Cardiovascular examination Flashcards
What are the introductory steps in a cardiovascular examination?
1) Wash hands
2) Apron + gloves
4) Introduce yourself
3) Identify the patient (Name + DOB) - check wristband if applicable.
4)Briefly explain the examination.
5) Obtain consent (explain what you are going to do and why you are going to be doing it).
6) Offer a chaperone for the examination.
7) POSITION THE BED AT A 45 DEGREE ANGLE.
What is the next step of the cardiovascular exam after introduction?
General inspection:
1) General inspection around the bed.
2) Inspection of patient from the end of the bed.
What kinds of things are being looked for around the bed? What are their potential implications?
- GTN spray. Indicative of angina.
- Lots of pillows to prop themselves up. Indicative of heart failure.
What are the key things to look for when inspecting the patient from the end of the bed? What can they potentially indicate?
- Is the patient in any obvious pain/discomfort?
- How is the patient built? This includes age, exercise levels, gender etc. and can help to identify which conditions they are at high risk of.
- What colour is the patient? Cyanosis is indicative of poor circulation. Has both cardiac and respiratory causes.
Palor can be indicative of anaemia or CHF. Malar flush could be indicative of mitral stenosis. - How is the patient breathing? SOB indicative of many cardiovascular and pulmonary diseases (e.g. CHF).
- Is the patient oedematous? CHF can cause pitting oedema, most commonly in the calves.
After general inspection, what comes next?
Inspect the appearance of the hands.
What are the key cardiovascular things to look for when inspecting the patient’s hands?
- Colour (especially in the creases of the hands). Pallor can be indicative of CHF. Cyanosis is most commonly caused by cold hands, but can also be caused by peripheral vascular disease.
- Tar staining. Indicative of a significant smoking history.
- Presence of excessive sweating. Can be indicative of angina/MI.
- Xanthomata (yellow deposits of cholesterol, typically found on the palm and/or tendons of the wrist and elbow. Associated with hyperlipidaemia.
- Clubbing. Associated with IE (infective endocarditis) and CHD (congenital heart disease).
- Signs of endocarditis:
Splinter haemorrhages.
Janeway lesions (thenar/hypothenar regions, non-tender).
Osler’s nodes (fingers/toes, tender).
What is the next step after inspecting the hands?
Palpation of the hands.
What does palpation of the hands involve?
- Assess the temperature of the hands using the dorsal aspect of your hand. Check warmth is symmetrical. Cool hands suggestive of poor peripheral perfusion (CHF or ACS).
- Assess capillary refill time. Compress the distal phalanx for 5 seconds, then release. Normal colour should return within 2 seconds, over 2 seconds indicative of CHF or ACS.
What is the next step after palpation of the hands?
Assessment of the radial and brachial pulse.
How is the radial/brachial pulse assessed?
What are the common pathological pulse characters?
1) Assess the right radial pulse:
- Rate
- Rhythm
- Character
2) Assess both radial pulses simultaneously:
- Radio radial delay? Subclavian stenosis, aortic dissection or aortic coarctation.
3) Assess the brachial pulse:
- Rate
- Rhythm
- Character
4) Assess for a collapsing (sometimes called “water hammer”) pulse.
- Ask patient if they have any pain or discomfort in their shoulder - if they do, exclude this part of the assessment.
- Palpate the brachial pulse with your left hand and the radial with your right and lift the patient’s right arm briskly above their head.
- Assess for a collapsing pulse (sharp rising and sharp falling pulse).
Common pathological pulse characters:
Slow rising - aortic stenosis.
Bounding - Aortic regurgitation OR Co2 retention.
Thready - hypovolaemia (e.g. sepsis).
Collapsing - Aortic regurgitation, fever, pregnancy, anaemia.
What is the next step after assessment of the radial and brachial pulses?
- Assessment of the carotid pulse:
- Rate
- Rhythm
- Character
What is the next step after assessment of the carotid pulse?
- Assessment of the JVP.
How is the JVP assessed?
What is a raised JVP indicative of?
- Ensure the head of the bed is at a 45 degree angle.
- Patient turns their head to the left.
- Locate the JVP (Double waveform pulsation, located approx. in the vertical plane of the earlobe whilst in this position). IT MAY NOT BE IDENTIFIABLE IN ALL PEOPLE.
- Measure distance between the sternal angle and the top of the IJV pulsation VERTICALLY.
Healthy individuals should have no greater than a 3cm distance between the two.
Raised JVP is indicative of venous hypertension, caused by:
- RHF
- Tricuspid regurgitation
- Constrictive pericarditis.
What is the next step of cardiac examination following assessment of the JVP?
- Hepatojugular reflex test.
How is a hepatojugular reflux test performed?
What is a positive test result indicative of?
- Press firmly on the RUQ (liver) of the patient for approx 10-20 seconds.
- Observe the patient for a sustained (after the release of pressure) raise of JVP for at least 15 seconds. This is a positive result.
- +ve test result is indicative of constrictive pericarditis, heart failure, restrictive cardiomyopathy. (because the RV cannot accomodate the increase in venous return).
