Cardiovascular Exam Flashcards
Which pulses must you first palpate bilaterally in your cardiovascular exam?
Radial
Brachial
Pedal
Femoral
Popliteal
Where can you palpate a patients radial pulse?
Radial artery
Feel between wrist bone and tendon on the thumb side of the wrist, apply enough pressure to feel a pulse
Where can you palpate a patients brachial pulse?
Brachial artery
Feel the bicep area of the antecubital fossa 2cm medial of the tendon and 3cm above the ACF, apply pressure to feel a pulse
Where can you palpate a patients carotid pulse?
Carotid artery
Located on both sides of the neck
Feel the front of the neck just below the angle of the jaw, only apply light pressure
Where can you palpate a patients femoral pulse?
Femoral artery
Located along the crease midway between the pubic bone and the anterior iliac crest
If there is a lot of fat you may need to press firmly
Where can you palpate a patients popliteal pulse?
Popliteal artery
Branch from the femoral arteries in your legs, can be felt behind the patients kneecap
The patient may need to raise their legs for you to be able to palpate effectively
Where can you palpate a patients pedal pulse?
Dorsalis pedis artery
Found on the dorsal aspect of the foot, begins on the anterior aspect of the ankle joint and ends just before the proximal aspect of the first intermetatarsal space (between the big toe and second toe)
What would you expect a pulse to be on a healthy adult?
60-100bpm
If you observe a pulse of > 100bpm what could this indicate?
Tachycardia
Can be a sign of; infection, arrhythmia or anxiety.
If you observe a pulse of < 60bpm what could this indicate?
Bradycardia
Could be indicative of a heart block
Could be normal in a fit person
When palpating pulses what are we observing?
Rate
Rhythm
Quality
Bilaterally equal
What would an irregularly irregular rhythm indicate?
Atrial fibrillation
When describing quality of pulse what are we describing?
Strength
What could a pulse of poor/weak strength/quality indicate?
Reduced cardiac output
Hypotension
What could a particularly strong pulse indicate?
Hypertension
Why must you not palpate the carotid artery bilaterally?
Applying pressure to the artery on both sides at the same time can reduce cerebral blood flow and stimulate a vagal response
What can unequal bilateral pulses be a sign of?
Cardiovascular problems such as aortic dissection - but you would expect the patient to feel more unwell
Which two pulses do we palpate at the same time and compare?
Radial and femoral
Why do we compare the rate of the radial and femoral pulses?
A delay in the pulses could indicate aortic coarction, a congenital condition due to the narrowing of the aorta.
Often not picked up until adulthood
If aortic coarction is present, which pulse will be delayed?
Femoral pulse will be delayed compared to the radial
When inspecting the jugular vein what angle would you want the patients head to be when laying on the bed?
45 degrees
How do you inspect for jugular venous pulsation?
Ask the patient to turn their head to the left
This separates the sternocleidomastoid muscles and allows for a better view of the right jugular vein
The jugular vein pulsation is not always visible in a healthy individual but if is visible I am looking to see a double pulsation and it won’t be palpable.
How do you measure jugular vein distension?
So, I place my ruler in the angle of louis and take a straight line from the top of the pulsation.
A normal value will be below 4cm.
Anything above 4cm can indicate jugular venous distention, which can indicate right ventricular heart failure.
What is dependent-part oedema?
excess fluid builds up in the body causing swelling
oedema that is specific to parts of the body that that are influenced by gravity, such as your legs, feet, or arms
How do you test for pitting oedema?
Press finger on the dial tibia for 10 seconds, after releasing if the skin does not return to normal after 15 seconds
Where should you also check for dependent-part oedema in bed bound patients?
Sacral area
Due to gravity that is where the fluid is most likely to sit
What can pitting oedema be a sign of?
A localised problem with veins in the affected area
Or a systemic problem with your heart, kidneys, or liver function causing fluid to be retained
Right ventricular heart failure
What does DVT stand for?
Deep vein thrombosis
Where do DVTs commonly occur?
In the deep leg vein in the calf and thigh
Can also occur in pelvis and abdomen in some cases
What are the most common signs of a DVT that you should check for?
Redness, swelling, pain and heat in the calf
History indicative of risk factors
Common risk factors of DVT?
Recent long haul flight
Recent surgery
Pregnancy
Long periods of immobility
What are varicose veins?
Enlarged veins near the surface of the skin
What are varicose veins a sign of?
A sign of poor circulation cause by weak valves and vein walls
If you are unsure on whether you can see varicose veins, how can you make them more visible?
Ask the patient to sit on the edge of the bed as the force of gravity would make them more visible
Common risk factors for varicose veins?
Age
Family history
Obesity
Sitting/standing for long periods of time
Pregnancy
Female
Before moving past criteria 5 what should you ask the patient to do?
Remove their top
During your cardiovascular exam what should you inspect the anterior chest for?
Deformities
Scars
Pulsations
What deformities are the main deformities you are looking for when performing a cardiovascular exam?
Funnel chest
Pigeon chest
What is funnel chest?
A deformity where there are depressions on all or part of the sternum
What is pigeon chest?
A deformity where the sternum protrudes outwards further than the ribs.
Latin name for funnel chest?
pectus excavatum
What causes funnel chest?
due to too much growth of the connective tissue that joins the ribs to the breastbone (sternum).
This causes the sternum to grow inward. As a result, there is a depression in the chest over the sternum, which may appear quite deep.
Why do conditions such as pigeon chest and funnel chest affect the cardiovascular system?
Impacts the cardiovascular system due to displaced organs
Severe cases can compress the heart and lungs or push the heart over to one side
What main scars should you be observing for during a cardiovascular exam?
Midline scars to indicate sternotomy
Left lateral scars observed in mitral valvotomy
Left clavicle scars seen in patients with a pacemaker
What deformity can be seen here?
Pigeon chest
What deformity can be seen here?
Funnel chest
Where can you find the apical impulse?
Found in the 5th intercostal space (ICS), 1cm medially from the mid-clavicular line
When are you most likely to observe a regular apical impulse?
Children
Very thin people
What is the apical impulse?
The apical impulse is the apex of the heart hitting the chest wall
How do you palpate the apical impulse?
Feeling for the apical impulse again the 5th ICS 1cm medially from the mid-clavicular line, starting with a flat hand to attempt to pinpoint to a specific point.
If the apical impulse is displaced towards the left axillar what can this indicate?
Can indicate an enlarged heart such as observed in left ventricular hypertrophy
Where are heaves best felt?
In the mitral region
What causes heaves?
Heaves are the result of a forceful apical impulse
What do heaves often indicate?
Right ventricular hypertrophy
Very rarely in severe left atrial enlargement
How do you palpate for heaves?
Using the ball of your hand, press firmly on the patents chest in the mitral region
Where would you palpate for heaves?
Mitral region
How do you palpate thrills?
Place the palm of your hand in each of the four heart zones in the precordium and then on the upper left and right chest wall
What are thrills?
palpable heart murmurs
What may thrills feel like when palpating if severe enough?
Feel like harsh vibrations if the murmur is severe enough
Associated with loud, harsh, or rumbling murmurs.
VERY loud when you auscultate.
What causes thrills?
aortic stenosis
mitral stenosis
What is the larger side of the stethoscope called?
Diaphragm
What is the smaller side of the stethoscope called?
Bell
What cardiac area is 1?
Aortic area
What cardiac area is 2?
Pulmonic area
What cardiac area is 3?
Tricuspid area
What cardiac area is 4?
Mitral area / apical area?
What types of sounds is the diaphragm of the stethoscope most useful for picking up?
Diaphragm is most useful for picking up high-pitched sounds
Example some sounds that the diaphragm of the stethoscope opposed to the bell is better suited to listening for?
S1, S2, aortic or mitral regurgitation, pericardial friction rubs
What types of sounds is the bell of the stethoscope most useful for picking up?
The bell is most useful for picking up low-pitched sounds
Example some sounds that the bell of the stethoscope opposed to the diaphragm is better suited to listening for?
S3, S4, mitral stenosis
Why must you press the bell lightly on the skin when auscultating?
Applying more pressure stretches the skin taut and results in the bell functioning like the diaphragm
Why do we listen for heart sounds in specific spots on the chest?
Not directly over the valve
We listen in the best place to hear them
Where is the best place to listen to the mitral valve?
Mitral area
5th ICS, 1cm medially from the mid-clavicular line
Which side of the stethoscope do you use when listening to the mitral valve?
diaphragm
Where is the best place to listen to the tricuspid valve?
Tricuspid area
5th ICS either side of the sternal border
Which side of the stethoscope do you use when listening to the tricuspid valve?
diaphragm
Where is the best place to listen to the aortic valve?
Aortic area
2nd ICS on the right sternal border
Which side of the stethoscope do you use when listening to the aortic valve?
diaphragm
Where is the best place to listen to the pulmonary valve?
Pulmonic area
2nd ICS to the left of the sternal border
Which side of the stethoscope do you use when listening to the pulmonary valve?
diaphragm
Where can you locate Erbs point?
3rd ICS to the left of the sternum
What sounds can be heard when auscultating Erbs point?
Best place to hear overall heart sounds
What side of the stethoscope do you use when listening to Erbs point?
diaphragm
When performing a cardiovascular assessment - when auscultating with the bell of your stethoscope which points would you listen to?
Apical area
Bilaterally lower sternal borders
Bilaterally 2nd ICS at sternal borders
Other areas along sternal borders
What sound can be heard when auscultating S1?
LUB
What causes the LUB sound heard at S1?
Closure of the AV valves during systole
(mitral and tricuspid valves)
Where can S1 be best heard?
Mitral Area
Tricuspid Area
What sound can be heard when auscultating S2?
DUB
What causes the DUB sound heard at S2?
Closure of semi lunar valves during start of diastole
(aortic and pulmonary valves)
Where can S2 be best heard?
Aortic area
Pulmonary area
What sound may be heard when auscultating S3?
(Low pitched) LUB de DUB
What causes the sound heard at S3?
Rapid filling of the ventricles
Stretching of the chordae tendonae
When can S3 most often be heard?
Pregnancy
Children
Adults under 40
Where can S3 best be heard?
Mitral area
What heart sound follows S2?
S3
If S3 is present in those over 40 what can this indicate?
Can be pathological
Occurs in conditions such as heart failure
What heart sound occurs before S1?
S4
What sound may be heard when auscultating S4?
(Low pitched) LE Lub Dub
What causes the sound heard at S4?
Atria contracting against stiffened ventricles
Where can S4 best be heard?
Mitral area
If S4 is present, what does this indicate?
ALWAYS pathological
Can be a sign of ischaemia, heart failure and left ventricular hypertrophy
Why is S2 usually ‘split’?
Because the aortic valve closes before the pulmonary valve
The closing pressure on the left is 80 mmHg as compared to only 10 mmHg on the right
This higher closing pressure leads to earlier closure of the aortic valve
Where is splitting of S2 best heard?
Pulmonic area
How can splitting of the S2 best be heard?
Using the diaphragm of your stethoscope
Splitting of S2 is often normal, but can be heard in what condition?
LBBB
What does splitting of the S2 valve sound like?
(High pitched) Split of DUB DE-DUB
What causes murmurs to be heard when auscultating?
Turbulent blood flow through the heart
Where can murmurs best be heard?
Murmurs can be heard in all areas if present.
You should auscultate all cardiac areas when assessing for murmurs
What does a murmur sound like?
Whoosing
What can causes murmurs?
Increased stroke volume of the heart, for example in; pregnancy, children, fever and athletes
Stenosis
Regurgitation
What is stenosis of the heart valves an issue?
The valves don’t fully open
What is regurgitation of the heart valves an issue?
The valves collapse back on themselves
You ask the patient to lay on their left side, which valves are best appropriate to auscultate in this position?
Mitral and Tricuspid valves
Which heart sounds can best be heard with the patient lying on their left side?
S3 and S4
You ask the patient to sit up and lean forward, which valves are best appropriate to auscultate in this position?
Aortic and Pulmonic
Which heart sounds can be best heard with the patient sat up and leaning forward?
Diastolic murmurs
Under which cardiac area does the apex of the heart lie?
Mitral area
When palpating the right side carotid pulse which valve should you also listen to?
Mitral valve
Why do we palpate the carotid pulse while auscultating at the apex?
Listening to hear that S1 occurs at the same time as the upstroke of the pulse
What is bruits?
Bruits are sounds heard associated with turbulent blood flow
What does bruits sound like?
Whoosing sound
What causes bruits?
Caused by the narrowing of the arteries caused by atherosclerosis
When auscultating the carotid artery which side of your stethoscope should you use?
Bell as carotid bruits is often a lower pitched sound
How many places along the carotid artery should you listen for carotid bruits?
3
How do you auscultate for carotid bruits?
Ask the patient to look the opposite way to where you are standing
Ask the patient to hold their breath
Listen for any whooshing noises at 3 points along the carotid artery with the bell of your stethoscope
Why must the patient hold their breath when assessing for carotid brutis?
Taking a breath can mimic the sound of whooshing
What is considered a normal finding when assessing for carotid bruits?
No sound will be heard
