Cardiovascular exam - findings minus chest Flashcards
Introduction of exam
WASH HANDS
introduce yourself - name and role
Confirm the patient’s name and date of birth.
Briefly explain what the examination - examination of heart, look feel and listen
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
Exposure of the patient’s lower legs for signs of PAD
Ask the patient if they have any pain before proceeding with the clinical examination.
General inspection things?
Cyanosis
Shortness of breath
Pallor
Odema
Malar Flushing
What causes cyanosis (cardiac causes)
Poor circulation/poor oxygenation
Right-to-left shunting
peripheral vasoconstriction secondary to hypovolaemia
What cause SOB
may indicate underlying cardiovascular (e.g. congestive heart failure, pericarditis) or respiratory disease (e.g. pneumonia, pulmonary embolism).
What causes pallor
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.
What causes mallor flush
plum-red discolouration of the cheeks associated with mitral stenosis.
Cardiac cause of odoema
Congestive heart failure
What is this
Malar flush
What objects might be present around the bed
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.
What signs do you see on the hands
Pallor
Tar staining
Xanthoma
Arachnodactyly (‘spider fingers’)
Clubbing
Endocarditits signs
Pallor in hands causes
CHF
Cyanosis underlying hypoxia
Tar staining causes
Smoking RF for PAD and HTN and CAD
Xanthoma causes
Xanthomata are associated with hyperlipidaemia (typically familial hypercholesterolaemia) RF for CAD
Arachnodactyly causes
CTD Marfan’s associated with mitral/aortic valve prolapse –> aortic dissection
Clubbing cardio causes
Congenital cyanotic heart disease
Atrial myoxoma
Infective endocarditis
Endocardititis hand signs
Janeway lesions
Osler’s nodes
Splinter haemorrhages
Temperature assessment of hands causes
Warm - normal
Cold - poor perfusion
CHF/ACS
Cool and Clammy - ACS
CRT delay causes and normal time
Normal <2 seconds
poor peripheral perfusion (e.g. hypovolaemia, congestive heart failure) and the need to assess central capillary refill time.
What pulses do you assess
Radial
Brachial
Collapsing
Radio-radio delay
Radio-femoral delay
Carotid
Radial pulse tells you
Rate and rhythm
irregular pulse - commonly AF but can be AV block or ectopic beats
Causes of radio-radio delay
Subclavian artery stenosis (e.g. compression by a cervical rib)
Aortic dissection
Aortic coarctation
Causes of collapsing pulse
Normal physiological states (e.g. fever, pregnancy)
Cardiac lesions (e.g. aortic regurgitation, patent ductus arteriosus)
High output states (e.g. anaemia, arteriovenous fistula, thyrotoxicosis)
What does brachial pulse assess
Volume and character
Different characters of the brachial pulse
Normal
Slow-rising (associated with aortic stenosis)
Bounding (associated with aortic regurgitation as well as CO2 retention)
Thready (associated with intravascular hypovolaemia in conditions such as sepsis)
What should you always offer after doing pulses
Blood pressure including lying and standing
Causes of narrow pulse pressure
Narrow pulse pressure: less than 25 mmHg of difference between the systolic and diastolic blood pressure. Causes include aortic stenosis, congestive heart failure and cardiac tamponade.
Causes of wide pulse pressure
Wide pulse pressure: more than 100 mmHg of difference between systolic and diastolic blood pressure. Causes include aortic regurgitation and aortic dissection.
Causes of different blood pressure in arms
Difference between arms: more than 20 mmHg difference in blood pressure between each arm is abnormal and may suggest aortic dissection.
Carotid pulse what to do before palpating
Auscultate for bruits
Carotid pulse assessment
Volume and character same as brachial
After pulses what else in the neck
Assess JVP and perform hepatojugular reflex
Causes of raised JVP (venous hypertension)
Right-sided heart failure: commonly caused by left-sided heart failure. Pulmonary hypertension is another cause of right-sided heart failure, often occurring due to chronic obstructive pulmonary disease or interstitial lung disease.
Tricuspid regurgitation: causes include infective endocarditis and rheumatic heart disease.
Constrictive pericarditis: often idiopathic, but rheumatoid arthritis and tuberculosis are also possible underlying causes.
Signs on the face (eyes)
Conjunctival pallor: suggestive of underlying anaemia.
Corneal arcus: a hazy white, grey or blue opaque ring located in the peripheral cornea, typically occurring in patients over the age of 60. In older patients, the condition is considered benign, however, its presence in patients under the age of 50 suggests underlying hypercholesterolaemia.
Xanthelasma: yellow, raised cholesterol-rich deposits around the eyes associated with hypercholesterolaemia.
Kayser-Fleischer rings: dark rings that encircle the iris associated with Wilson’s disease. The disease involves abnormal copper processing by the liver, resulting in accumulation and deposition in various tissues (including the heart where it can cause cardiomyopathy).
Signs in the mouth
Central cyanosis: bluish discolouration of the lips and/or the tongue associated with hypoxaemia (e.g. a right to left cardiac shunt)
Angular stomatitis: a common inflammatory condition affecting the corners of the mouth. It has a wide range of causes including iron deficiency.
High arched palate: a feature of Marfan syndrome which is associated with mitral/aortic valve prolapse and aortic dissection.
Dental hygiene: poor dental hygiene is a risk factor for infective endocarditis.
