Cardiovascular Examination Flashcards
Observation
General observation:
-Scars- open heart surgery
-Pectus Excavatum, Pectus Carinatum
-Cyanosis- decreased oxygen blue/purple colour
-Pallor skin- could suggest underlying anemia or poor prefusion
-Malar flush- associated with Mitral stenosis
Breathing:
- Shortness of Breath (Underlying cardiovascular/respiratory disease)
Hands:
-Pallor – Poor perfusion
-Raynauds - Cold, Plae hands
-Peripheral cyanosis
-Tar staining - Cigarette smoker
-Cyanosis- blueish/purple colour decreased oxygen
-Long thin fingers – Associated with Marfans Syndrome
Nails:
-Splinter hemorrhages- IE.
-Clubbing-IE. 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)
-Spooning- iron deficiency/ anemia.
-Onchylosis- sign of heart failure.
- Leukonychia - Heart disease
Skin:
-Malar rash- crosses face->mitral stenosis. or SLE if it crosses the nose
-Xanathelasma- high cholesterol.
Eyes:
-Conjunctiva- pale=anemia.
-Arcus Senelis- white/grey rings around cornea—>carotid disease.
-Hypertensive Retinopathy- Damage to retina from high BP copper wiring, cotton wool spots, AV nicking.
Mouth:
-mouth/tongue peripheral cyanosis- anemia, arterial disease.
-Teeth Rotting- infective endocarditis.
Observation hands
Hands:
-Pallor – Poor perfusion
-Raynauds - Cold, Plae hands
-Peripheral cyanosis
-Tar staining - Cigarette smoker
-Cyanosis- blueish/purple colour decreased oxygen
-Long thin fingers – Associated with Marfans Syndrome
Nails:
-Splinter hemorrhages- IE.
-Clubbing-IE. 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)
-Spooning- iron deficiency/ anemia.
-Onchylosis- sign of heart failure.
Upper limb pulses and tests
Pulses;
-Carotid
-Axillary
-Brachial
-Ulnar
-Radial
Tests;
Allen’s- apply pressure in ulnar and radial arteries and ask patient to rapidly open and close hands while in a flexed position. Then ask them to make a fist and bring their hands down. Ask them to open their hand and slowly release Ulnar pulse. Observe how quickly blood re enters the hand
Do same for Radial
Release one at a time, anything more that 5 sec indicates poor circulation.
Anemia test - Spread open the hands and check the crevesses, need to be red if they were white could indicate anemia
Capilarry refill test - Gently press on the fingertip/nail bed causing it to turn white and keep pressure for 5 seconds. I am seeing how quickly the blood refills.
Checking Pulse
Usually initially assessed with the radial pulse. If weak, try carotid pulse
If regular rate and rhythm, often counted for 15 seconds
and multiplied by 4
If any irregularities count for 60 seconds
Pulses and their meaning?
60/100bpm
>100=tachycardia
<50=bradycardia
Thready pulses
Low cardiac output, Weak cardiac contraction
D/t:
decreased stroke volume
-Heart failure; hypovolemia; aortic stenosis
Large, bounding pulses
High cardiac output, Forceful beats
D/t:
increased stroke volume
-Fever; anaemia; hyperthyroidism; aortic
regurgitation; AV fistula;
Bisferians pulse
– Double systolic peak
– d/t aortic stenosis and/or regurgitation;
hypertrophic cardiomyopathy
Pulsus Alternans
– Difference in amplitude between beats
– Indicates severe L ventricular failure
– Sphygmomanometer may cut off the alternate
pulse early
– Alternating strong & weak beats
Rate and Rhythm
– Feel for rhythm first
Regular
– What is the rate?
» Fast (>100)
» Normal (60-100)
» Slow (<60)
Irregular
– What is the pattern of irregularity?
» Sporadic
» Regularly irregular - dt caffeine, Nicotine, Thyroid disease
» Irregularly irregular - dt caffeine, Atrial Fibrulation
Radio-Radial delay - (Feel both radial pulses at the same time) Can mean aortic coarctation.
Observation chest
Scars for surgery / Pacemaker
Palpation
Apex beat PMI (over mitral valve): 5th intercostal space in the Mid-clavicular line
Ask patient to go forward and to the left, looking for a displced PMI that will indicate ventricular hypertrphy.
-Ventricular hypertrophy–> aortic stenosis, hypertrophic cardiomyopathy, hypertension
Heaves:
Base of the hand
-Left parasternal area to assess for right ventricular hypertrophy
At apex for left ventricular hypertrophy
-Precordial impulses visible/felt over heart region
d/t Enlarged atrium or Ventricles
Thrills:
Tip of the fingers
All 4 heart valves
-Palpable murmur d/t incompetent heart valve / Ventricular hypertrophy
Heaves?
Precordial impulses are visible or palpable pulsations of the chest wall, which originate on the heart or the great vessels.
What is a thrill?
A palpable murmur
A thrill is a palpable vibration on the chest wall caused by turbulent blood flow
Auscultation
Auscultate all 4 heart valves
Auscultate Carotid artery -
Bruits: use the bell to listen over carotid arteries.
-Audible turbulence within a vessel due to intrinsic stenosis- seen over carotid, renal and femoral vessels
Mitral valve - Fifth intercostal space in mid-clavicular line
Tricuspid valve- Fourth intercostal space at lower left sternal edge
Pulmonary valve - Second intercostal space at left sternal edge
Aortic valve - Second intercostal space at the right sternal angle
Erbs Point - Third intercostal space
Repeat using bell
Explain heart sounds S1 S2 S3 S4
Explain Heart murmurs
What does S1 mean?
-LUB
-Beginning of ventricular systole.
-Represents closure of the atrioventricular (mitral
and tricuspid) valves
What does S2 mean?
DUB
-End of ventricular systole
- Begining of diastole
-Represents closure of the semilunar (aortic and
pulmonary) valves
What does S3 gallop mean?
Lub->De->Dub
S1—> S2->S3
-Represents a transition from
rapid to slow ventricular filling in early diastole.
-S3 may be heard in normal children
-abnormal in elderly- indicating heart failure=CHF
What does S4 gallop mean?
Lub->Dub—>Ta
S4–>S1—>S2
-Always abnormal
-Rare
-Stiff Hypertrophic Ventricle
-Left ventricular failure
Ask patient to bend forward, breathe out and hold for?
Over the Aortic valve - aortic regurgitation
Ask patient to lie on their left side to listen to?
Over mitral valve- Mitral stenosis
Murmurs?
STENOSIS=valve is narrowed d/t hypertrophy
-Aortic stenosis- left ventricular hypertrophy
-Mitral stenosis-left atrial hypertrophy
REGURGITATION=Valve becomes weakened
-Aortic regurgitation-left ventricular dilatation
-Mitral regurgitation-left atrial dilatation
JVP (Jugular Venous Pressure)
JVP reflects right atrium and central venous pressure
JVP falls due to blood loss
JVP increases due to increased right atrial filling
pressure -e.g. right primary or secondary heart failure or increased pulmonary resistance e.g. lung disease
How to Measure JVP
- Place the patient in a supine positon at 45* angle
- Turn the patients head to the left to expose the right side of the neck.
- Look for Jugular venous pulsations visible between the sternal and clavicular heads of the scm in the Internal jugular vein.
- Identify the highest point of Pulsations
-Use a ruler to measure the vertical distance (in cm) from the sternal angle to the highest point of the jugular venous pulsation.
-The sternal angle is approximately 5 cm above the right atrium.
-Normal JVP: Should be 3-4cm above the sternal angle
Elevated JVP: Indicates raised right atrial pressure, which may suggest Right sided heart failure or Respiratory conditions
Absent or low JVP: May indicate Severe dehydration
