Cardiovascular Examination Flashcards
In what position should the patient and bed be in for a basic cardiovascular examination
The patient should be on the bed comfortably supported by a pillow with the bed/their chest at an angle of 45 degrees. (This may not be possible if the patient is too sick to sit up)
Briefly name the 15 steps as listed in the PCP handbook for the basic CV examination
- Prepare patient
- Hand hygiene
- General inspection
- Inspection of the hands
- Measurement of the radial pulse/radio-radial delay*
- Measurement of blood pressure (ideally in both arms)/brachial pulse assessment*
- Examination of the head and neck
- Examination of the jugular venous pulse/hepatojugular reflux*
- Examination f the carotid artery pulse
- Inspection of the chest
- Palpation of the chest (apex beat/heaves*/thrills*)
- Auscultation of the heart
- Examination of the posterior chest
- Examination of the lower limbs
- Complete the examination
During the general inspection, what are you looking for?
Patient’s general mental state
Alertness
Respiratory effort/SOB at rest*
Malar flush*
Apparent comfort of patient: does the patient look in pain*
Treatments or adjuncts: Use of supplemental O2, GTN spray*, medications*, mobility aid*
Missing limbs or digits*
Cachexia (cardiac cachexia)*
During inspection of the hands, what are you looking for? (11 signs listed)
Nicotine stains
Clubbing
Pale palmar creases
Splinter haemorrhages*
Dusky bluish discolouration*
Temperature*
Sweaty/clammy hands*
Janeway lesions*
Osler’s nodes*
Xanthomata*
Capillary refill*
What do you note when measuring radial pulse?
- Rate (60-100bpm is normal), rhythm (regular vs irregular)
- radio-radial delay*
- radio-femoral delay*
- collapsing pulse*
(The character and volume of pulse are better assessed from palpation of the brachial or carotid arteries)
During examination of the head and neck what clinical signs are you looking for and what do they indicate?
Conjunctival pallor - anaemia
Lips and tongue - central cyanosis
Corneal arcus* - hypercholesterolaemia
Xanthelasma* - hypercholesterolaemia
Angular stomatitis* - iron deficiency
High arched palate* - suggestive of marfans syndrome
Dental hygiene* - important if considering causes of infective endocarditis
Sclera* - icterus/jaundice
Mucosa - petechiae suggestive of infective endocarditis
Which type of lighting is best for examining the JVP?
Natural light where possible
Which JVP is conventionally inspected?
Right side; internal jugular
Is the head rotated to look for JVP? Why, why not?
No as it will tense the sternocleidomastoid muscle
Which jugular vein is best for examining the cardiac wave form? Why?
The internal jugular vein as it is in a straight line with the right atrium. The external jugular vein is usually easier to see but can be falsely elevated due to external pressure.
How is JVP measured?
The height is measured as the vertical distance between the sternal angle and the upper level of pulsation of the internal jugular vein
What is an abnormal JVP and what does it indicate?
A measurement greater than 3cm indicates raised pressure in the right side of the heart: fluid overload, right ventricular failure, tricuspid regurgitation
When examining the carotid arteries, why should you check for bruits first?
Checking for bruits allows you to ascertain whether there is a partial obstruction to the artery. If an obstruction present is due to atherosclerosis/plaque, it may dislodge and embolise to the brain
REMEMBER TO GO THROUGH EACH SIGN AND DEFINE THEM. EG WHAT IS A BRUIT
hi :)
Why might checking both carotid pulses at the same time be problematic?
Decreasing significant amounts of blood flow to the brain may cause LOC
During inspection of the praecordium, what may be found?
Pulsations of apex beat - a forceful beat may be visible*
Scars - thoractomy*, sternotomy*, clavicular*
Chest wall deformities* - pectus excavatum, pectus carinatum
Where is the apex beat usually found? What other horizontal markers may the apex beat be found?
Mid clavicular line in the fifth intercostalspace/6th rib. Anterior axillary line (AAL) and the mid-axillary line (MAL)
What does dusky bluish discolouration of the hands suggest?
Cyanosis indicates hypoxia
What sign is present in these pictures and what does it suggest?
Cyanosis indicates hypoxia
What sign in present in this picture and what does it suggest:
Janeway Lesion indicate infective endocarditis
What sign is present in this picture and what does it suggest?
Osler’s nodes indicate infective endocarditis
What sign is present in this picture and what does it suggest:
Splinter haemorrhages* - bacterial/infective endocarditis
What sign is present in the following pictures
(tendon) Xanthomata indicate hyperlipidaemia
Name the sign
Tendon xanthomata
Name the sign
Cyanosis
Name the sign
Clubbing
Name the sign
Nicotine staining
Two different hands. Name the sign in the abnormal hand
Pale hands/palmer creases in an anemic caucasian person vs pink flesh of a non-anaemic caucasian person
What do nicotine stains on fingers suggest?
smoker > increased risk of cardiac disease
Pale palmer creases suggest ________. ________ is:
Pale palmer creases suggest anaemia. Anaemia is defined as Hb less than the lower limit of the reference range for age and may be due to iron deficiency, Thalassaemia minor, haemolysis, blood loss, marrow hypoplasia, leukaemia, infiltration, folate deficiency or B12 deficiency
What are splinter heamorrhages and what do they suggest?
Small, linear subungual haemorrhagew, which are red when fresh and brown when aged, located at the distal 1/3 of the nailbed.
Splinter haemorrhages (SHs) are characteristic of acute and subacute bacterial endocarditis, but are more commonly due to trauma, occurring in up to 10% of normal subjects and in 40% of patients with mitral stenosis;
What is cyanosis?
Cyanosis occurs when a person has 5 g/dL of unoxygenated hemoglobin in the arterial blood. Central cyanosis (cyanosis of the lips, mucous membranes, and tongue) occurs when arterial oxygen saturation falls below 85% in patients with normal hemoglobin levels.
In light-skinned patients, cyanosis presents as a dark bluish tint to the skin and mucous membranes (which reflects the bluish tint of unoxygenated hemoglobin). But in dark-skinned patients, cyanosis may present as gray or whitish (not bluish) skin around the mouth, and the conjunctivae may appear gray or bluish. In patients with yellowish skin, cyanosis may cause a grayish-greenish skin tone.
Sweaty/clammy hands are associated with what type of syndromes?
Acute coronary syndromes
What do cool peripheries suggest?
Poor cardiac output/hypovoleamia
What are Janeway lesions and what do they suggest?
Non-tender macular erythematous palm and sole pulp lesions that contain bacteria indicating bacterial endocarditis. Will last for weeks before healing completely. Relatively more commonly seen in acute endocarditis, where bacteria Staphylococcus aureus gets cultured from the lesions. These bacteria may be found inside the blood cells. The lesions on the skin will heal without leaving any scar.
They are less commonly seen now that effective treatments for infective endocarditis exist
What are Osler’s nodes and what do they suggest?
Tender/painful red nodules on finger pulps/thenar/hypothenar eminences indicating infective endocarditis
Before antibiotics, Osler’s nodes occuring in 50% of patients. They are currently seen in fewer than 5% of patients
What are tendon xanthomatas and what do they suggest?
Raised yellow/orange deposits of lipid often noted on tendons of wrists and ankles - caused by type 2 hyperlipidaemias
(Palmer xanthomata and tuboeruptive xanthomata over elbows and kees are characteristic of type 3 hyperlipidaemia)
What is normal capillary refill and what does prolonged refilling time suggest?
<2 seconds
Prolonged filling time suggests tissue ischaemia/hypovolaemia etc
What normal sign is lost when fingers are clubbed?
Ie what disappears
Schamroth’s window
What is clubbing and what are some common causes?
Proliferation of soft tissue around the ends of fingers or toes, without osseous change.
Lung cancer
Bronchiectasis
Lung abscess
Empyema
Congenital heart disease
Infective endocarditis
Hypersensitivity pneumonitis (extrinsic allergic alveolitis)
What is the name of the angle that is increased in clubbed fingers?
Lovibond’s angle
What may a radio-radial delay suggest?
Aortic coarctation
What is aortic coarctation?
A congenital heart defect which occurs in 7% of patients with congenital heart disease; male:female ratio, 2:1.
Aortic coarctation is characterised by narrowing of the aortic lumen, often distal to the origin of the left subclavian artery at the site of the aortic ductal attachment (the ligamentum arteriosum); extensive collateral arterial circulation develops though the internal thoracic, intercostal, subclavian and scapular arteries to supply the rest of the body in patients with AC.
What is a collapsing pulse
A pulse with forcible impulse but immediate collapse, characteristic of aortic incompetency/regurg.
AKA Water-hammer pulse
What can cause a collapsing pulse?
Fever
Pregnancy
Cardiac lesions: AR/PDA
High output states: anaemia/AV fistulas/thycotoxicosis
What is pulse pressure?
The variation in blood pressure occurring in an artery during the cardiac cycle; the difference between systolic and diastolic pressures.
What is a narrow pulse pressure associated with?
Aortic Stenosis
What is a wide pulse pressure associated with?
Aortic regurgitation
When palpating carotid pulse, what are you assessing?
Character and volume of pulse. eg a slow rising character occurs in aortic stenosis
What is a positive hepatojugular reflux sign and what does it suggest?
A positive hepatojugular reflux sign occurs when pressure applied to the liver results in a rise in JVP that is sustained and equal to or greater than 4cm
This suggests right sided heart failure/tricuspid regurgitation
If applying pressure to the liver, the corressponding rise in JVP in healthy individuals should last for how long before falling?
No longer than 1-2 cardiac cycles
What is a corneal arcus/arcus senilis and what is it suggestive of?
A greyish-white ring (or part of a ring) opacity occurring in the periphery of the cornea, in middle and old age. It is due to a lipid infiltration of the corneal stroma. With age the condition progresses to form a complete ring.
Hypercholesterolaemia
“Probably associated with some increase in cardiovascular risk”
What sign is this and what does it suggest?
Corneal arcus/arcus senilis which is suggestive of hypercholesterolaemia
What are xanthelasmas and what do they suggest?
Planar xanthomas affecting the eyelids (raised intracutaneous yellow lesions/deposits). They are relatively common.
“They can be a normal variant or may indicate type II or III hyperlipidaemia, though they are not always associated with hyperlipidaemia”
What is this sign and what does it suggest?
Xanthelasmas indicate hypercholesterolaemia
What is angular stomatitis?
A condition characterised by inflammation, exudation, maceration and fissuring at the angles of the lips at the level of the epithelium but does not involve the mucosa.
AKA: Angular cheilitis
What is this sign and what does it suggest?
Angular stomatitis/cheilitis:
Inflammation and fissuring radiating from commissures of mouth secondary to predisposing factors such as lost vertical dimension in denture wearers, nutritional deficiencies, atopic dermatitis, or Candida albicans infection.
This picture shows a normal clinical picture in the top left and abnormal signs increasing in severity with the bottom right as the most severe.
What is this sign and what does it suggest?
A high arched palate suggests Marfan’s syndrome
What cardiovascular risk is associated with Marfan’s Syndrome?
Aortic aneurysms/dissections
During inspection of the chest, the following scars may be seen:
- thoracotomy
- sternotomy
- clavicular
What surgeries do they suggest?
Thoracotomy - miminally invasive valave surgery
Sternotomy - Coronary artery bypass graft / valve surgery
Clavicular - pacemake
What is pectus excavatum?
An abnormality of the chest in which the sternum (breastbone) sinks inward; sometimes called “funnel chest.”
A congenital malformation of the chest wall characterized by a funnel-shaped depression with its apex over the lower end of the sternum; it is caused by shortening of the central portion of the diaphragm, which pulls the sternum backward during inhalation, and by the growth of ribs.
Except in mild cases, it decreases the ability of the child to engage in sustained exercise. It also delays recovery from coughs and colds, reduces the ability to eat a full meal (so that most patients are underweight), and often produces a functional heart murmur. Noisy breathing may occur during sleep. A child may develop an emotional problem because of embarrassment over the deformity. It can be satisfactorily corrected by surgery
What is this sign?
Pectus excavatum
What sign is this?
Pectus excavatum
What is pectus carinatum?
An abnormality of the chest in which the sternum (breastbone) is pushed outward. It is sometimes called “pigeon breast.”
Pectus carinatum is a far less common (ratio, 1:3 to 1:13) chest wall deformity than pectus excavatum; it is more common in men (2–3:1). While it is generally asymptomatic, cardiorespiratory symptoms in the form of palpitations, dyspnea, and wheezing are not uncommon, may be accentuated during exercise and disappear after surgery. Bronchial and pulmonary symptoms of asthma and chronic bronchitis occur in 16.4% of the patients. Because the physical deformity can evoke ridicule from their peers, these patients are often introverted with low self-esteem and tend to avoid appearing in public venues or engaging in sports in which they may have to remove their shirts. Some degree of kyphosis is present in most patients
What is this sign?
Pectus carinatum
what is this sign?
Pectus carinatum
What may a visible forceful apex beat suggest?
Hypertension or ventricular hypertrophy
What is a parasternal heave?
A parasternal heave is a precordial impulse that may be felt palpated in patients with cardiac or respiratory disease. Precordial impulses are visible or palpable pulsations of the chest wall, which originate from the heart or the great vessels.
How is a parasternal heave detected and what may it indicate?
A parasternal heave is detected by placing the heel of the hand over the left parasternal region. In the presence of a heave the heel of the hand is lifted off the chest wall with each systole.
A parasternal heave is caused by:
right ventricular enlargement, or
rarely, severe left atrial enlargement which pushes the right ventricle forwards
What is a thrill and what may it indicate?
The vibration accompanying a cardiac or vascular murmur, detectible on palpation.
A fine vibration, felt by an examiner’s hand on a patient’s body over the site of an aneurysm or on the precordium, resulting from turmoil in the flow of blood and indicating the presence of an organic murmur of grade 4 or greater intensity. A thrill can also be felt over the carotids if a bruit is present and over an arteriovenous fistula in the patient undergoing hemodialysis
What is a bruit and what may it indicate?
an abnormal blowing or swishing sound or murmur heard while auscultating a carotid artery, the aorta, an organ, or a gland, such as the liver or thyroid, and resulting from blood flowing through a narrow or partially occluded artery. The specific character of the bruit, its location, and the time of its occurrence in a cycle of other sounds are all of diagnostic importance. Bruits are usually of low frequency and are heard best with the bell of a stethoscope.
INDICATIONS
What are the four sites for valve auscultation?
Aortic valve: 2nd intercostal space at right sternal edge
Pulmonary valve: 2nd intercostal space at left sternal edge
Tricuspid valve: 5th intercostal space at left sternal edge
Mitral valve - 5th intercostal space at midclavicular line
Radiation of a murmur to the carotid arteries while the patient’s breath is held suggests what type of murmer?
Aortic stenosis murmer
Radiation of heart murmur into the left axilla suggests what?
Mitral regurgitation
A muruer heard at the left sternal edge suggests what?
Aortic regurgitation
Mitral murmers may be more easily heard after doing what?
Roll patient onto left side and listen to mitral area with bell during expiration
Rolling patient onto left side and listen to a particular area with the bell during expiration will cause what type of murmurs to become louder?
Mitral murmurs
Aortic murmers may be more heard more loudly if the patient is in what postion?
Patient lent forward listening over the aortic area during expiration
Leaning the patient forward and listening during expiration will make which type of murmurs louder?
Aortic murmers
Crackles/crepitations heard in the lung bases may suggest what?
Pulmonary oedema -> Left ventricular failure
Pulmonary oedema suggests what in a cardiovascular context?
Left heart failure
Sacral oedema/Pedal oedema may suggest what inthe cardiovascular context?
Right heart failure
List 5 further assessments or investigations you may want to do after doing a cardiovascular examination and state what you are looking for with each one
Full peripheral vascular examination - PVD
12-lead ECG - arrhythmias/myocardial ischaemia
Dipstick Urine - proteinuria/haematuria - hypertension
Bedside capillary blood glucose - diabetes
Fundoscopy -papilloedema - malignant hypertension
Name two sites to test for peripheal oedema
Behind the medial malleolus
Anterior tibia
Which two lower limb pulses should be checked and where are they palpable?
Dorsalis pedis - dorsum of the foot lateral to the extensor hallicus longus tendon
Posteior tibial pulse - behind medial malleolus
Stretching the extensor hallicus longus tendon may make which pulse easier to palpate?
dorsalis pedis
What should be offered during completion of the exam?
Assistance; repositioning of table, chairs etc
In the average person, where does the right atrium lie relative to the sternal angle?
5cm below
What are some clinical signs of Marfan’s syndrome (7)?
Tall stature
Thoracic kyphosis
Pectus Excavatum
Arachnodactyly
Long limbs
Aortic regurgitation (secondary to aortic root dilation)
Mitral regurgitation (due to mitral valve prolapse)
High arched palate
Do you want to know about the interphalangeal depth ratio?
Talley and OConner seem to think you do.
What does it indicate?
Whether clubbing is present.
What are some causes of splinter hemorrhages?
Trauma
Infective endocarditis
vasculitis on rheumatoid arthritis
polyarteritis nodosa
antiphospholipid syndrome
sepsis
haematological malignancy
profound anaemia
What affet can fever have on heart rate?
Fever can increase HR.
When interpreting a tachycardia, allow 15-20 beats per minute for every degree above normal
What is a pulse deficit?
“Patients with atrial fibrillation or frequent ectopic beats may have a detectable pulse deficit. This means that the HR when counted by listening to the heart with the sethoscope is higher than the rate obtained when the radial pulse is counted at the wrist.
In these patients the heart sounds will be audible with every systole, but some early contractions preceded by short diastolic filling periods will not produce enough CO for a pulse ot be palpable at the wrist”
T&OC
What are some causes of a bradycardia with a regular rhythm (9)?
Physiological - athletes, during sleep
Drugs - beta-blockers, digoxin, amiodarone
Hypothyroidism
Hypothermia
Raised ICP - late sign
Third degree AV block or second degree (type II) AV block
MI
Vasovagal syncope
Severe Jaundice
What are some causes of a bradycardia with an irregularly irregular rhythm?
Atrial fibrilllation (in combination with conduction system disease or AV nodal bloack drugs) due to alcohol, post-thoracotomy, idiopathioc, mitral valve disease or other cuase of LA enlargement.
Frequent ectopic beats
WHat are some causes of a bradycardia with a regularly irregular rhythm?
Sinus arrhythmia
Second degree AV block (type 2)
What are some causes of a tachycardia with a regular rhythm (13)?
- Hyperdynamic circulation due to: excerise or emotion, fever, pregnancy, thyrotoxicosis, anaemia, AV fistula, thiamine deficiency
- CCF
- Constrictive pericarditis
- drugs (salbutamol etc).
- normal varient
- Denervated heart egin diabetes
- Hypovolaemic shock
- supraventricular tachycardia
- atrial flutter with regular 2:1 AV block
- ventricular tachycardia
- sinus tachycardia due to thyrotoxicosis, PE, myocarditis, myocardial ischaemia, fever, acute hypoxis or hypercapnia (paroxysmal)
- multifocal atrial tachycardia
- atrial flutter with variable block
What are some causes of a tachycardia with irregular rhythm?
1. Atrial fibrillation due to:
MI
mitral valve disease or any cause of LA enlargement
thyrotoxicosis
hypertensive heart disease
sick sinus syndrome
PE
myocarditis
fever, acute hypoxia or hypercapnia (Paroxysmal)
alcohol
post-thoracotomy
idiopathic
2. multifocal atrial tachycardia
3. atrial flutter with variable block
What is bigeminy and describe the pulse pattern.
When every second heart beat is an ectopic beat. The radial pulse has a characteristic pattern of normal pulse, weak/absent pulse, delay, normal pulse and so on
What is trigeminy?
When every third heart beat is ectopic. The palpable rhythm is of two normal pulses then a delay.
List the BP ranges of optimal, normal, high normal BP and the classes of HTN according to:
(European Society of Cardiology guidelines)
What are petechiae?
- pertaining to tiny red or purple spots caused by an extravasation of blood into the skin
- a condition in which capillary hemorrhages produce small red or purplish pinpoint discolorations of the mucous membrane and skin. Petechiae are typical of blood dyscrasias, vitamin C deficiency, positive Rumpel-Leede test, liver disease, and bacterial endocarditis.
What sign is this?
Petechiae -
The most common cause of petechiae is through physical trauma such as a hard bout of coughing, holding breath, vomiting or crying, which can result in facial petechiae, especially around the eyes. Petechiae in this instance are harmless and usually disappear within a few days. Petechiae may be a sign of thrombocytopenia (low platelet counts) when platelet function is inhibited (e.g., as a side effect of medications or during certain infections), or in clotting factor deficiencies.[1] They may also occur when excessive pressure is applied to tissue (e.g., when a tourniquet is applied to an extremity or with excessive coughing or vomiting).
If unsure, petechiae should always be quickly investigated. They can be interpreted as vasculitis, an inflammation of the blood vessels, which requires immediate treatment to prevent permanent damage. Some malignancies can also cause petechiae to appear. Petechiae should be investigated by a doctor to rule out the more dangerous conditions.
The significance of petechiae in children depends on the clinical context in which they arise. Petechiae in children can occur with viral infections. In this instance, they do not necessarily signify a serious illness. However, they are a hallmark signal of some potentially serious illnesses, such as meningococcemia, leukemia, and certain causes of thrombocytopenia, of which meningococcemia can cause death within 48 hours of infection. Therefore, their presence should not be ignored.
Petechiae (in the face) may also be present in cases of self asphyxiation. (WIKI)
What sign is this?
(mild) kyphoscoliosis
(A condition in which the spinal disorders of kyphosis and scoliosis occur together.)
What sign is this?
(severe) kyphoscoliosis (A condition in which the spinal disorders of kyphosis and scoliosis occur together.)
