Cardiovascular

Question 1

Specific Qs for CVS history?

Answer 1

PMH- hospital/ A&E visits, seeing GP regularly, previous stents?, smoking, alcohol, diet and lifestyle, occupation- sedentary?, home- carers?, coping with household activities, FMH- MI< 55 y/o 1st degree relative significant, main concern/ symptom most problematic?

Question 2

Common CVS HPCs?

Answer 2

Chest pain, palpitations, ankle swelling, leg pain, SOB, syncope and presyncope

Question 3

Cardiac causes of chest pain?

Answer 3

ACS, pericarditis, stable angina, aortic stenosis, aortic dissection

Question 4

SOCRATES for chest pain?

Answer 4

Central/ left/ right sided
Sudden/ gradual- what were they doing when pain onset?
Crushing, tearing, heavy, tight, burning
Jaw/ left arm/ back/ neck, trapezius ridge/ shoulder
SOB, nausea, vomiting, sweating, palpitations, ankle swelling, syncope, calf swelling, haemoptysis, sputum/ trauma
How long does it last, multiple episodes?
Exercise, position make better/ worse?
Out of 10 severity

Question 5

Causes of palpitations?

Answer 5

Arrhythmias, valve pathology, HF, congenital heart disease

Psychosomatic, hyperthyroidism, anaemia, medication/ recreational drugs, high levels of caffeine

Question 6

What to ask about palpitations?

Answer 6

What do you mean by palpitations, can you tap out the beat? How often and how long does it last? Associated symptoms? Sweating/ breathlessness? Syncope/ pre-syncope? Chest pain, palpitations associated with exercise
Family history of cardiac disease<55 y/o, 1st degree relative

Question 7

Qs if heart failure suspected?

Answer 7

How many pillows using at night? Are they sleeping in a chair? Can they climb the stairs? Exercise tolerance? What was normal for them before?

Question 8

Symptoms to ask about relating to leg pain? Generally think what, but don’t rule out what?

Answer 8

Leg swelling, increase in skin temp, skin discolouration
Recent surgery, long haul flight, history of malignancy, immobility, previous VTE, family history of VTE
Intermittent claudication- how far can you walk before pain starts, ask about CVS RFs
Associated= gangrene, burning, foot pain

Question 9

Causes of syncope? Ask about what?

Answer 9

Vasovagal syncope, postural hypotension, aortic stenosis, cardiac arrhythmias
Onset and duration- how long did it last and what were they doing when it occurred?
Previous episodes, how frequently?
Associated symptoms- palpitations, sweating, chest pain, headache etc

Question 10

Introducing a cardiovascular examination?

Answer 10

Wash hands, introduce yourself, confirm patient, explain and consent: general inspection of arms, face and chest before having a feel of your chest and listening with my stethoscope
Chaperone, ask if any pain?

Question 11

Inspect for around bedside?

Answer 11

Treatments, adjuncts- GTN, O2, medication, mobility aids, general appearance- colour, breathing, comfort, position, build

Question 12

Inspect for what palms down? Palms up?

Answer 12

Splinter haemorrhages, finger clubbing- IE, cyanotic congenital heart disease, tar staining- smoking= RF for CVD

Colour- peripheral cyanosis= hypoxia
Temperature- cool peripheries= poor CO/ hypovolaemia
Sweaty- ACS
Janeway lesions- IE
Osler’s nodes- IE
Tendon xanthomas- hyperlipidaemia
Capillary refill time- <2 normal, >2= hypovolaemia

Question 13

Pulses?

Answer 13

Radial
Radial-radial delay- subclavian artery stenosis/ aortic dissection
Brachial pulse- slow rising= aortic stenosis, collapsing= aortic regurgitation
Collapsing- radial pulse with hand wrapped around wrist, raise arm above head briskly, water hammer pulse= aortic regurgitation
Carotid pulse- slow rising= aortic stensis, collapsing= aortic regurgitation

Question 14

Measuring JVP?

Answer 14

Ensure 45 degrees, turn head to left side, observe in line with sternocleidomastoid, measure number of cm from sternal angle to upper border of pulsation, normal= 2-4cm
Raised= fluid overload/ RVF/ tricuspid regurgitation
Apply hepatojugular reflux- +ve= sustained >4cm

Question 15

Observe for what in eyes? Face and mouth?

Answer 15

Conjunctival pallor- anaemia, corneal arcus- hypercholesterolaemia, xanthelasma- hypercholesterolaemia
Malar flush; mitral stenosis
Mouth- central cyanosis, angular stomatitis= iron deficiency anaemia, high arched palate= Marfan syndrome- increased aortic aneurysm/ dissection risk, dental hygiene- IE risk

Question 16

Inspect for what on chest?

Answer 16

Scars: sternotomy= midline thorax scar from CABG/ valve surgery, clavicular= pacemaker, thoracotomy= minimally invasive valve surgery
Left mid-axillary line= subcut implantable cardioverter defibrillator

Chest wall deformities= pectus excavatum, pectus carinatum, severe kyphoscoliosis- hunched back

Visible pulsations- forceful apex beat; HTN, ventricular hypertrophy

Question 17

Palpate for what?

Answer 17

Apex beat- 5th IC space, MC line- lateral displacement= cardiomegaly

Parasternal heaves- precordial impulse that can be palpated, heel of hand parallel to left sternal edge with fingers vertical- present= hand lifted with each systole, present in RVH

Thrills- palpable vibration caused by turbulent blood flow through a heart valve, assess each valve with flats of fingers and palm over assessed valve

Question 18

Palpate what for first heart sound? Where is each valve? Left axilla for what? Back to diaphragm for what?

Answer 18

Carotid pulse
Aortic= 2nd IC space, R sternal edge, pulmonary= L sternal edge
Tricuspid= 5th IC space, lower sternal edge, mitral= 5th IC space, MC line, apex beat
To the bell- left axilla, roll onto left side for mitral murmurs
Diaphragm, sit forward, tricuspid region on held expiration for aortic regurgitation

Question 19

Do what when patient is sat forward too?

Answer 19

Lung bases- crackles= pulm oedema secondary to LVF, chronic lung disease- no other signs of fluid overload
Sacral oedema- RVF
Coarctation suspected= left of spine in 3rd/4th IC space

Question 20

Auscultate what when patient sat back?

Answer 20

Carotids while patient holds breath- accentuation manoeuvre for bruits/ transmitted systolic murmur

Question 21

Extra things to test for? Further assessments?

Answer 21

Hepatomegaly- if enlarged, feel for pulsation(tricuspid regurgitation)
Shifting dullness for ascites
Pitting oedema at ankles- always assess for ascites if present, saphenous vein harvesting for CABG

Femoral pulses and radiofemoral delay, BP and lying/ standing BP in one arm, ophthalmology and 12-lead ECG

Question 22

Intro for varicose veins?

Answer 22

Intro, confirm patient, explain, consent: examine veins in legs
Chaperone, any pain

Question 23

Inspect legs for what?

Answer 23

Varicosities- long saphenous and short saphenous veins especially
Venous eczema- venous HTN causing fluid to collect in tissues, oedema= venous stasis, lipodermatosclerosis
Venous ulceration- above medial malleolus, shallow, mildly painful, large irregular border with sloping edges
Scars; previous surgery/ healed ulceration
SFJ- 4cm lateral and 4cm inferior to pubic tubercle, inspect for saphenovarix

Question 24

Palpate for what?

Answer 24

Temperature- increased= phlebitis
Visible varicosities- hard, cord-like= thrombophlebitis
Cough test- finger on SFJ, palpate for thrills
Tap test- one finger on SFJ, other on any varicosity in long saphenous vein distribution
Tap on varicose vein being assessed- if thrill felt over SJJ, suggested continuity of vein secondary to incompetent valves

Question 25

Bruit when auscultating indicates what? Further tests?

Answer 25

Turbulent blood flow and so underlying AV malformation

Abdominal and peripheral arterial exam and doppler ultrasound of any varicosities

Question 26

Intro to lower limb peripheral vascular examination?

Answer 26

Wash hands, introduce, confirm patient, explain, consent, expose: general inspection of arms, legs, face and chest before having feel of your pulses in your arm and legs and listening with stethoscope
Chaperone, ask if any pain

Question 27

Look for what at bedside?

Answer 27

Comfortable at rest, mobility aids, dressings/ limb prosthesis, evidence of cyanosis/ pallor of limbs

Question 28

Eyes, mouth and abdomen?

Answer 28

Conjunctival pallor- anaemia, corneal arcus- hypercholesterolaemia
Central cyanosis, dehydration
Scars, visible masses+ visible pulsations

Question 29

Look for what on legs, feet and toes?

Answer 29

Scars; bypass surgery/ vein harvest sites
Hair loss; peripheral vascular disease
Discolouration; necrosis
Pallor; poor arterial supply
Missing limbs/ toes; previous amputation
Muscle wasting; PVD
Ulcers= site, depth, size, margins, ulcer bed, exudate, odour- between toes+ on posterior aspect of legs
Arterial ulcers= very painful, punched out apperance, located at end of digits, sole/ lateral surface of ankle

Question 30

Two things to palpate?

Answer 30

Temperature- back of hands, cold/ pale limb may indicate poor arterial supply
Capillary refill time<2 normal

Question 31

What pulses palpate for? How to feel for aorta?

Answer 31

Aorta, femoral pulses, popliteal pulses, posterior tibial pulses, dorsalis pedis pulses
Using fingers from both hands, just above umbilicus at border of aortic pulsation, upwards= pulsatile, outward= expansile (AAA?)

Question 32

Feeling for femoral pulses? Popliteal pulses?

Answer 32

Mid-inguinal point(halfway between ASIS and pubic symphysis,) assess volume, radio-femoral delay; aortic coarctation

Inferior of popliteal fossa, patient prone, ask to relax legs, thumbs on tibial tuberosity, flex knee to 30 degrees and curl fingers into popliteal fossa feeling pulse as you compress popliteal artery against tibia

Question 33

Posterior tibial and dorsalis pedis pulses?

Answer 33

Posterior to medial malleolus of tibia, volume and compare to other foot
Over dorsum, lateral to extensor hallucis longus tendon over 2nd and 3rd cuneiform bones, volume and compare feet

Question 34

How to assess sensation and power?

Answer 34

Light touch sensation, starting distally to identify limb paraesthesia which can be symptom of acute limb ischaemia, intact distally= normal
Reduced= assess to identify extent of paraesthesia
Assess power in legs/ foot

Question 35

Auscultate for what?

Answer 35

Aortic bruits just above umbilicus= AAA, femoral arteries

Question 36

How to do Buerger’s test for critical limb ischaemia?

Answer 36

Patient supine, both legs to 45 degrees and hold for 1-2 minutes, pallor= ischaemia, poorer arterial supply= less angle to which legs have to be raised to become pale< 20 degrees= severe limb ischaemia

Sit patient up, hang legs down over side of bed at 90 degrees, skin first becomes blue, then red due to reactive hyperaemia from post-hypoxic vasodilation, time takes to become pink/red relates to severity of ischaemia

Both legs examined simultaneously

Question 37

Further assessments for peripheral vascular exam?

Answer 37

Upper limb exam, ABPI, foot exam and measure blood glucose

Question 38

How is ABPI calculated?

Answer 38

Dividing highest systolic BP in arteries in anjle by higher of two systolic BPs in arms, >1= normal, <0.8= significant arterial disease, <0.4= critical limb ischaemia