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MBBS 3: Physical Examinations > Cardiovascular Examination > Flashcards

Cardiovascular Examination Flashcards

1
Q

Components of a physical exam?

A

Introduction
Inspection
Palpation
Percussion
Auscultation

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2
Q

Order of examination?

A

‘general’ > hands > pulse > neck > face > chest > abdomen > legs

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3
Q

Introduction?

A
  1. Ensure adequate hygiene of hands and stethoscope
  2. Introduce self and confirm patient’s name
  3. Ask if patient is in any discomfort
  4. Briefly explain what the examination will involve using patient-friendly language.
  5. Seek permission to examine the cardiovascular system (gain Consent)
  6. Position patient appropriately with chest adequately exposed (45 degrees, shirt off)
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4
Q

Order of inspection?

A

> Begin with general inspection of the patient
inspect the hands, pulse, BP
work up to the head and neck
finally moving to the chest

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5
Q

General inspection?

A
  1. Signs of discomfort / respiratory distress
  2. Oxygen
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6
Q

Inspection of hands?

A
  1. Warmth / capillary refill
  2. peripheral cyanosis
  3. Tar/tobacco staining
  4. nail clubbing
  5. splinter haemorrhages / Janeway lesions / Osler’s nodes
  6. Koilonychia/xanthoma (palmar or tendon)
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7
Q

What are the signs of endocarditis?

A
  1. splinter haemorrhage
  2. Oslers nodes
  3. Janeway lesions
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8
Q

Palpation (pulses)?

A
  1. Radial
    - Rate
    - Rhythm (Regular / irregular / irregularly irregular)
    - Blood pressure
  2. Carotid:
    - volume Character
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9
Q

What is jugular venous pressure exam?

A

aspect of assessing a patients volume status especially in patients with heart failure, liver failure and kidney failure

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10
Q

How to measure the jugular venous

A

by assessing the vertical distance between the sternal angle and the top of the pulsation point of IJV
- in healthy individuals this should be no greater than 3 cm
Note:
- with patient at 45 degrees
- located between 2 heads of SCM
- raised right heart failure

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11
Q

Inspection of the face?

A
  1. malar flush
  2. Pallor
  3. xanthelasmata
  4. corneal arcus
  5. central cyanosis
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12
Q

Malar flush?

A

a plum red discolouration of the high cheeks
- associated with mitral valve stenosis due to the resulting CO2 retention and its vasodilatory effects

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13
Q

Pallor/anemia?

A

pale palmar creases
- sign of anemia

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14
Q

Xanthelasma?

A

yellow bump on or near your eyelid skin
- a type of xanthoma or cholesterol deposit
NB: sign of hyperlipidemia

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15
Q

Corneal arcus?

A

blue or white crescent shape (arc) made of lipid (fatty deposits) that curves around the outer edges of the cornea of the eye

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15
Q

Corneal arcus?

A

blue or white crescent shape (arc) made of lipid (fatty deposits) that curves around the outer edges of the cornea of the eye

16
Q

Inspection of the preacordium?

A
  1. Scars
  2. Shape (bulge on left side of chest due to cardiac enlargement
  3. Visible apex
  4. Other pulsations
17
Q

What are scars indicative of?

A

suggestive of previous thoracic surgery

18
Q

What is the shape indicative of?

A
  1. Pectus excavatum:a caved-in or sunken appearance of the chest.
  2. Pectus carinatum:protrusion of the sternum and ribs
19
Q

What is a visible apex indicative of?

A

Visible pulsations:a forceful apex beat may be visible secondary to underlying ventricular hypertrophy

20
Q

Name and describe thoracic scars?

A
  1. Median sternotomy scar
    - located in the midline of the thorax
    - cardiac valve replacement and coronary artery bypass grafts (CABG).
  2. Anterolateral thoracotomy scar
    -located between the lateral border of the sternum and the mid-axillary line at the 4thor 5thintercostal space
    - minimally invasive cardiac valve surgery.
  3. Infraclavicular scar
    -located in the infraclavicular region (on either side)
    -pacemaker insertion.
  4. Left mid-axillary scar
    - insertion of a subcutaneous implantable cardioverter-defibrillator (ICD).
21
Q

What to look out for on palpation?

A

the location of theapex beatand to identifyheavesorthrills.

22
Q

Apex beat?

A
  • Most lateral and inferior place you can detect a cardiac impulse
  • A sign of cardiac enlargement
  • Measure rib space from sternal angle
  • Mention site in relation to clavicular / axillary lines
23
Q

What are Heaves?

A

An impulse along the left sternal edge lifting the hand

24
Q

How to palpate for heaves?

A

Aparasternal heaveis a precordial impulse that can be palpated.
1. Place theheel of your handparallel to theleft sternal edge(fingers vertical) to palpate for heaves.
2. If heaves are present you should feel the heel of your hand beingliftedwith each systole.
Note: Parasternal heaves are typically associated withright ventricular hypertrophy.

25
Q

What are thrills?

A

palpable murmurs

26
Q

How do you palpate for thrills?

A

a thrillis apalpable vibrationcaused byturbulent blood flowthrough a heart valve (a thrill is a palpable murmur).
1. You should assess for a thrill acrosseach of the heart valvesin turn
2. To do this place your handhorizontallyacross the chest wall, with theflats of your fingersandpalmover thevalveto be assessed.

27
Q

What to listen for in auscultation of heart sounds?

A

1st and 2nd sounds
Added sounds (3rd and 4th, clicks)
Murmurs (turbulent flow)
Use diaphragm and bell in all 4 areas

28
Q

How to distinguish between heart sounds in auscultation?

A

Use carotid pulse to distinguish 1st and 2nd heart sounds and to ‘time’ murmurs:
- Palpable pulse implse = systole

29
Q

Sites for auscultation?

A
  1. mitral/apex area
    - 5th intercostal space, ICS, mid clavicular line
  2. tricuspid area
    - 4th left ICSs, at the left sternal edge, LSE
  3. pulmonary area
    - 2nd left ICS lateral to sternum, LSE
  4. aortic area
    - 2nd right ICS lateral to sternum
30
Q

Describe different kinds of murmurs?

A
31
Q

Describe manoueuvres to accentuate murmurs?

A
  1. Roll on left side:
    - Listen for diastolic murmur of Mitral Stenosis with the bell
    - Listen for axillary radiation of mitral regurgitation
  2. Sit forward / breathe out:
    - Listen for diastolic murmur of aortic regurgitation
32
Q

Bell vs diaphragm in a stethoscope?

A
  1. Thebellof the stethoscope is more effective at detectinglow-frequency sounds, including themid-diastolic murmurof mitral stenosis.
  2. The diaphragm of the stethoscope is more effective at detecting high-frequency sounds, including:
    - theejection systolic murmurof aortic stenosis
    - theearly diastolic murmurof aortic regurgitation
    - thepansystolic murmurof mitral regurgitation
33
Q

What else to listen to on auscultation besides heart sounds?

A
  1. The neck (carotids)
  2. The back (crackles of pulmonary oedema)
34
Q

What to look for on palpation?

A
  1. Sacral oedema
    - Inspectandpalpatethesacrumfor evidence ofpittingoedema.
  2. Hepatomegaly
  3. Leg warmth / discoloration of poor perfusion
  4. Leg pulses (radio-femoral delay)
  5. Leg oedema
    - Inspectandpalpatethe patient’sanklesfor evidence ofpitting pedal oedema(associated with right ventricular failure).
  6. BP (if not done already)
35
Q

Examination of the posterior aspect?

A
  1. Inspect theposteriorchestwallfor anydeformitiesorscars(e.g. posterolateral thoracotomy scar associated with previous lung surgery).
  2. Auscultatethelungfieldsposteriorly - Coarse cracklesare suggestive ofpulmonary oedema(associated withleft ventricular failure)
    - Absent air entryandstony dullnessonpercussionare suggestive of an underlyingpleural effusion(associated with left ventricular failure).
36
Q

To complete the examination?

A

Explainto the patient that the examination is nowfinished.
Thank the patientfor their time.
Dispose of PPEappropriately andwash your hands.
Summariseyour findings.

37
Q

Further assessments and investigations?

A

Measureblood pressure:to identify hypotension, hypertension or significant discrepancies between the two arms suggestive of aortic dissection.
Peripheral vascular examination:to identify peripheral vascular disease, which is common in patients with central cardiovascular pathology.
Record a 12-lead ECG:to look for evidence of arrhythmias or myocardial ischaemia.
Dipstick urine:to identify proteinuria or haematuria which can be associated with hypertension.
Bedside capillary blood glucose:to look for evidence of underlying diabetes mellitus, a significant risk factor for cardiovascular disease.
Performfundoscopy:if there were concerns about malignant hypertension, fundoscopy would be performed to look for papilloedema.

MBBS 3: Physical Examinations (19 decks)

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