Cardiovascular exam Flashcards
How should the patient be positioned during a cardiovascular exam?
at 45° with the chest exposed
What are you looking for upon general inspection of the patient during a cardiovascular exam?
- appear comfortable + well at rest (any SOB or malaria flushing/pallor?)
- Is the patient cyanosed?
- Any kind of medication (such as GTN spray, O2, mobility aids)
- Any scars/visible pulsations on the chest or chest wall deformities?
What might you see upon inspection of the hand and nails during a cardiovascular exam?
Nails:
- Splinter haemorrhages
- Clubbing
Hands:
- Colour (are they cyanosed?)
- Temperature
- Sweating/clammy
- Janeway lesions
- Osler’s nodes
- Tendon xanthoma
- Tar staining
- Capillary refill
What are splinter haemorrhages and what are they a sign of?
- Reddish-brown streaks in the nail bed
- Indicate infective endocarditis
How do you test for clubbing, if it is present what is it a sign of?
- Ask patient to make a heart shape with their index finger and thumbs
- Normal: Small diamond shaped window called Shamroth’s window
- Clubbing: window is lost
- -> sign of infective endocarditis and cyanotic congenital heart disease
What do cool peripheries indicate?
Poor cardiac output/hypovolaemia
What are sweaty/clammy palms a sign of?
acute coronary syndrome
(decreased blood flow in the coronary arteries such that part of the heart muscle is unable to function properly or dies).
What are Janeway lesions and what do they indicate?
- Non-tender, erythematous/haemorrhagic nodular lesions (on the palm pulp)
- indicative of bacteria endocarditis
What are Osler’s nodes and what do they indicate?
- painful, red raised lesions (on finger pulps/thenar eminence
- indicative of infective endocarditis
What is (tendon) xanthoma and what is it a sign of?
- raised yellow lesions
- caused by hyperlipidaemia
- tendon xanthoma can be associated with familial hypercholesterolaemia
Why is it important to look for tar staining on a cardiovascular exam?
indicates smoking which is a risk factor for cardiovascular diseases
What is the normal time for capillary refill? If it is prolonged, what does it indicate?
- <2 seconds
- Prolonged = hypovolaemia
What is the next step in the cardiovascular exam, once inspection is complete?
Pulses:
- Radial pulse: assess for rate and rhythm
- count for 15 seconds and multiply by 4 or 30 seconds and multiply by 2
- can also roll artery for width/size of lumen/bounciness - Brachial pulse: assess volume and character
(can do blood pressure at this step - separate flashcards on these)
What are the surface markings used to locate the radial pulse?
Lateral to the flexor carpi radials of the wrist
What are the surface markings used to locate the brachial pulse?
Medial and little underneath the biceps tendon
What is the next step in the cardiovascular exam, once pulses/BP are complete?
Neck
- Carotid pulse: character and volume
* explain to pt what you are doing before you touch their neck lol - Jugular venous pulse (JVP)
- ask pt to turn their head away form you
- observe the neck for the JVP
- measure the JVP (should be <3 cm from the vertical height of the sternal angle)
What surface markings are used to locate the carotid pulse?
Carotid artery runs down the side of the thyroid cartilage, between the trace and the SCM, and just slightly under the SCM
What is radio-radial delay a sign of?
Aortic coarctation
What is collapsing pulse a sign of?
Aortic regurgitation
Why is it important to look at the JVP?
Represents the preload on the heart (RA pressure) as it empties into it
What does a raised JVP indicate?
- fluid overload
- right ventricular failure
- tricuspid regurgitation
(heart failure and impending decompensation)
What does a non-visible or low JVP indicate?
- healthy
2. hypovolaemic
How can you elicit the JVP?
- lie the patient flatter
- hepatojugular reflux
- filling and emptying the external jugular
What surface markings are used to locate the JVP?
IJV enters the neck between the two heads of the SCM
What are the 7 differences between the JVP and the carotid pulse?
- Waveform:
- JVP = double
- Carotid = single - Positional change:
- JVP = varies with position
- Carotid = no change - Respiration:
- JVP = descends with inspiration
- Carotid = no change - Effect of palpation:
- JVP = Impulse non-palpable
- Carotid = Impulse palpable - Pressure:
- JVP = pressure occludes pulse and vein refills from above
- Carotid = non-compressible - Hepatojugular reflux:
- JVP = elevates pulse
- Carotid = no change - Type of pulse:
- JVP = venous pulse
- Carotid = arterial pulse
What is step in the cardiovascular exam follows carotid pulse and JVP?
Palpation of chest
- Apex beat
- Heaves + thrills
What is the apex beat, where is it usually found? What does a displaced apex beat indicate?
It is the lowermost and outermost palpable cardiac impulse
- normal apex beat is ~5th intercostal space in the mid-axillary line
- displaced apex beat is either a result of:
1. cardiomegaly (dilation/failure)
2. heart being pushed as a result of a lung pathology
What are heaves and thrills?
- Heaves = palpable cardiac impulse
- parasternal heaves = right ventricular hypertrophy - Thrills = palpable murmur
What step in the cardiovascular exam follows palpation of the chest?
Auscultation
- listen to the 4 main valve areas to identify normal heart sounds
- always feel a central pulse (e.g. carotid) whilst auscultating in order to time the heart sounds in the cardiac cycle
- listen to the 1st heart sound
- 2nd heart sound (as the pulse drops away from fingers, is it split?)
Where do you listen for each of the heart valves on the chest?
- Aortic valve = 2nd intercostal space
- Pulmonary valve = 2nd intercostal space
- Tricuspid = left sternal border (4th intercostal space)
- Mitral = apex/ 5th intercostal space mid-clavicular line
During second heart sound the pulse may split, when is this a good/normal sign and a bad sign?
- if it splits during respiration then this is normal
- if it split is fixed then this is a bad sign
Where on the chest would you listen for aortic murmurs?
aortic area and left sternal edge in expiration and over the carotids
Where on the chest would you listen for mitral murmurs?
Listen with the bell over the apex, and while patient is lying on left side, and in the left axilla
What step in the cardiovascular exam follows auscultation?
Feet:
- examine the feet/ankles for peripheral oedema
- palpate the dorsalis pedis and posterior tibial pulses
What surface markings are used to locate the dorsalis pedis?
Lateral to tendon of extensor hallucis longus
What surface markings are used to locate the posterior tibial pulse?
Posterior and inferior to the medial malleolus
What else would you auscultate, apart from valves + murmurs?
Lung bases (for fine crepitations/crackles) = may indicate pulmonary oedema secondary to left ventricular failure
Where else should you look for oedema? Why?
Sacral oedema
- may indicate right ventricular failure
What further assessments/investigations might you suggest at the end of a cardiovascular exam?
- Full peripheral vascular examination
- Record a 12-lead ECG – arrhythmias / myocardial ischaemia
- Dipstick urine – proteinuria / haematuria – hypertension
- Bedside capillary blood glucose – diabetes
- Perform fundoscopy – malignant hypertension – papilloedema
