Cardiovascular Examination Flashcards
What should be done in the introduction of the cardiovascular examination?
- Wash hands
- Identify patient
- Explain examination
- Gather consent
- Position the patient at 45 degrees on examination couch
- Expose chest & offer chaperone
- Confirm well-being
What should be noted on general inspection of the bedside in a cardiovascular exam?
- Mobility aids
- GTN spray & other medications
What should be noted on the general appearance of the patient in a cardio exam?
- Cyanosis
- Shortness of breath
- Pallor
- Malar flush
- Oedema
What does cyanosis indicate?
Bluish discolouration of the skin due to poor circulation or inadequate oxygenation of the blood
What does shortness of breath indicate in a cardio exam?
Underlying cardiovascular or respiratory disease
What does pallor indicate in a cardio exam?
A pale colour of the skin that may suggest anaemia/poor perfusion
What does malar flush indicate in a cardio exam?
May indicate mitral stenosis
How does malar flush present?
Plum-red discolouration of the cheeks
What signs may be picked up from the hands in a cardio exam?
- Tar staining
- Vasodilation/constriction & temperature
- Sweating
- Pallor of palm creases
- Peripheral cyanosis
- Clubbing
- Splinter haemorrhages
- Janeaway lesions
- Oslers nodes
- Xanthomata
What may sweating of the hands indicate in a cardiovascular exam?
- Increased sympathetic drive
- Indicates acute coronary syndrome
What does peripheral cyanosis indicate on a cardio exam?
Hypoxia
What does clubbing indicate on a cardio exam?
Cyanotic heart defect, endocarditis or chronic hypoxia
What are splinter haemorrhages and what do they indicate?
- Red/brown streaks on nail bed
- Indicate bacterial endocarditis
What are Janeaway lesions and what do they indicate?
- Painless red spots which blanch on pressure on the hands
- Indicate bacterial endocarditis
What are Osler’s nodes and what do they indicate?
- Painless red spots which blanch on pressure on the fingers
- Indicate bacterial endocarditis
What is xanthomata and what does it indicate?
Raised yellow lesions on the hands - indicate hyperlipidaemia
What are Roth spots and what do they indicate?
- Red haemorrhages seen on fundoscopy
- Indicative of bacterial endocarditis
What is normal capillary refill time on cardio exam?
Less than 2 seconds
What should be assessed when feeling the radial pulse?
- Rate, rhythm, volume and character
What is arachnodactyly and why might it be seen on cardio exams?
- Abnormally long and slender toes/fingers
- Feature of Marfan’s = associated with mitral/aortic valve prolapse & aortic dissection
How is finger clubbing assessed?
- Ask the patient to place their index nails back to back
- Should be a small diamond shaped window present in healthy individuals
- This is lost in clubbing
What may cool hands indicate in a cardiovascular exam?
Poor peripheral perfusion e.g. congestive cardiac failure, ACS
What may cool and clammy hands indicate in a cardio exam?
ACS
What may a long capillary refill time indicate?
Poor peripheral perfusion e.g. hypovolaemia & congestive heart failure
What is a normal healthy pulse rate?
Between 60-100bpm
What are some causes of bradycardia?
- Healthy athletic individuals
- AV block
- Medications
- Sick sinus syndrome
What are some causes of tachycardia?
- Anxiety
- Supraventricular tachycardia
- Hypovolaemia
- Hyperthyroidism
What is the most common cause of irregular rhythm?
Atrial fibrillation
What is radio-radial delay?
A loss of synchronicity between the radial pulse on each arm, resulting in the pulses occurring at different times
How do you assess for radio-radial delay?
- Palpate both radial pulses simultaneously
- In healthy individuals, the pulses should occur at the same time
- If the radial pulses are out of sync, this would be described as radio-radial delay
Name 3 causes of radio-radial delay
- Subclavian artery stenosis
- Aortic dissection
- Aortic coarctation
How else can a collapsing pulse be referred to?
Water hammer pulse
What is a collapsing pulse?
A forceful pulse that rapidly increases and subsequently collapses
How do you assess for a collapsing pulse?
- Ask the patient about pain in the right shoulder
- Palpate the radial pulse of the right arm and the brachial pulse of the left arm
- Ask about pain in the shoulder
- Briskly raise the patient’s arm above their head
- Feel for a loss of radial pulse, with it returning soon after.
- When it is lost radially, it should be felt brachially
What is the main cause of a collapsing pulse?
Aortic regurgitation
Name some minor causes of a collapsing pulse
- Fever/pregnancy
- Patent ductus arteriosus
- High output states e.g. anaemia, arteriovenous fistula, thyrotoxicosis
What pulses should be felt in a cardiovascular examination?
- Radial
- Brachial
- Carotid
How do you palpate the brachial pulse?
- Support the patient’s right forearm with your left hand
- Position the patient so that their upper arm is abducted, their elbow is partially flexed and their forearm is externally rotated
- Palpate in line with the ‘pinky finger’
What are the 4 types of pulse character?
- Normal
- Slow-rising
- Bounding
- Thready
What may a slow-rising pulse character indicate?
Associated with aortic stenosis
What may a bounding pulse character indicate?
Aortic regurgitation OR CO2 retention
What may a thready pulse character indicate?
Intravascular hypovolaemia in conditions such as sepsis
What are the 5 types of blood pressure abnormalities?
- Hypertension
- Hypotension
- Narrow pulse pressure
- Wide pulse pressure
- Difference between arms
What is a narrow pulse pressure?
Less than 25 mmHg of difference between the systolic and diastolic blood pressure
What 3 conditions may cause a narrow pulse pressure?
- Aortic stenosis
- Congestive heart failure
- Cardiac tamponade
What is a wide pulse pressure?
More than 100 mmHg of difference between systolic and diastolic blood pressure
What 2 conditions may cause a wide pulse pressure?
- Aortic regurgitation
- Aortic stenosis
What may a difference in BP between arms indicate, and when is it significant?
- More than 20 mmHg is significant
- May indicate aortic dissection
What are the two things that need to be done to a carotid pulse?
- Auscultate
- Palpation
Why is the carotid artery auscultated before palpation?
To exclude the presence of a bruit
What may a bruit of the carotid artery indicate and why is this important?
- Carotid stenosis
- Palpation of the vessel may dislodge a carotid plaque and cause an ischaemic stroke
How do you auscultate the carotid artery?
- Place the diaphragm of the stethoscope between the larynx and the anterior border of the sternocleidomastoid muscle
- Ask the patient to take a deep breath and hold it whilst you listen
What is it important to be aware of when auscultating the carotid artery?
A ‘bruit’ may be a radiating cardiac murmur
How do you palpate the carotid pulse?
- Place the fingers between the larynx and the anterior border of the sternocleidomastoid muscle to locate the carotid pulse
- Assess the character (e.g. slow-rising, thready) and volume of the pulse
What is the jugular venous pressure used for?
To give an indirect measure of central venous pressure
How do you measure the JVP?
- Position the patient at a 45 angle on the bed
- Ask the patient to turn their head slightly to the left
- Look for the IJV (inferior jugular vein) between the medial point of the clavicle and the ear lobe
- Measure the JVP by assessing the vertical distance between the sternal edge and the top of the pulsation of the IJV
What is a healthy length of the IJV when measuring JVP?
- When healthy, it should be no greater than 3cm
What does a raised JVP indicate?
Venous hypertension
Name 3 causes of a raised JVP
- Right-sided heart failure (caused by left sided)
- Tricuspid regurgitation (caused by infective endocarditis & rheumatic heart disease)
- Constrictive pericarditis
What is the hepatojugular reflux test?
- Involves the application of pressure to the liver to help see for a sustained rise in JVP
At which point should you perform a hepatojugular reflux test?
Should be at least a 3cm distance from the upper margin of the baseline JVP to the angle of the mandible
How do you perform the hepatojugular reflux test?
- Position the patient at 45 degrees
- Apply direct pressure to the liver
- Closely observe the IJV for a rise
- If healthy: rise shouldn’t last longer than 1-2 cardiac cycle
- If raise is sustained and equal to or greater than 4cm = positive result
What may a positive hepatojugular reflux test indicate?
That the right ventricle is unable to accommodate an increased venous return
Name 4 conditions which may give a positive hepatojugular reflux test
- Constrictive pericarditis
- Right ventricular failure
- Left ventricular failure
- Restrictive cardiomyopathy
What may conjunctival pallor indicate on a cardio exam?
Underlying anaemia
What is corneal arcus?
A hazy white, grey or blue opaque ring located in the peripheral cornea
What may a corneal arcus indicate in a cardio exam?
May suggest hypercholesterolaemia
What is xanthelasma?
Yellow, raised cholesterol-rich deposits around the eyes
What may xanthelsasma indicate?
Hypercholesterolaemia
What are Kayser-Fleischer rings?
Dark rings that encircle the iris
What is the relevance of Kayser-Fleischer rings in a cardio exam?
- Associated with Wilson’s disease
- May be excess deposition in the heart, which may cause cardiomyopathy
What is angular stomatitis?
An inflammatory condition at the corners of the mouth
What is the relevance of angular stomatitis in a cardio exam?
May indicate iron deficiency
What is the relevance of poor dental hygiene in a cardio exam?
Risk factor for infective endocarditis
What are the 3 things to palpate for in a cardio exam?
- Apex beat
- Heaves
- Thrills
How do you palpate for the apex beat?
- Palpate the apex beat with the fingers placed horizontally across the chest
- When healthy = 5th intercostal space in the midclavicular line
What may cause displacement of the apex beat?
Due to ventricular hypertrophy
What is a parasternal heave?
A precordial impulse that can be palpated
How do you feel for a parasternal heave?
- Place the heel of your hand parallel to the left sternal edge (vertical fingers)
- If present, the heel of the hand will be lifted with each systole
What does a parasternal heave indicate?
Right ventricular hypertrophy
What is a thrill in a cardio exam?
A palpable vibration caused by turbulent blood through a heart valve
How do you feel for a thrill in a cardio exam?
- Place your hand horizontally across the chest wall, with the flats of your fingers and palm over the valve to be assessed
- Do this for every valve
- This is to assess for palpable murmurs
Where is the mitral valve located in the chest?
5th intercostal space in the midclavicular line
Where is the tricuspid valve located in the chest?
4th or 5th intercostal space at the lower left sternal edge
Where is the pulmonary valve located in the chest?
2nd intercostal space at the left sternal edge
Where is the aortic valve located in the chest?
2nd intercostal space at the right sternal edge
In which order should you auscultate the heart valves?
- Aortic, pulmonary, tricuspid, mitral
- Listen with the diaphragm, then the bell
How do you check for mitral regurgitation on auscultation?
- Auscultate the left axilla
- Listen with the diaphragm of the stethoscope
How do you check for mitral stenosis on auscultation?
- Have the patient rolled 45 degrees to the left
- Place the stethoscope over the mitral area and listen with the bell
- Listen while the patient is holding their breath
How do you check for aortic regurgitation on auscultation?
- Sit patient forwards
- Auscultate at the 4/5th intercostal space to the left of the sternum on held expiration
- Listen while the patient is holding their breath
When auscultating the carotid arteries, what are you listening for?
A bruit or a transmitted systolic murmur
What you should be assessed for when auscultating the back of the chest?
- Sacral oedema
- Any crackles in the base of the lung
What auscultation should be performed is coarctation is suspected?
Auscultate to the left of the spine in the 3rd/4th intercostal space
What should be checked peripherally in a cardiovascular exam?
- Ankles - pitting oedema
- Hepatomegaly & pulsations
- Shifting dullness if ascites suspected
- Posterior chest wall for lungs
If ankle oedema is found in a cardiovascular exam, what else should be examined?
The abdomen, to check for ascites
What is significant about checking for hepatomegaly and pulsations in a cardiovascular exam?
- If there is a pulsation = may indicate tricuspid regurgitation
What would coarse posterior chest crackles indicate on a cardiovascular examination?
Pulmonary oedema
What would a absent air entry and stony dullness on percussion of the posterior chest wall indicate on a cardiovascular exam?
Potential pleural effusion
Name 6 potential tests/exams/investigations which would be useful after a cardiovascular examination?
- Blood test (inc. capillary blood glucose)
- Blood pressure (lying and standing - in different arms)
- Twelve-lead ECG
- Fundoscopy
- Femoral pulses (to check for femoral-radio delay)
- Peripheral vascular examination
What does the 1st heart sound represent?
The closure of the mitral and tricuspid valves
What does a loud 1st heart sound represent?
Mitral stenosis
What does a soft 1st heart sound represent?
Mitral incompetence
What does the 2nd heart sound represent?
Aortic and pulmonary valve closure
What may a soft 2nd heart sound indicate?
- Aortic stenosis
- Pulmonary stenosis
What may a harsh 2nd heart sound indicate?
- Pulmonary hypertension
What may a 3rd heart sound indicate?
- Rapid ventricular filling (mitral regurg, VSD)
- Poor LV function (post-MI)
When is a 3rd heart sound heard?
Just after a 2nd heart sound
When is a 4th heart sound heard?
Just before a 1st heart sound
What may a 4th heart sound indicate?
Aortic stenosis
What may cause an ejection-systolic murmur?
- Aortic stenosis
- Pulmonary stenosis
What may cause a pan-systolic murmur?
Mitral or tricuspid regurgitation
What may cause an early diastolic murmur?
- Characterised by absence of silence
- Aortic/pulmonary regurgitation
What may cause a mid-diastolic murmur?
- Mitral stenosis
- Rheumatic fever
- Aortic regurgitation
