Cardiovascular Flashcards
Cardiovascular examination
Introduction
Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Confirm the patient’s name and date of birth.
Briefly explain what the examination will involve using patient-friendly language.
Gain consent to proceed with the examination.
Adjust the head of the bed to a 45° angle.
Adequately expose the patient’s chest for the examination (offer a blanket to allow exposure only when required and if appropriate, inform patients they do not need to remove their bra). Exposure of the patient’s lower legs is also helpful to assess for peripheral oedema and signs of peripheral vascular disease.
Ask the patient if they have any pain before proceeding with the clinical examination.
Cardiovascular examination
General inspection : Clinical signs
Inspect the patient from the end of the bed whilst at rest, looking for clinical signs suggestive of underlying pathology:
Cyanosis: 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). Shortness of breath: may indicate underlying cardiovascular (e.g. congestive heart failure, pericarditis) or respiratory disease (e.g. pneumonia, pulmonary embolism). Pallor: 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. Malar flush: plum-red discolouration of the cheeks associated with mitral stenosis. Oedema: 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.
Cardiovascular examination
General inspection : Objects and equipment
Look for objects or equipment on or around the patient that may provide useful insights into their medical history and current clinical status:
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.
Cardiovascular examination
Hands : Inspection
General observations
Inspect the hands for clinical signs relevant to the cardiovascular system:
Colour: pallor suggests poor peripheral perfusion (e.g. congestive heart failure) and cyanosis may indicate underlying hypoxaemia. Tar staining: caused by smoking, a significant risk factor for cardiovascular disease (e.g. coronary artery disease, hypertension). Xanthomata: 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.
Cardiovascular examination
Hands : Inspection
Finger clubbing
Finger clubbing involves 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. Finger clubbing is associated with several underlying disease processes, but those most likely to appear in a cardiovascular OSCE station include congenital cyanotic heart disease, infective endocarditis and atrial myxoma (very rare).
Cardiovascular examination
Hands : Inspection
Signs in the hands associated with endocarditis
There are several other signs in the hands that are associated with endocarditis including:
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.
Cardiovascular examination
Hands : Palpation
Temperature
Place the dorsal aspect of your hand onto the patient’s to assess temperature:
In healthy individuals, the hands should be symmetrically warm, suggesting adequate perfusion. Cool hands may suggest poor peripheral perfusion (e.g. congestive cardiac failure, acute coronary syndrome). Cool and sweaty/clammy hands are typically associated with acute coronary syndrome.
Cardiovascular examination
Hands : Palpation
Capillary refill time (CRT)
Measuring capillary refill time (CRT) in the hands is a useful way of assessing peripheral perfusion:
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.
Cardiovascular examination
Pulses and blood pressure
Radial pulse
Palpate the patient’s radial pulse, located at the radial side of the wrist, with the tips of your index and middle fingers aligned longitudinally over the course of the artery.
Once you have located the radial pulse, assess the rate and rhythm.
Cardiovascular examination
Pulses and blood pressure
How to assess the heart rate
You can calculate the heart rate in a number of ways, including measuring for 60 seconds, measuring for 30 seconds and multiplying by 2 or measuring for 15 seconds and multiplying by 4.
For irregular rhythms, you should measure the pulse for a full 60 seconds to improve accuracy.
Cardiovascular examination
Pulses and blood pressure
Normal and abnormal heart rates
In healthy adults, the pulse should be between 60-100 bpm.
A pulse <60 bpm is known as bradycardia and has a wide range of aetiologies (e.g. healthy athletic individuals, atrioventricular block, medications, sick sinus syndrome).
A pulse of >100 bpm is known as tachycardia and has a wide range of aetiologies (e.g. anxiety, supraventricular tachycardia, hypovolaemia, hyperthyroidism).
An irregular rhythm is most commonly caused by atrial fibrillation, but other causes include ectopic beats in healthy individuals and atrioventricular blocks.
Radio-radial delay
Radio-radial delay describes a loss of synchronicity between the radial pulse on each arm, resulting in the pulses occurring at different times.
To assess for radio-radial delay :
Palpate both radial pulses simultaneously.
In healthy individuals, the pulses should occur at the same time.
If the radial pulses are out of sync, this would be described as radio-radial delay.
Causes of radio-radial delay include:
Subclavian artery stenosis (e.g. compression by a cervical rib)
Aortic dissection
Aortic coarctation
Collapsing pulse
A collapsing pulse is a forceful pulse that rapidly increases and subsequently collapses. It is also sometimes referred to as a ‘water hammer pulse’.
