Cardiovascular Examination Flashcards
Inspection
Palpating
Auscultation
Patient is to be positioned at what angle?
……………. exposed downwards.
Patient should be placed in an anatomical position True or False?
From the foot end of the bed 🛏 inspect?
CARDIOVASCULAR EXAMINATION
At an angle of 45 degrees.
The patient’s trunk and mid-thighs exposed downwards
True— Place patient in an anatomical position
Gaining consent and others.
FROM THE FOOT OF THE BED
1. Patient’s general habitus
• Is the patient obese
• Is the averagely built?
• Is the patient slender?
• Is the patient cachectic?
• Is the patient in respiratory distress? Evidence by:
a. Nasal flaring
b. Increased respiratory rate
c. Noisy breathing
d. Tracheal tag
e. Subcostal and intercostal recessions
f. Use of abdominal muscles and sternocleidomastoid
If you pick this up, mention it in your opening general statement of you patient.
• Is there any obvious pedal swelling, or obvious facial swelling, or anasarca, you must note it in your general statement.
• Is there any ulcers?
• Is there any bandages?
• Is there any dressings?
• Are there any tubes?
• Are there any catheters?
• Is there any NG tube?
- Environment
• If patient is on oxygen, check how the oxygen is being delivered (Nasal prongs, nasal cannula, simple face, non-rebreather mask). Check the different flow rate.
• Cannulas in situ and infusion running.
• Drugs by their bedsides.
NB: If you are doing any system examination and you catch a positive sign in other systems, note 📝 them down.
What do you do at the right hand side of the bed 🛌 during examination 🧐 On:
Inspection 🧐 of the hands 🙌/ arm
RIGHT HAND SIDE OF THE BED
HAND
Inspection
• Digital clubbing.
• Peripheral cyanosis
• Tar stains or nicotine stains
• Capillary refill
• Splinter hemorrhages
• Osler’s nodes
• Janeway lesions.
• Leukonychia
Dorsum
• Finger clubbing:
The hand should be at eye level. Look at the finger within two planes.
Check for sponginess of the nail bed.
Ask your patient to do a Schamroth sign and observe, if he or she doesn’t have stage one and stage 2 clubbing…
Palm:
—Look inside the palm and palpate for Osler’s nodes and Janeway lesions (Seen in infective endocarditis).
—They are non-tender you may not also see them, so you need to palpate and see if you can feel them there.
—And for the Osler’s nodes, are tender so you obviously are not going to be pressing hard. So observe and see before you try to do a light palpation.
—Osler’s nodes are tender and located at the pulp of the fingers.
—And Janeway lesions are non-tender located in the palm and sometimes at the proximal phalanges.
—Look for palmar erythema (seen in polycythemia).
—You check the capillary refill…
**Do the same on the other hand.
WRIST
• Pulse
Preparation
- Come with a functioning watch.
- Use your right hand.
- If it is a regular pulse it is enough to count for 15 seconds and multiply by 4.
- If it is an irregular pulse, you must count for the entire 1 minute.
Rate
Rhythm
Volume
- Good
- Weak
- thready
Palpable arterial wall (seen in arteriosclerosis)
Character of the pulse (SEEN IN OXFORD)
- The name of the character
- What it means?
- Conditions that will give you that character.
Collapsing pulse.
- The main thing we are looking at is you not putting pressure on the hand.
- Once you lift the patient’s hand, you will feel the pulse hit very strongly, and after that it is going to vanish.
- There are about 23 or more conditions that gives collapsing pulse.
Way 1: First, ask the patient if there is any pain in his or her shoulder, then palpate the patient’s pulse with your fingers, then switch your hand to hold the wrist and still feel the pulse. (THE POINT IS NOT TO SQUEEZE THE PULSE TIGHTLY, BE VERY LOOSE). Support the elbow of the patient with your left hand and raise the hand using the elbow.
Way 2: … shake the hands, and the movements come from the hands.
If the patient has pain in his elbow, you can choose not to do it, or you say sorry make sure whatever movement you do does not aggravate the pain.
Radio-radial delay (which is as a result of the difference in the volume of the pulse not the timing of the pulse).
Radio-femoral delay
NB: SEEK CONSENT BEFORE SLIDING YOU HANDS DOWN THERE.
What are the conditions that can cause radio-radial delay and radio-femoral delay.
In summary, rate, rhythm, character, volume, radio radial, radio femoral, palpable arterial wall, collapsing pulse.
**e.g The pulse is 75bpm, it was regular and of good volume, it was non-collapsing, there was no radio-radial delay or radio-femoral asynchrony. Arterial wall is not palpable.
** In exam, for our level you should say, “I would like to check for the blood pressure”.
HEAD
Remember, we are mixing the general and cardiovascular.
- Is it well nourished?
- Is it pluckable?
Eyes
- Pallor
- Jaundice
- Corneal arcus
Another condition in which you will see a ring around the iris is Wilson’s disease (which is deposition of copper) – SO IN GIT TOO WE EXPECT YOU TO LOOK AT THE EYE TOO
- Look for signs of xanthelasma fat deposits.
Mouth
- Ask the patient to say “Aaa” and bring his tongue out.
- Central cyanosis (which is very evident when they lift the tongue up)
- Oral hygiene
Caries
- Dental implants (because they are risk factors for infective endocarditis)
Neck
- Look for obvious venous congestion
- You may need to differentiate
- Inspect the neck for pulsations, it may be venous or arterial. You must be able to differentiate between them.
- Pathway of internal jugular vein: Between the two heads of the SCM, which inserts at Clavicular head and sternal heads of the SCM.
- You can let the patient tense the SCM muscle in order to identify
- YOU MUST KNOW THE WAVEFORMS OF THE JVP
- The main difference between the venous and arterial pulsations is a double waveform for the venous.
- First inspect, if it is a double wave form or not. Then next you palpate. Venous pulsations are visible but not palpable however arterial are palpable.
- Veins are capacitance vessels, so if you occlude the region, it will feel up(engorge) as oppose to an arterial which you cannot compress for it to get engorged.
When you palpate, do you feel it? When you occlude does it feel up?
As if patient feels pain at the abdomen, then come to the abdomen, so you palpate or compress the abdomen (hepatojugular reflux) – ALL TO CONFIRM THE JUGULAR VEIN
Press your hand gently at the right side of the abdomen for a short period of time then release.
Ask your patient to sit up and gradually lean back. JVP changes with position. When the patient sits up it will fall, and will release as patient leans back.
ONCE YOU HAVE CONFIRMED, you need to measure the highest point.
Palpate the sternum for the sternal angle (corresponds to the second intercostal space) – WE WANT TO SEE YOU PALPATE
Place the first ruler 90 degrees on the sternal angle.
The second ruler is going to slide upwards along the first ruler until the tip of that ruler gets to the highest point of the pulsation. Mark the level on the first ruler
PRECORDIUM (IN CARDIOVASCULAR)
Inspect (Showmanship)
- Look for visible pulsations on the precordium (hyperactive pulsations)
- Are there any scars? Scarification marks? Are there abnormal chest wall deformation?
Palpation
- Apex beat: It is the inferior most and lateral most point on the precordium at which the examining finger will be raised at an angle of 90 degrees.
Start from lateral aspect and more inferior to the normal (i.e. axilla) and palpate with your right palm and feel for the apex beat. Use one finger to point at where you felt the apex beat – LET US ALL SEE WHERE THE APEX BEAT IS.
With your other hand, you come back and palpate for the angle of Louis and the fingers will be used to count the intercostal space (DON’T DANCE ON THE PATIENTS CHEST). IF THE PINKY FINDS THE 2ND INTERCOSTAL SPACE, LEAVE IT THERE AND USE THE OTHER FINGERS TO COUNT THE SUBSEQUENT INTERCOSTAL SPACES.
THERE ARE DIFFERENT CHARACTERISTICS/DESCRIPTIONS OF APEX BEAT (Tapping, Heaving, Thrusting) – ALL LISTED IN THE OXFORD.
E.g. apex beat was palpated in the 5th intercostal space midclavicular line, and it was heaving in nature.
The nature of the apex beat will give you indication of the state of the heart and that will let you arrive at a diagnosis.
- You need to measure the distance between clavicle find the middle trace it along and see far away the apex is from the mid-clavicular line.
- E.g. Apex beat was found in the 7th intercostal space 2cm lateral from the midclavicular line
- Palpate again for THRILSS (a palpable murmur). It feels like something squiggling under your hand. ONCE YOU PALPATE A THRILL, COMMON SENSE SHOULD TELL YOU THAT WHEN YOU ARE REPORTING IN AUSCULTATION THERE SHOULD BE A MURMUR.
- Check for heaves at the left parasternal joint with your hands at eye level.
What is the indication of HEAVES? Depending on where the heave is…CAUSES OF HEAVES
Percussion
- There are four auscultatory areas (Bell-bell-diaphragm-diaphragm-diaphragm-diaphragm)
- As you are auscultating, you must be palpating the carotids – DON’T PRESS HARD ON THE CAROTIDS.
- Are there any murmurs?
- Is the murmur systolic or diastolic?
- Are there any added sounds? – TAKE YOUR TIME TO AUSCULTATE, YOU ARE NOT IN A RUSH.
- Summary: Heart sounds, added sounds (S3 & S4), murmurs.
NORMALLY, THE MURMUR YOU WILL BE GIVEN, WILL BE A PANSYSTOLIC MURMUR SO YO SHOULD KNOW ABOUT 7 CAUSES.
Maneuvers to accentuate your murmurs.
- KNOW ALL THE MANEUVERS
- Once you are done auscultate first 4, come back and auscultate into the axilla (Because Pansystolic murmur commonly radiates into the axilla).
- Ask your patients to sit up and take a deep breath in, and ask them to exhale. As they exhale tell them to hold. So they hold their breath, mid-expiration. – THERE IS A PARTICULAR TYPE OF MURMUR ACCENTUATED BY THAT.
- Ask them to lean forward.
- Summary: auscultate into the axilla, hold breath mid-expiration, leaning forward.
CAROTID ARTERY
As they are siting up, auscultate over the carotid (for BRUITS – TURBULENT FLOW OF BLODD) whenever there is turbulent flow of blood, there is increased noise.
IF THE PATIENT IS BREATHING VERY HEAVILY, IT WILL BE VERY DIFFICULT FOR YOU TO HEAR SO YOU TELL THEM TO HOLD THEIR BREATHS MOMENTARILY AS YOU LISTEN OVER THE CAROTIDS.
LUNG BASES
- As the patient is still sitting up, you auscultate for the lung bases for pulmonary oedema.
- Then you palpate the sacral region.
ABDOMEN
- Go straight to palpate the liver, because you would established if the abdomen is tender or not. So you just ask, Can I palpate the liver
- Check for tenderness and edema
- Liver enlargement
PERIPHERAL PULSES
- Femoral
- Popliteal (You need to flex the leg and press) – WHEN YOU ARE EXAMINING YOUR, BACK SHOULD NEVER FACE THE PATIENT)
- Posterior tibialis
- Dorsalis pedis.
FOOT
- Pedal edema.
- Use both hands and use your thumbs to press against the bony prominences, hold for a few seconds release and then feel in the groove for a depression.
- If there’s no depression at the ankle, then there is no point moving up to check for edema. But if you press and there is a depression, then you need to continue upwards until you find the highest point of edema.
DONE WITH A CARDIOVASCULAR EXAM.
PRESENT YOUR FINDINGS.
