Cardiovascular examination Flashcards
How to get started with a CVS examination
Wash hands
Bare forearms
Introduce yourself
Ask if it is all right to perform an examination
Patient comfortable
Propped up at 45 degrees
Adequate support for head, chest exposed
Good light
Use Mr and Mrs or Ms - dont call them by their first name
What are female and old patients with clicking sounds most likely to have?
Metallic mitral valve - particularly if they have AF
If they are young what are they most likely to have>
Congenital heart condition
Missing lower limb veins - mid line sternotomy CABG
What are you checking for in a general CVS examination?
Stand back: general inspection
Well or ill?
Distress
Pale
Sweaty
Cyanosed
Tachypnoeic
Scars
Clues
When examining the hands of patient what are we looking for?
Look
Clubbing or splinter haemorrhages
Feel the temperature
Feel for tendon xanthomata
Feel the radial pulses bilaterally
Pulse rate and rhythm – regular, regular abnormality or completely irregular?
What do need to feel for the dissection of the aorta and radio femoral delay for coarctation?
Radial - radial delay - dissection of aorta
Radio - femoral delay - coarctation of aorta
What are the causes of regularly irregular pulse?
sinus arrythmia or second degree heart block (with wenckeback).
Causes of irregularly irregular pulse?
ventricular etopics, AF, Aflutter with variable block and wandering atrial pacemaker
What are the cardiac causes of clubbing?
myxoma, congenital cyanotic heart diease, any chronic hypoxia and endocarditis.
What is clubbing?
Fluctuation and softening of the nail bed (increased ballotability)
Thickening of the whole distal (end part of the) finger (resembling a drumstick)
Shiny aspect and striation of the nail and skin
Causes of splinter haemorrhages
Endocarditis, Vasculitis e.g. SLE, Trauma
What is pulse character?
Brachial pulse for character
normal, slow rising or collapsing?
Lift the arm and feel for
‘waterhammer’ or collapsing (AR)
Palpate R carotid pulse with L thumb
What gives a slow rising pulse?
Aortic valve stenosis - rate of ejection of blood into the aorta is decreased so that the duration of the ejection is prolonged. The amplitude of the pulse is diminished as a consequence.
poorly functioning left ventricle may give rise to a slow rising wave form due to slow ejection from the poorly functioning ventricle.
What gives a collapsing pulse? (fast upstroke and downstroke)
Aortic regurgitation - blood is pumped out rapidly but then regurgitates into the LV as quickly as it came out
Anaemia - Little blood - large shunts of blood from arterial to venous, placental or bone system or thyrotoxicosis
How doe we examine the face?
Eyes: conjunctival pallor, corneal arcus, eyelids for xanthelasmata
Cheeks: malar flush (mitral stenosis)
Check under the tongue and/or inside the lower lip for central cyanosis
How do we examine the jugular venous pressure? (Very difficult) Tells you the volume status of the patient
Turn head slightly to the left but not to make skin too tight over the jugular veins
Assess the pulsation
normal?
High (RHF)
Exaggerated (TR)?
Fixed - tamponade?
Examine height above the sternal angle (normal 2-4 cm)
If JVP low or high what does this mean?
Low = Dehydrated patient
High = Patient volume overloaded
Normal - patient is just right
How can we measure JVP using your arm?
when the veins go from distended to flat, that height is equivalent to the JVP
Where are there no valves in the body?
Most important thing to remember is that there is no valves between the RA and SVC or IVC.
Look at slide 10 of Cardiovascular examination - what does A, C, X, V and Y stand for?
A - before arterial pulse – end of atrial systole (tricuspid valve open) thus pushes column of blood in IJV up
C - start of ventricular systole (tricuspid valve shut and bulges towards atrium) thus pushes column of blood in IJV up (not really noticeable)
X - atrial diastole, rapid atrial filling and thus column of blood in IJV drops (tricuspid valve still shut)
V - after arterial pulse– atria is now full of blood and so the column begins to rise again (as it can’t go anywhere else
Y - passive ventricular filling (triscupid valve open but atria don’t contract) thus blood rushes rapidly into the RV and so the column falls
What happens if we have a Big A wave and Giant CV wave?
Big A – simply because the atria has to contract more forcefully against higher afterload e.g. Raised PAP or stiff tricuspid valve
Giant CV wave – because when the RV contracts, the blood shuts back up into the RA and the IJV, as there is nothing stopping it.
What happens if there is no A wave?
AF why because the atria don’t contract.
What do the waves look like in constrictive pericarditis?
prominent Y descent, blood rushes extremely quickly into the RV because the pericardium is so stiff, that passive ventricular filling occurs so quickly
How can we check for a low JVP?
Low JVP – dehydration:
hepatojugular reflux – pressing on abdomen
Hand veins – raise arms
Check for a very high level by ear lobes and sitting the patient vertically
Identify A and V waves by palpating opposite carotid pulse
