Cardiovascular examination Flashcards
What are the first part of an the introduction?
Wash hands
Introduce self
Pt details (Name, DOB +/- age)
Explain a cardiac examination to a patient
I’ve been asked to examine you heart which will involve me having a general look at the hands, arms, face and chest before having a feel and listen to your chest.
Does that sound okay?
What else would you say after gaining consent in the introduction?
exposure of pt (cardiac = top off is that okay?)
chaperone?
any pain or discomfort?
What do you inspect in a cardiac exam?
General
Bedside
Hands
Neck
Face
Eyes
Mouth
Chest
When inspecting the patient generally what are you looking for?
Inspect the general appearance (colour, breathing, comfort, position, build).
When inspecting the bedside what are you looking for?
Any treatments or adjuncts (GTN spray, O2, medication, mobility aids.
When inspecting the dorsum of the hand in a cardiac exam what are you looking for?
Splinter haemorrhages
Finger clubbing
Tar staining
What could the following signs indicate in a cardiac examination?
a) Splinter haemorrhages; (1)
b) Finger clubbing; (2)
c) Tar staining; (1)
a) Infective endocarditis.
b) Infective endocarditis.
Cyanotic congenital heart disease.
c) Smoking = risk factor for cardiovascular disease.
When inspecting the palm of the hand in a cardiac exam what are you looking for?
Colour;
Janeway lesions;
Osler’s nodes;
Tendon xanthomas;
What could the following signs indicate in a cardiac examination?
a) Peripheral cyanosis
b) Janeway lesions
c) Osler’s nodes
d) Tendon xanthomas
a) Hypoxia
b) IE
c) IE
d) Hyperlipidaemia
Describe the appearance of Janeway lesions
Non-tender maculopapular erythematous palm pulp lesions
Describe the appearance of Osler’s nodes
Tender red nodules on finger pulps/thenar eminence
What would you assess in the hands in a cardiac examination?
CRT
Temperature (bilat to compare)
What is a normal CRT?
If CRT is raised what may it suggest?
<2
Hypovolaemia
During a cardiac examination what pulses are examined?
Radial
Radio radial delay
Brachial
Collapsing
Carotid
What do you assess when feeling the following pulses?
a) radial
b) brachial
c) carotid
a) rate and rhythm (find BPM)
b) character and volume
c) character and volume (1 AT A TIME)
For both the brachial and carotid pulses what do the following suggest?
a) Slow rising
b) Collapsing
a) Aortic stenosis
b) Aortic regurg
How do you assess for a collapsing pulse?
Ensure no shoulder pain in pt
palpate radial pulse
wrap hand around the wrist whilst still palpating the pulse.
Raise their arm above their head briskly
What are you feeling for when checking for a collapsing pulse?
Feel for a tapping impulse through the muscle bulk of the arm as blood empties from the arm very quickly in diastole, resulting in palpable sensation.
What does a water hammer pulse suggest?
Aortic Regurg
What is a Radio-radial delay associated with?
Subclavian artery stenosis (e.g. compression by a cervical rib)
Aortic dissection.
How do assess for the JVP?
Ensure patient is at 45 degrees.
Ask patient to turn head to their left side.
Observe the neck for the JVP (located in line with the sternocleidomastoid).
Measure the JVP
Apply pressure to the liver + observe JVP rise. (Hepatojugular reflux)
Where do you measure the JVP from?
Number of cm from the sternal angle to the upper border of the pulsation
What is a normal JVP?
2 - 4 cm
What could a raised JVP indicate?
fluid overload
right ventricular failure
tricuspid regurgitation.
What is a healthy (-ve result) Hepatojugular reflux and what is classed as a positive result?
Healthy = no longer than 1–2 cardiac cycle then falls
+ve result = If JVP is sustained + ≥4cm
When inspecting the face in a cardiac exam what do you look for and what does this indicate?
Malar flush -> Mitral stenosis
When inspecting the eyes in a cardiac exam what do you look for and what does this indicate?
Conjunctival pallor -> Anaemia
Corneal arcus -> hypercholesterolaemia
Xanthelasma -> hypercholesterolaemia
When inspecting the mouth in a cardiac exam what do you look for and what does this indicate?
Central cyanosis
Angular stomatitis -> Iron deficiency anaemia.
High arched palate -> Marfan’s - ^ risk of aortic
aneurysm / dissection.
Dental hygiene (caries) -> Potential source for IE
When generally inspecting the chest in a cardiac exam what do you look for?
Scars
Chest wall deformities
Visible pulsations
What scars might you see on a chest in a cardiac exam?
Sternotomy =
midline thorax scar from CABG/valve surgery.
Clavicular =
pacemaker (can be either side).
Thoracotomy =
minimally invasive valve surgery.
Left mid-axillary line =
subcutaneous implantable cardioverter defibrillator.
What chest deformities might you see in a cardiac exam?
Pectus excavatum (chest sticks in).
Pectus carinatum (chest sticks out).
Severe kyphoscoliosis (hunched back).
What visible pulsations on a chest might you see in a cardiac exam and what may they indicate?
Forceful apex beat
HTN, ventricular hypertrophy
What do you palpate for in a cardiac exam?
Apex beat
Parasternal heaves?
Thrills
Where is the apex beat felt normally?
5th intercostal space, midclavicular line.
What does lateral displacement of the apex beat indicate?
Cardiomegaly
What is a parasternal heave?
Precordial impulse that can be palpated.
How do you feel for parasternal heaves?
What would you feel if they were present?
What are they present in?
Place the heel of hand parallel to left sternal edge with fingers vertical.
If present, should feel heel of hand being lifted each systole.
RVH
What are thrills?
What are they caused by?
Palpable vibration
Turbulent blood flow through a heart valve
How do you assess for thrills?
Assess each valve in turn with flats of fingers + palm over the assessed valve.
During a cardiac examination what do you auscultate?
Aortic valve
Pulmonary valve
Tricuspid valve
Mitral valve
Left axilla
Lung bases
Where do you place your stethoscope to hear the following?
a) Aortic valve
b) Pulmonary valve
c) Tricuspid valve
d) Mitral valve
a) 2nd intercostal space, R sternal edge
b) 2nd intercostal space, L sternal edge
c) 5th intercostal space, lower L sternal edge
d) 5th intercostal space, midclavicular line, apex beat
Why do we auscultate the left axilla?
For mitral incompetence
What can we do to accentuate mitral murmurs?
Switch to the bell while still auscultating the left axilla + ask patient to roll onto their left side
What can we do to accentuate an aortic regurgitation murmur?
Switch back to the diaphragm, sit patient forward + auscultate in the tricuspid region on held expiration
When auscultating what do you do to determine the first heart sound?
Palpate the carotid pulse
During a cardiac examination when a patient is sat forward what else should you assess in addition for accentuation of murmurs?
Auscultate lung bases;
Assess for sacral oedema;
Where would you auscultate if aortic coarctation is suspected?
left of the spine in 3rd/4th intercostal space
When auscultating lung bases what do crackles indicate?
Pulmonary oedema secondary to LVF
Chronic lung diseases if no sx of overload (Pulmonary fibrosis)
After sitting the patient back what else do you want to auscultate?
What instructions if any do you give to the pt?
What is the reason for this?
Auscultate the carotids
Hold their breath;
Accentuation manoeuvre for bruits or transmitted systolic murmur.
Before completing the examination what else do you what to assess for?
Hepatomegaly
Shifting dullness (ONLY IF ASCITES SUSPECTED)
pitting oedema in the ankles
Upon completing the exam what do you do first?
Thank patient
Wash hands
Ask if they need a hand getting dressed / they can now get dressed
To complete my examination…
I’d like to check the femoral pulses and assess for radio femoral delay, check blood pressure in both arms and perform a lying/standing blood pressure in one arm, perform fundoscopy and obtain a 12-lead ECG
Summarise a normal cardiac examination
Today I performed a cardiovascular examination on _____ a ____ year old ______.
On general inspection, _____ appeared comfortable at rest.
There was no peripheral stigmata of cardiac pathology.
The pulse was _____ BPM and was of normal rate and rhythm.
On palpation, there were no heaves and thrills.
On auscultation, 1st and 2nd heart sounds were present with no added sounds
To conclude, this is consistent with a normal cardiovascular examination.
