart rate be taken from when considering rate control
Heart rate when considering Rate Control should, therefore, be taken from the heart via auscultation or ECG, not arterial pulse rate
heart rate in atrial fibrillation should always…
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)
