Cardio Year 2 Flashcards
what are you looking for when you look at the precordium
: inspect, palpate for heaves & thrills, apex beat, auscultate heart sounds.
Lung bases: fine crepitations.
what do you palpate for
oedema
what is included in general demeanour
Alert and oriented? This includes talking coherently etc.
Are they in obvious pain? (this includes writhing or continually moving with colicy pain (abdomen wise), & keeping absolutely still with peritonitis.
Do they look ill?
Is there any medical equipment round the bed?
Intravenous infusion? Ambulant oxygen?
Ventilator? Tablets, Sputum pots
Are there any indicators of disability?
Wheelchair? Crutches? Limb in plaster? Amputation? Etc, etc.
what do you look for in the legs
Amputations? Bandages etc. Gross oedema- get this in heart failure? Ulcers?
Varicose veins? Scars? Colour, colour difference?
Are the legs moving?
what do you look form in the abdomen
Re cardiovascular system: pulsating mass of AAA - abdominal aortic aneurysm
what do you look for in the chest
moving? Symmetrical? Any obvious abnormality or effort in respiratory movements? Obvious pulsation? Drains?
what do you look form in the arms and hands
amputations? Bandages etc? Swelling? Scars? Shunts or fistulae? Colour, colour difference? Are they moving?
what do you form in the neck
obvious pulsation? Obvious swelling? Tracheostomy/tomy?
what do you look for in the face
Obvious cyanosis, Obvious pallor, Obvious jaundice? Facial flush? symmetrical? Moving?
what does vitamin B12 deficiency lead to
pernicious anaemia
what do you look for in the hands
colour? Temperature/sweaty? Peripheral cyanosis- poor circulation? Tar staining? Clubbing? Splinter haemorrhage? Osler’s nodes (etc)? Koilonychia? Dupuytren’s contracture? Capillary refill
what is sinus arrhythmia
- heart rate speeds up and slow down as you breath in and out - not pathological
what should you look for in the mouth
Sores around mouth, & at corners (angular stomatitis, or angular cheilosis), Central cyanosis, Glossitis? Mouth ulcers? (Soft palate & tongue movements)
what should you look for in the eyes
Mucosal pallor, scleral jaundice, xanthelasmata, arcus, pupils (equal?), (squints & eye movements
what should you take in regards to circulation
Take the pulse: rate rhythm, character/volume.
Rate: count for 15 or 20 secs, multiply appropriately.
Rhythm: regular or irregular. If there is sinusarrhythmia (speeds up & slows down as breathes in and out) you should comment on this, but not pathological.
Character/volume: slow rising pulse of aortic stenoisis, collapsing pulse of aortic regurgitation, fast weak “thready” pulse of shock, asymetrical pulse of coarctation or vascular disease: you need experience for this!
Kolionychia is classically due to…
iron deficiency anaemia
how should a patient sit in a Cardio examination
- exposed from waist up sitting at 45 degrees
where is the radial pulse
lateral side of the wrist, lateral to the FCR
what do you look for in the radial pulse
- rate
- rhythm
- character volume
- symmetry
what are the other pulses
- brachial
- carotid
- dorsalis pedis
- posterior tibial
how do you do blood pressure
- locate radial pulse (lateral – thumb side of wrist) & brachial pulse (medial side arm!).
- Put on cuff, & pump up while feeling radial pulse. When pulse disappears is systolic BP approximately.
- Let down, & put on stethoscope (if you are slick, don’t have to let down)
- Pump up cuff to higher than your estimate of systolic.
- Listen over brachial pulse: you hear nothing.
- Let down cuff slowly: the pressure when the Korotkoff sounds appear is systolic, the pressure when they disappear is diastolic.
when the cuff is above the systolic pressure you don’t hear anything
when they appear it is systolic
stop hearing them when diastolic
what are korotkoff sounds due to
- turbulent blood flow under the cuff
how do you measure theJVP
You are looking for the pulsation of the internal jugular vein in the neck, & measure its height vertically above the angle of Louis.
where is the internal jugular vein
- between the two heads of SCM
when does the external jugular vein rise
- when they talk as they raise the intrathoracic pressure
how can you see the external jugular vein
a) lower the patient down, or b) press over liver, or c) get them to take a long slow breath in and out, or d) lift up their legs.
how is the external jugular different from the carotid arterial pulse
Waveform, position, & pulse not palpable distinguish it from carotid arterial pulse.
when is the JVP raised
The JVP will be raised in Right heart failure, & low in hypovolaemia
how to measure the JVP
- from the top of the pulsation to the angle of Louis
what are the three peaks of the venous pulse
A
C - tricuspid valve close a start of ventricular systole
V- maximum atrial filling pressure before ventricular diastole
what is the praecordium
front of the chest
what do you do at the precordium
Praecordium
1 inspect. This is more careful than in “feet to face”. Pulsation, scars, pectus excavatum etc. Look at back now, or when you auscultate for fine basal crepitations.
- Palpate. Heaves & thrills. Parasternal heave is due to R ventricular hypertrophy or enlargement. Thrills are palpable murmurs.
Locate apex beat, counting down ribs & intercostal spaces from angle of Louis (second rib). Normal position is 5th intercostal space mid-clavicular line.
- Auscultate for murmurs: mitral area is at apex. Mitral stenosis murmur is low pitched: use bell. Mitral regurgitation murmur may radiate into axilla. Mitral murmurs are best heardwith patient rolled onto L side. Tricuspid area is in 4th intercostal space at L sternal edge. Pulmonary area is in 2nd intercostal space L sternal edge, & aortic area is 2nd intercostal space R sternal edge. Aortic regurgitation also audible at L sternal edge 3rd intercostal space sitting up in expiration. Aortic stenosis may radiate to carotids.
- Pericardial friction rub etc.
- Identify first & second heart sounds by feeling carotid pulse: pulse is just on or after 1st heart sound.
what is a parasternal heave due to
Parasternal heave is due to R ventricular hypertrophy or enlargement that pushes against the sternum
what are thrills
palpable murmurs
where is the apex beat
counting down ribs & intercostal spaces from angle of Louis (second rib). Normal position is 5th intercostal space mid-clavicular line.
where are the valves
- mitral - 5 intercostal space mid clavicular line
- tricuspid - 4th intercostal space left sternal edge
- pulmonary - 2 intercostal space L sternal edge
- aortic - 2nd intercostal space right sternal edge
where is aortic regurgitation audible at
Aortic regurgitation also audible at L sternal edge 3rd intercostal space sitting up in expiration.
where does aortic stenosis radiate to
Aortic stenosis may radiate to carotids.
describe mitral stenosis
mid-diastolic murmur. Best heard at apex (mitral area), while lying on left side. best heard with a bell
Also loud first heart sound, tapping apex beat, opening snap. Malar flush.
Signs of Right heart failure.
what is mitral stenosis best head at
Best heard at apex (mitral area), while lying on left side.
what is mitral stenosis a sign of
Signs of Right heart failure.
describe mitral regurgitation
pan-systolic (throughout systole) murmur, best heard over apex, when lying on L side, radiates into axilla. High-pitched. Loud Second sound. Often third heart sound.
where can you hear mitral regurgitation
best heard over apex, when lying on L side
patients with mitral valve lesions are….
prone to develop Atrial Fibrillation.
describe aortic stenosis
mid-systolic murmur best heard in aortic area, radiating into carotids R>L.
describe aortic regurgitation
early diastolic murmur, Left sternal edge, loudest in 3rd intercostal space
what do you listen to the lung bases for
Listen to lung bases for Fine crepitations
where are the lung bases
This is on the back, one hands-breadth below scapula.
how do you test for oedema
Palpate feet for pitting oedema. Press over bone firmly with thumb for 10 secs, then stroke to see if has pitted.
If patient had been bedbound, pitting oedema is over sacrum.
what causes clubbing
Lung disease: chronic infection & inflammation: lung abscess, longstanding empyema, TB, interstitial lung disease. Neoplasia of lung: carcinoma & mesothelioma,
what can cause heart disease
infective endocarditis, any cyanotic heart disease, atrial myxoma (a benign neoplasm).
what causes cirrhosis of the liver
Esp primary biliary cirrhosis.
what is graves disease part of
thyroid acropachy
what can cause fine tremor
thyrotoxicosis
salbutamol
what can cause coarse flapping tremor
- versions of this in co2 retention, liver failure, uraemia
describe symptoms of infected endocarditis
Looks ill. Splinter haemorrhages, clubbing, Osler’s nodes, Janeway lesions, lymphadenopathy, heart murmurs, fever, Roth spots in retina, red cells in urine etc.
describe iron deficiency anaemia symptoms
koilonychia, sore corners of mouth.
describe B12 deficiency symptoms
sore tongue, pallor, sometimes slight jaundice.
what can cause left sided heart failure
systemic hypertension mitral and aortic valvular disease, myocardial disease (ischaemic, inflammatory, others), arrhythmia.
what are the effects of left heart failure
: Pulmonary oedema (SOB on lying flat = orthopnoea, fine crepitations).
- Peripheral oedema due to fluid retention possibly because raised renin, poor renal perfusion pressure.
Weak pulse tachycardia.
Fatigue, lethargy etc.
Findings due to the causes: murmurs, displaced apex beat etc.
what can cause right sided heart failure
pulmonary hypertension (esp COPD) “cor pulmonale”, tricuspid or pulmonary valvular disease,
myocardial disease,
2ary to L sided heart failure
what are the effects of right sided heart failure
raised JVP,
enlarged liver (engorged with blood)
peripheral oedema (raised venous pressure).
