Cardiovascular exam - findings minus chest

Question 1

Introduction of exam

Answer 1

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.

Question 2

General inspection things?

Answer 2

Cyanosis
Shortness of breath
Pallor
Odema
Malar Flushing

Question 3

What causes cyanosis (cardiac causes)

Answer 3

Poor circulation/poor oxygenation
Right-to-left shunting
peripheral vasoconstriction secondary to hypovolaemia

Question 4

What cause SOB

Answer 4

may indicate underlying cardiovascular (e.g. congestive heart failure, pericarditis) or respiratory disease (e.g. pneumonia, pulmonary embolism).

Question 5

What causes pallor

Answer 5

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.

Question 6

What causes mallor flush

Answer 6

plum-red discolouration of the cheeks associated with mitral stenosis.

Question 7

Cardiac cause of odoema

Answer 7

Congestive heart failure

Question 8

What is this

Answer 8

Malar flush

Question 9

What objects might be present around the bed

Answer 9

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.

Question 10

What signs do you see on the hands

Answer 10

Pallor
Tar staining
Xanthoma
Arachnodactyly (‘spider fingers’)
Clubbing
Endocarditits signs

Question 11

Pallor in hands causes

Answer 11

CHF
Cyanosis underlying hypoxia

Question 12

Tar staining causes

Answer 12

Smoking RF for PAD and HTN and CAD

Question 13

Xanthoma causes

Answer 13

Xanthomata are associated with hyperlipidaemia (typically familial hypercholesterolaemia) RF for CAD

Question 14

Arachnodactyly causes

Answer 14

CTD Marfan’s associated with mitral/aortic valve prolapse –> aortic dissection

Question 15

Clubbing cardio causes

Answer 15

Congenital cyanotic heart disease
Atrial myoxoma
Infective endocarditis

Question 16

Endocardititis hand signs

Answer 16

Janeway lesions
Osler’s nodes
Splinter haemorrhages

Question 17

Temperature assessment of hands causes

Answer 17

Warm - normal
Cold - poor perfusion
CHF/ACS
Cool and Clammy - ACS

Question 18

CRT delay causes and normal time

Answer 18

Normal <2 seconds
poor peripheral perfusion (e.g. hypovolaemia, congestive heart failure) and the need to assess central capillary refill time.

Question 19

What pulses do you assess

Answer 19

Radial
Brachial
Collapsing
Radio-radio delay
Radio-femoral delay
Carotid

Question 20

Radial pulse tells you

Answer 20

Rate and rhythm
irregular pulse - commonly AF but can be AV block or ectopic beats

Question 21

Causes of radio-radio delay

Answer 21

Subclavian artery stenosis (e.g. compression by a cervical rib)
Aortic dissection
Aortic coarctation

Question 22

Causes of collapsing pulse

Answer 22

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)

Question 23

What does brachial pulse assess

Answer 23

Volume and character

Question 24

Different characters of the brachial pulse

Answer 24

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)

Question 25

What should you always offer after doing pulses

Answer 25

Blood pressure including lying and standing

Question 26

Causes of narrow pulse pressure

Answer 26

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.

Question 27

Causes of wide pulse pressure

Answer 27

Wide pulse pressure: more than 100 mmHg of difference between systolic and diastolic blood pressure. Causes include aortic regurgitation and aortic dissection.

Question 28

Causes of different blood pressure in arms

Answer 28

Difference between arms: more than 20 mmHg difference in blood pressure between each arm is abnormal and may suggest aortic dissection.

Question 29

Carotid pulse what to do before palpating

Answer 29

Auscultate for bruits

Question 30

Carotid pulse assessment

Answer 30

Volume and character same as brachial

Question 31

After pulses what else in the neck

Answer 31

Assess JVP and perform hepatojugular reflex

Question 32

Causes of raised JVP (venous hypertension)

Answer 32

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.

Question 33

Signs on the face (eyes)

Answer 33

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).

Question 34

Signs in the mouth

Answer 34

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.