Cardiovascular examination Flashcards
How would you begin the examination?
Wash hands and don PPE Introduce self (name and role) Identify patient (name and DOB) Explain examination and gain consent Ask if patient has any pain Move head of bed to 45 degrees Expose chest and ankles (offer blanket)
What would you look for on general observation?
Patient: Cyanosis, Pallor, Oedema, SOB, malar flush
Environment: Oxygen, Mobility aids, Medications, Vital signs, ECG leads, pillows, fluid balance
What would you look for on inspection of the hands?
Colour Xanthomata Tar staining Clubbing Arachnodactyly Splinter haemorrhages Osler's nodes Janeway lesions
What would you palpate on the hands?
Temperature Capillary refill Radial pulse - rate, rhythm, character Radio-radial delay Collapsing pulse
What are some causes of radio-radial delay?
Subclavian stenosis
Aortic dissection
Aortic coarctation
What are the causes of collapsing pulse?
Normal state (fever, pregnancy) Cardiac lesions (aortic regurgitation, PDA) High output states (anaemia, arteriovenous fistula, thyrotoxicosis)
What would you examine involving the arms?
Brachial pulse - volume, character
Blood pressure - both arms, lying + standing
What would you examine on the neck?
Carotid bruits
If no bruits, palpate carotid pulse
JVP
Hepatojugular reflex if JVP at least 3m from angle of mandible. Measure JVP distance from sternal angle
How would you assess for carotid bruits? What does the presence of a bruit suggest?
Place diaphragm between anterior angle of sternocleidomastoid and larynx. Ask patient to hold breath and listen for sounds
Bruit suggests carotid stenosis
But could be radiation of aortic stenosis murmur
What indicates a raised JVP and what could cause this?
Raised JVP = >3cm between sternal angle and top of double wave JVP pulsation
Causes: tricuspid regurgitation, Right heart failure, constrictive pericarditis
How do you elicit a hepatojugular reflex? What indicates a positive reflex?
Do if baseline JVP is at least 3cm from angle of mandible
Exert pressure on liver (uncomfortable for patient so warn them)
Watch JVP rise - normally will return to normal after 1-2 cardiac cycles
Positive reflex: Sustained rise >4cm
What causes a positive hepatojugular reflex?
Inability for ventricles to cope with increased venous return
- constrictive pericarditis
- RV failure, LV failure
- Restrictive cardiomyopathy
What signs of cardiovascular disesase can you look for in the eyes?
Conjunctival pallor (anaemia)
Corneal arcus (hypercholesterolaemia)
Xanthelasma (hypercholesterolaemia)
Kayser-Fleischer rings (Wilson disease)
What signs of cardiovascular disease can you look for in the mouth?
Cyanosis (lips, tongue)
Angular stomatitis
High arched palate (Marfan’s)
Dental hygiene
What can you inspect for on the chest?
Scars
Pectus excavatum
Pectus carinatum
Visible pulsations (ventricular hypertrophy)
What do you palpate on the chest?
Apex beat (mid-clavicular line, 5th intercostal space) Parasternal heaves (RV hypertrophy) Thrills (over valve landmarks)
Where are the locations for palpating/auscultating over valves?
Mitral valve = mid-clavicular, 5th intercostal
Tricuspid = left sternal edge, 4th/5th intercostal
Pulmonary = left sternal edge, 2nd intercostal
Aortic = right sternal edge, 2nd intercostal
What accentuation manoeuvre can you do for auscultating aortic stenosis?
Auscultate carotid artery with diaphragm of stethoscope and patient holding breath
= ejection systolic murmur
What accentuation manoeuvre can you do for aortic regurgitation?
Auscultate with diaphragm over aortic valve (right sternal edge, 2nd intercostal).
Ask patient to sit forward
On expiration will hear early diastolic murmur
What accentuation manoeuvre can you do for mitral regurgitation?
Ask patient to lie on left side
Auscultate with diaphragm over mitral valve (mid-clavicular, 5th intercostal)
On expiration will hear pansystolic murmur
Continue auscultating into axilla to find radiation
What accentuation manoeuvre can you do for mitral stenosis?
Ask patient to lie on left side
Auscultate with BELL over mitral valve (mid-clavicular, 5th intercostal)
On expiration will hear mid-diastolic murmur
When would you use bell vs diaphragm for auscultation?
Bell is for low frequency sounds e.g. mitral stenosis mid-diastolic murmur
Diaphragm is for high frequency sounds e.g. aortic stenosis, regurgitation, mitral regurgitation
What would you examine on the back of the patient?
General inspection - scars, deformities
Auscultate lung field posteriorly
Percuss lung fields
Palpate for sacral oedema
What would you examine on the legs of the patient?
Ankles for pitting oedema
Check for evidence of saphenous vein harvesting used in CABG
How would you complete the examination?
Thank the patient and explain examination is finished
Tell them they can get dressed
Remove PPE and wash hands
Summarise findings
To complete: blood pressure (both arms, lying+standing), hepatojugular reflex (if not already done), fundoscopy, urinalysis (protein/haematuria), blood glucose, ECG, peripheral vascular examination (femoral pulses)
What are the signs of infective endocarditis to look for on inspection?
Hands: splinter haemorrhages, osler’s nodes, janeway lesions
Mouth: poor dental hygiene
Peripheral scars, venous insufficiency (IVDU?)
What are the peripheral signs to look for in CVD examination that suggest Marfan’s syndrome?
What are the CVD risks with Marfan’s?
Signs: Arachnondactyly, long limbs, pectus excavatum/carinatum, high-arched palate
Risks: Aneurysms, dissections, mitral/aortic prolapse
