Cardiovascular Examination 🫀 Flashcards
In the general observation what are you looking for ?
Does the patient look well ?
Are they in respiratory distress?
Do they have cachexia?
Signs of Marfans and Down syndrome, Turner’s syndrome - associated with cardiac abnormalities.
Malar flush
Oedema
What are then hand sighns in the cardiacvascular system? 7
Pallor of the Palmer creases
Finger clubbing
Splinter haemorrhages
Tendon xanthomata
Tar staining
Peripheral cyanosis /cap refill
Arachnodactyly (‘spider fingers’)
What do you look for in the face ? 10
Open or closed moth breathing
Sighns of pain
Sweating
Skin chenages rash
Pallor of the conjunctiva
Osler’s nodes
Janeway lesions
Corneal arcus
Kayser-Fleischer rings
Xanthelasma
What signs do you look for in the month
Dentition
Recent essential work
Missing teeth
Angular stomatitis
High arched palate
What are the things you look for in the neck ?
Jugular venous pressure
Carotid pulse
hepatojugular reflux test
What do you look for at the wrist and arm ?6
Temperature
Radial pulse
Radial radial delay
Collapsing pulse
Brachial pulse
Blood pressure
Inspection of the chest?
Scars
Chest wall abnormality’s
Visible pulsations
Bruises /rash ect
What do you palpate for ?
Apex beat
Heaves
Thrills
Auscultation
The four heat valves listening with the bell and the diaphragm
The neck
The axilla
What do you look for on the posterior chest
nspect the posterior chest wall for any deformities or scars
Auscultate the lung fields posteriorly
Lower limb to look for on the cardio exam
Leg oedema
Sacral oedema
evidence of saphenous vein harvesting
.”
Further assessments and investigations
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.
Perform fundoscopy: if there were concerns about malignant hypertension, fundoscopy would be performed to look for papilloedema.
Chest X-ray, troponin
a bluish discolouration of the skin due to poor circulation (e.g. peripheral vasoconstriction secondary to hypovolaemia) or inadequate oxygenation of the blood (e.g. right-to-left cardiac shunting).
Cyanosis
may indicate underlying cardiovascular (e.g. congestive heart failure, pericarditis) or respiratory disease (e.g. pneumonia, pulmonary embolism).
Shortness of breath
a pale colour of the skin that can suggest underlying anaemia (e.g. haemorrhage, chronic disease) or poor perfusion (e.g. congestive cardiac failure). It should be noted that a healthy individual may have a pale complexion that mimics pallor, however, pathological causes should be ruled out.
Pallor
plum-red discolouration of the cheeks associated with mitral stenosis.
Malar flush
typically presents with swelling of the limbs (e.g. pedal oedema) or abdomen (i.e. ascites). There are many causes of oedema, but in the context of a cardiovascular examination OSCE station, congestive heart failure is the most likely culprit.
Oedema
Look at the background for
Medical equipment: note any oxygen delivery devices, ECG leads, medications (e.g. glyceryl trinitrate spray), catheters (note volume/colour of urine) and intravenous access.
Mobility aids: items such as wheelchairs and walking aids give an indication of the patient’s current mobility status.
Pillows: patients with congestive heart failure typically suffer from orthopnoea, preventing them from being able to lie flat. As a result, they often use multiple pillows to prop themselves up.
Vital signs: charts on which vital signs are recorded will give an indication of the patient’s current clinical status and how their physiological parameters have changed over time.
Fluid balance: fluid balance charts will give an indication of the patient’s current fluid status which may be relevant if a patient appears fluid overloaded or dehydrated.
Prescriptions: prescribing charts or personal prescriptions can provide useful information about the patient’s recent medications.
suggests poor peripheral perfusion (e.g. congestive heart failure) and cyanosis may indicate underlying hypoxaemia.
pallor
caused by smoking, a significant risk factor for cardiovascular disease (e.g. coronary artery disease, hypertension).
Tar staining
raised yellow cholesterol-rich deposits that are often noted on the palm, tendons of the wrist and elbow. Xanthomata are associated with hyperlipidaemia (typically familial hypercholesterolaemia), another important risk factor for cardiovascular disease (e.g. coronary artery disease, hypertension).
Xanthomata
fingers and toes are abnormally long and slender, in comparison to the palm of the hand and arch of the foot. Arachnodactyly is a feature of Marfan’s syndrome, which is associated with mitral/aortic valve prolapse and aortic dissection.
Arachnodactyly (‘spider fingers’)
involves uniform soft tissue swelling of the terminal phalanx of a digit with subsequent loss of the normal angle between the nail and the nail bed. associated with several underlying disease processes, but those most likely to appear in a cardiovascular OSCE station include
congenital cyanotic heart disease, infective endocarditis and atrial myxoma (very rare).
To assess…..
Finger clubbing
Ask the patient to place the nails of their index fingers back to back.
In a healthy individual, you should be able to observe a small diamond-shaped window (known as Schamroth’s window)
When finger clubbing develops, this window is lost.
a longitudinal, red-brown haemorrhage under a nail that looks like a wood splinter. Causes include local trauma, infective endocarditis, sepsis, vasculitis and psoriatic nail disease.
Splinter haemorrhages
non-tender, haemorrhagic lesions that occur on the thenar and hypothenar eminences of the palms (and soles). Janeway lesions are typically associated with infective endocarditis.
Janeway lesions
red-purple, slightly raised, tender lumps, often with a pale centre, typically found on the fingers or toes. They are typically associated with infective endocarditis.
Osler’s nodes
Place the………. aspect of your hand onto the patient’s to assess temperature:
dorsal
Note: In healthy individuals, the hands should be symmetrically warm, suggesting adequate perfusion.
Cool hands may suggest poor peripheral perfusion (e.g. congestive cardiac failure, acute coronary syndrome).
Cool and sweaty/clammy hands are typically associated with acute coronary syndrome.
How to assess capillary refill time
(CRT) in the hands is a useful way of assessing peripheral perfusion:
Apply five seconds of pressure to the distal phalanx of one of a patient’s fingers and then release.
In healthy individuals, the initial pallor of the area you compressed should return to its normal colour in less than two seconds.
A CRT that is greater than two seconds suggests poor peripheral perfusion (e.g. hypovolaemia, congestive heart failure) and the need to assess central capillary refill time.
Assessing heart rate: radial pulse
For irregular rhythms, you should measure the pulse for a full 60 seconds to improve accuracy.
60-100 bpm.
Radio-radial delay
Causes of radio-radial delay include:
Subclavian artery stenosis (e.g. compression by a cervical rib)
Aortic dissection
Aortic coarctation
To assess for a collapsing pulse: 5 steps
1: Ask the patient if they have any pain in their right shoulder, as you will need to move it briskly as part of the assessment for a collapsing pulse (if they do, this assessment should be avoided).
2: Palpate the radial pulse with your right hand wrapped around the patient’s wrist.
3: Palpate the brachial pulse (medial to the biceps brachii tendon) with your left hand, whilst also supporting the patient’s elbow.
4: Raise the patient’s arm above their head briskly.
5: Palpate for a collapsing pulse: As blood rapidly empties from the arm in diastole, you should be able to feel a tapping impulse through the muscle bulk of the arm. This is caused by the sudden retraction of the column of blood within the arm during diastole
Causes of a collapsing pulse
Normal physiological states (e.g. fever, pregnancy)
Cardiac lesions (e.g. aortic regurgitation, patent ductus arteriosus)
High output states (e.g. anaemia, arteriovenous fistula, thyrotoxicosis)
Palpate the brachial pulse in their right arm, assessing
Types of pulse character
volume and character
Normal
Slow-rising (associated with aortic stenosis)
Bounding (associated with aortic regurgitation as well as CO2 retention)
Thready (associated with intravascular hypovolaemia in conditions such as sepsis)
Measure the blood pressure
Measure the patient’s blood pressure in both arms
A comprehensive blood pressure assessment should also include lying and standing blood pressure.
Blood pressure abnormalities 5
Hypertension: blood pressure of greater than or equal to 140/90 mmHg if under 80 years old or greater than or equal to 150/90 mmHg if you’re over 80 years old.
Hypotension: blood pressure of less than 90/60 mmHg.
Narrow pulse pressure: less than 25 mmHg of difference between the systolic and diastolic blood pressure. Causes include aortic stenosis, congestive heart failure and cardiac tamponade.
Wide pulse pressure: more than 100 mmHg of difference between systolic and diastolic blood pressure. Causes include aortic regurgitation and aortic dissection.
Difference between arms: more than 20 mmHg difference in blood pressure between each arm is abnormal and may suggest aortic dissection.
The carotid pulse can be located between
the larynx and the anterior border of the sternocleidomastoid muscle.
rior to palpating the carotid artery, you need to auscultate the vessel to rule out the presence of a bruit. The presence of a bruit suggests underlying
carotid stenosis, making palpation of the vessel potentially dangerous due to the risk of dislodging a carotid plaque and causing an ischaemic stroke.
Auscultate the carotid artery
Place the diaphragm of your stethoscope between the………. and the anterior border of the…………………. muscle over the carotid pulse and ask the patient to take a deep breath and then hold it whilst you listen.
Be aware that at this point in the examination, the presence of a ‘carotid bruit’ may, in fact, be a radiating cardiac murmur (e.g. aortic stenosis).
larynx
sternocleidomastoid
Measure the JVP
45°
sternal angle and the top of the pulsation point of the IJV (in healthy individuals, this should be no greater than 3 cm).
Causes of a raised JVP
A raised JVP indicates the presence of venous hypertension. Cardiac causes of a raised JVP include:
Right-sided heart failure: commonly caused by left-sided heart failure. Pulmonary hypertension is another cause of right-sided heart failure, often occurring due to chronic obstructive pulmonary disease or interstitial lung disease.
Tricuspid regurgitation: causes include infective endocarditis and rheumatic heart disease.
Constrictive pericarditis: often idiopathic, but rheumatoid arthritis and tuberculosis are also possible underlying causes.
Causes of a raised JVP
A raised JVP indicates the presence of venous hypertension. Cardiac causes of a raised JVP include:
Right-sided heart failure: commonly caused by left-sided heart failure. Pulmonary hypertension is another cause of right-sided heart failure, often occurring due to chronic obstructive pulmonary disease or interstitial lung disease.
Tricuspid regurgitation: causes include infective endocarditis and rheumatic heart disease.
Constrictive pericarditis: often idiopathic, but rheumatoid arthritis and tuberculosis are also possible underlying causes.
The hepatojugular reflux test involves
the application of pressure to the liver whilst observing for a sustained rise in JVP.
JVP is sustained and equal to or greater than 4cm this is deemed a positive result.
Conditions associated with hepatojugular reflux
A positive hepatojugular reflux result suggests the right ventricle is unable to accommodate an increased venous return, but it is not diagnostic of any specific condition. The following conditions frequently produce a positive hepatojugular reflux test:
Constrictive pericarditis
Right ventricular failure
Left ventricular failure
Restrictive cardiomyopathy
suggestive of underlying anaemi
Conjunctival pallor
a hazy white, grey or blue opaque ring located in the peripheral cornea, typically occurring in patients over the age of 60. In older patients, the condition is considered benign, however, its presence in patients under the age of 50 suggests underlying hypercholesterolaemia.
Corneal arcus
yellow, raised cholesterol-rich deposits around the eyes associated with hypercholesterolaemia.
Xanthelasma
dark rings that encircle the iris associated with Wilson’s disease. The disease involves abnormal copper processing by the liver, resulting in accumulation and deposition in various tissues (including the heart where it can cause cardiomyopathy).
Kayser-Fleischer rings
dark rings that encircle the iris associated with Wilson’s disease. The disease involves abnormal copper processing by the liver, resulting in accumulation and deposition in various tissues (including the heart where it can cause cardiomyopathy).
Kayser-Fleischer rings
bluish discolouration of the lips and/or the tongue associated with hypoxaemia (e.g. a right to left cardiac shunt)
Central cyanosis
a common inflammatory condition affecting the corners of the mouth. It has a wide range of causes including iron deficiency.
Angular stomatiti
a feature of Marfan syndrome which is associated with mitral/aortic valve prolapse and aortic dissection.
High arched palate
a feature of Marfan syndrome which is associated with mitral/aortic valve prolapse and aortic dissection.
High arched palate
Thoracic scars
Median sternotomy scar: located in the midline of the thorax. This surgical approach is used for cardiac valve replacement and coronary artery bypass grafts (CABG).
Anterolateral thoracotomy scar: located between the lateral border of the sternum and the mid-axillary line at the 4th or 5th intercostal space. This surgical approach is used for minimally invasive cardiac valve surgery.
Infraclavicular scar: located in the infraclavicular region (on either side). This surgical approach is used for pacemaker insertion.
Left mid-axillary scar: this surgical approach is used for the insertion of a subcutaneous implantable cardioverter-defibrillator (ICD).
Where is the apex beat
Displacement…….
5th intercostal space in the midclavicular line.
Displacement of the apex beat from its usual location can occur due to ventricular hypertrophy.
A parasternal heave is a precordial impulse that can be palpated.
Place the heel of your hand parallel to the left sternal edge (fingers vertical) to palpate for heaves.
If heaves are present you should feel the heel of your hand being lifted with each systole.
Parasternal heaves are typically associated
right ventricular hypertrophy.
is a palpable vibration caused by turbulent blood flow through a heart valve
You should assess for a thrill across each of the heart valves in turn
hypertrophy.
Thrills
Valve locations
Mitral valve: 5th intercostal space in the midclavicular line.
Tricuspid valve: 4th or 5th intercostal space at the lower left sternal edge.
Pulmonary valve: 2nd intercostal space at the left sternal edge.
Aortic valve: 2nd intercostal space at the right sternal edge.
Accentuation manoeuvres
early diastolic murmur caused by aortic regurgitation.
Sit the patient forwards and auscultate over the lower left sternal border (3rd/4th intercostal space) with the diaphragm of the stethoscope during expiration to listen for an
Accentuation manoeuvres
pansystolic murmur caused by mitral regurgitation.
Roll the patient onto their left side and listen over the mitral area with the diaphragm of the stethoscope during expiration to listen for a pansystolic murmur caused by mitral regurgitation. Continue to auscultate into the axilla to identify radiation of this murmur.
Accentuation manoeuvres
mid-diastolic murmur caused by mitral stenosis.
With the patient still on their left side, listen again over the mitral area using the bell of the stethoscope during expiration for a mid-diastolic murmur caused by mitral stenosis
Bell vs diaphragm
The bell of the stethoscope is more effective at detecting low-frequency sounds, including the mid-diastolic murmur of mitral stenosis.
The diaphragm of the stethoscope is more effective at detecting high-frequency sounds, including the ejection systolic murmur of aortic stenosis, the early diastolic murmur of aortic regurgitation and the pansystolic murmur of mitral regurgitation.
Auscultate the lung fields posteriorly to find
Coarse crackles are suggestive of pulmonary oedema (associated with left ventricular failure).
Absent air entry and stony dullness on percussion are suggestive of an underlying pleural effusion (associated with left ventricular failure).
