CARDIOVASCULAR EXAMINATION Flashcards
How would you start any examination?
WIPER QQ Wash hands Introduce yourself Ask permission Expose the patient Reposition the patient
Ask if they are in any pain or discomfort
How exposed should the patient be for the cardiovascular examination?
Top half of their body fully exposed
How should the patient be positioned for the cardiovascular examination?
Lying down at 45 degrees
What are you looking for from the end of the bed at the beginning of your cardiovascular examination?
Is patient well within themselves Obvious cyanosis Respiratory rate Flushed ECG leads GTN spray Oxygen mask PCA (patient controlled analgesia) machine
What are you looking for in the hands during a cardiovascular examination?
Peripheral cyanosis Warmth Clamminess Nail clubbing Splinter haemorrhages Osler's nodes Janeway lesions Palmar erythema Nicotine staining
What are the cardiovascular causes of clubbing?
Any disease featuring chronic hypoxia Congenital cyanotic heart disease Subacute bacterial endocarditis Atrial myxoma (benign tumor) Tetralogy of Fallot
What is the most common cardiac cause of clubbing?
Congenital cyanotic heart disease
What can splinter haemorrhages, Osler’s nodes and Janeway lesions all be a sign of?
Infective endocarditis
Describe a Janeway lesion.
Non-tender, small erythematous or haemorrhagic macular or nodular lesion on the palm or sole only a few millimeters in diameter.
Describe an Osler’s node.
Painful, red, raised lesion found on the hands and feet.
Other than infective endocarditis, what might Osler’s nodes signify?
Systemic lupus erythematosus
Marantic endocarditis
Disseminated gonococcal infection
Distal to infected arterial catheter
Describe splinter haemorrhages.
Tiny blood clots that tend to run vertically under the nails
Other than infective endocardities, what might the presence of splinter haemorrhages signify?
Scleroderma Trichinosis Systemic lupus erythematosus (SLE) Rheumatoid arthritis Psoriatic nails Antiphospholipid syndrome Haematological malignancy
What is palmar erythema?
Reddening of the palms at the thenar and hypothenar eminences
What is palmar erythema a sign of?
Portal hypertension Chronic liver disease Pregnancy Polycythemia Thyrotoxicosis Rheumatoid Arthritis Eczema and Psoriasis Deep telangiectasias Coxsackievirus A infection Secondary Syphilis Kawasaki disease - vasculitis
What two things is it important to take note of when feeling the radial pulse?
Rate
Rhythm
How do you assess whether the patient has a collapsing pulse?
Locate the radial pulse and place your palm over it, then raise the arm above the patient’s head. A collapsing pulse will present as a knocking on your palm.
What must you ask the patient before checking for a collapsing pulse?
Whether the patient has any shoulder pain
What is a collapsing pulse a sign of?
Aortic incompetence (regurgitation)
What might you look for on the extensor aspect of the elbow during a cardiovascular examination?
Xanthomata
What are xanthomas a sign of?
Hypercholesterolemia
Hyperlipidemia
Why must you check the brachial pulse as well as the radial pulse?
The radial pulse cannot be used to assess character of the pulse
How might the character of the pulse be abnormal?
Weak
Bounding
Abnormalities in the form of the pulse wave (e.g. double wave in mild aortic stenosis)
What would you tell the examiner that you would like to assess having checked the brachial pulse?
Blood pressure
What would you look for in the neck during a cardiovascular exam?
Jugular venous pressure
Carotid pulse
What might a raised JVP be a sign of?
Right sided heart failure
Hypervolaemia
Should the JVP naturally go and up with breathing?
Yes, there should be a decrease in the JVP with inspiration.
What is the Kussmaul sign?
This is when the JVP paradoxically increases during inspiration. It is indicative of limited right ventricular filling.
What is the test that you can do if you are struggling to see the JVP?
The hepato-jugular reflex. Press firmly over the right upper quadrant of the abdomen for 10 seconds. Patient must not perform the Valsava maneuver. You are looking at the JVP once you have removed your hand.
Where would the JVP be found?
Between the two heads of the sternocleidomastoid.
How can you discern whether the pulsation you are seeing is the JVP or the carotid?
The JVP is a non palpable pulsation.
What might you be looking for in and around the eyes of the patient during a cardiovascular exam?
Conjunctival pallor as a sign of anaemia.
Corneal arcus
Xanthelasma
What is corneal arcus a sign of?
Hypercholesterolemia
What are you looking for in the mouth of the patient during a cardiovascular exam?
Glossitis
Central cyanosis
Angular stomatitis
What might glossitis be a sign of?
Anaemia
What is angular stomatitis
Anaemia
What are you looking for on the precordium during inspection?
Pulsations
Abnormalities such as pectus excavatum
Scars
What is pectus excavatum?
Most common congenital deformity of anterior chest wall. The chest wall has a caved-in or sunken appearance. It can impair both cardiac and respiratory function. It is associated with Marfan’s syndrome and Ehler’s Danlos syndrome.
If you see a scar from a sternotomy, what other body part could you check to help you make a discern what procedure this scar was a result of?
A scar on the leg would tell you that the sternotomy was probably as a result of a CABG.
Where would you look for the apex beat?
5th intercostal space
Mid-clavicular line
What is a thrill?
A palpable murmur
What is a heave a sign of?
Left ventricular hypertrophy
Where would you listen to the mitral valve?
5th intercostal space
Mid-clavicular line
Where would you listen to the tricuspid valve?
4th intercostal space
Left sternal edge
Where would you listen to the pulmonary valve?
2nd intercostal space
Left sternal edge
Where would you listen to the aortic valve?
2nd intercostal space
Right sternal edge
What should do with the hand not holding the stethoscope?
Feel for the carotid pulse to distinguish between the two heart sounds
Do you feel S1 or S2 in the carotid?
S1
What maneuver could you do to check for mitral stenosis?
Lay the patient on their left side, ask them to breathe in, out and then to hold. You should then listen at the apex and the axilla with the bell of the stethoscope.
What maneuver could you do to check for aortic regurgitation?
Ask the patient to sit forward. Ask them to breathe in, out and hold. You should then listen over the aortic region with the diaphragm.
How should you finish your cardiovascular examination?
Check peripheral pulses
Check for sacral and ankle oedema
Check the lung bases for reduced breath sounds.
If you have found any abnormalities, what tests might you say you would like to arrange?
ECG
Echocardiogram
