Cardiovascular examination

Question 1

General inspection of pt’s face

Answer 1

Face:
– yellow cholesterol deposits around the eye known as Xanthelasma (hyperlipidaemia)

– examine the iris of the eye, for senile arcus (grey or white arc visible around the cornea)
—- shows signs of hyperlipidaemia

– ask pt to pull down their eye, to look for conjunctival pallor
—- sign of anaemia

– red nose or blemishes on cheeks (malar flush)

– examine inside the mouth with a pen torch, underneath the tongue and around the lips for central cynosis
—- blue colouration due to hypoxia

– note the pt’s dental hygiene, as poor dental hygiene is a risk factor for infective endocarditis

Question 2

General inspection of pt’s neck

Answer 2

JVP (jugular venous pressure):
– non palpable
– provides an estimate of the central venous pressure and hence the pt’s volume status and heart function.
—- the higher the column the higher the pressure

To assess JVP:
– get pt to turn their head to the left and extend their neck directly backwards
– measure height of the JVP’s highest point in CM’s.
– measured horizontally from the vertical angle and horizontally from the JVP’s heights point
—- pt needs to be placed at 45 degrees as this angle influences the height of the JVP for any given CVP

Carotid pulse:
– find angle of the mandible

Question 3

General inspection of pt’s hands

Answer 3

– inspect fingernails for splinter haemorrhages
—- sign of previous trauma or pathologically of infective endocarditis

– also look for clubbing in the fingernails
—- clover test

– feel heat of hands, if they feel cold, there could be lack of blood flow to the hands

– peripheral veins- are they really prominent? really blue?

– blood flow of fingers by pressing on the nail, if takes longer than 3 seconds to go red again then blood flow to the hand and fingers is not good

Tar staining to show smoking, which is a risk factor of CVS

Radial pulse:
– right of left radial pulse
– just medial of radial styloid process

Radial-radial delay:
– palpate both at the same time to detect any inequality in timing

Jerky pulse:
– sign of hypertrophic cardiomyopathy, but is unlikely to be detected peripherally

Radio-femoral delay:
– should be at the same time
– if femoral pulse is more delayed could be a congenital aorta pathology

Question 4

Pulses

Answer 4

Looking for:
- rate
— most common causes of bradycardia are medication, physical conditioning
- rhythm
— when looking it’ll at rhythm it can be regular or irregular (most common causes of this are atrial fibrillation (irregularly irregular)
— can be regularly irregular like ectopic heartbeat
- volume
- character
— collapsing (the case in severe aortic regurgitation)

Pulse as low as 40bpm is normal is a fit young adult
Resting heart rate usually between 60-100bpm

Carotid

Radial (radial-radial, radio-femoral delay, feel for a collapsing radial pulse (hold it above their heart))

Femoral

Popliteus pulse

Question 5

Assessing the precordium (listening to the heart with a stethoscope)

Answer 5

Mitral valve/apex of the heart:
- location- intercostal space 5, between ribs 5 and 6 on the left side of the body
– should be the loudest beat
– if pt is female, get them to lift their boob as the location may be underneath breast tissue

Tricuspid valve:
- location- intercostal space 5, closer to the sternum than the mitral valve
– again, if pt is female may need to get them to lift up boob

Pulmonary valve:
- location- intercostal space 2, between ribs 2 and 3 on the left side of chest

Aortic valve:
- location- intercostal space 2, between ribs 2 and 3 on their right side of chest

Heart sounds:
- should hear a ‘lub dub’

Abnormalities in intensity of hearts sounds:
- quiet- poor left ventricular function, low cardiac output

Loud- mitral stenosis,

Variable- atrial fibrillation, complete heart block

Causes of a 3rd heart sound:
- it’s pathological after 40 years old it is not too common
- left ventricular failure (MC)
- however can be caused by things like pregnancy and in athletes

Murmurs:
- murmurs can be heard by turbulent flow across an abnormal valve
- innocent murmurs- caused by pregnancy and fever in children

Systolic murmurs:
- caused by increased stroke volume or stenosis of the aortic or pulmonary valve

Graded 1-6 for intensity with 6 being the worst and 1 being the least worst

Pansystolic murmurs- usually cussed by mitral regurgitation

Diastolic murmurs- aortic regurgitation

Question 6

Taking blood pressure

Answer 6

120/80 is normal blood pressure

Talk about different stages of hypertension, and what can cause it!!!!