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.
A radio-femoral delay (a noticable delay in the arrival of the femoral pulse wave) suggests what diagnosis?
Coarctation of the aorta - congenital narrowing in the aortic isthmus at the level where the ductus arteriosus joins the descending aorta - can cause upper limb hypertension
What might a radio-radial delay suggest?
- large arterial occlusion by an athersclerotic plaque or aneurysm
- subclavian artery stenosis on one side
- dissection of the thoracic aorta
“Character and volume are poorly assessed by palpating the radial pulse; the caroitd and brachial arteries should be used to determine the character and volume of the pulse, as these more accuratley reflect the form of the aortic pressure wave.”
Which two types of pulses may nonetheless be readily apparent in the radial pulse?
The collapsing/bounding pulse of aortic regurgitation
and
pulsus alternans (alternating strong and weak pulses) of advanced left ventricular failure
Which layer of the radial artery can bes assessed by palpation?
“Only changes in the medial layer of the radial artery can be assessed by palpation.”
Does thickening or tortuosity commonly detected in the arteries of elderly people indicate luminal narrowing due to athersclerosis?
No - “this sign is of little clinical value”
What affects does the incorrect blood pressure cuff have on the blood pressure measurement?
Too small a cuff: BP will be overestimated
Too large a cuff: a small underestimate of BP
Traditionally BP was not measured on the arm on the side of a previous mastectomy, especially if the axillary nodes had been removed.
Why?
What is the relevance these days?
There was fear of upsetting lymphatic draining.
“Modern mastectomies are less radical and the risk of causing trouble is very small.
In patients having renal dialysis, what determines which arm is used for BP measurement and why?
Which arm the AV fistula is in for fear of damaging it.
Why must the blood pressure cuff/arm be at the level of the heart when measuring BP?
Too high and the reading will record as lower
Too low and the reading will be higher than is accurate
List what is happening at each Korotkoff sound
Korotkoff I: Systolic blood pressure
KII: the sound increases in intensity as the cuff deflates
KIII: the sounds decrease
KIV: becomes muffled
KV: disappears
KV is probably the best measure for diastolic blood pressure but does provide a slight underestimate of the arterial diastolic BP. KIV is a better indicater in severe aortic regurgitation.
KV is absent in some normal people and KIV must then be used.
What is an ausculatory gap?
What is its significance?
Diminished Korotkoff sounds just below systolic that reappear before diastolic pressure in healthy people.
This can lead to an underestiamte of systolic BP if the cuff is not pumped up high enough
What is the normal BP variation from one arm to the other?
Up to 10mmHg
By how much do the lower limbs differ in BP compared to the upper limbs?
Where is the cuff placed when measuring lower limb BP?
In the legs, blood pressure is normally up to 20mmHg higher than in the arms, unless the patient has coarctation of the aorta.
Cuff - thigh
Steth - popliteal fossa
List three causes of pulsus paradoxus (there are many: cardiac, pulmonary and neither)
constrictive pericarditis
pericardial effusion
sever asthma
What happens to BP during inspiration?
Both systolic and diastolic normally decrease (<10mmHg) becase intrathoracic pressure becomes more negative, blood pools in the pulmonary vessels, so left heart filling is redued.
What is pulsus paradoxus?
When the normal reduction in BP with inspiration is exaggerated (>10mmHg).
The fall in blood pressure has a paradoxical rise in pulse rate.
As measured by intra-arterial catheters, what are normal minute to minute changes in BP?
Short term changes of 4mmHg in the systolic and 3mmHg int he diastolic readings are common. Hour to hour and day to day variations are even greater.
What is the standard deviation between visits for BP measurements?
Up to 12nnMh for systolic and 8mmHg for diastolic - therefore repeat meaurements are necessary
What is pseudohypertension?
BP as measured by sphygmomanometer is artifically high because of arterial wall calcification.
What is the white coat phenomenon?
Blood pressure measured by the patient at home, or by a 24 hour monitor tends to be up to 10/5 mmHg less than measured in surgery/by a doctor.
List the BP ranges of optimal, normal, high normal BP and the classes of HTN according to:
(European Society of Cardiology guidelines)
Postural hypotension is defined as what drop in BP?
A fall of more than 15mmHg in systolic or 10mmHg in diastolic on standing comapred to sitting is abnormal
What is the most common cause of postural hypotension?
What is the mneumonic of other causes?
Anti-hypertensive drugs; particularly alpha-adrenergic antagtonists in particular
HANDI:
H- hypovolaemia (dehydration, bleeding); hypopituitarism
A- Addison’s disease (adrenal gland failure - insufficent steroid production)
N- Neuropathy -autonomic (diabetes mellitus, amyloidosis, Shy-Drager syndrome)
D- Drugs (vasodilators and other anti-hypertensives, tricyclic antidepressants, diuretics, antipsychotics)
I - idiopathic orthostatic hypotension (rare progressive degeneration of the autonomic nervous system, usually in elderly men)
What are the symptoms of postural hypotension?
It may cause dizziness or not be associated with symptoms
What are the causes of postural hypotension
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 is malar flush/mitral facies and what does it indicate?
Rosy cheeks with a bluish tinge due to dilation of the malar capillaries.
This is associated with pulmonary hypertension and a low cardiac output such as occurs in severe mitral stenosis.
It is now rare
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)
Why are teeth inspected in a cardiovascular exam?
Diseased dentition can be a source of infective endocarditis
What lies medial to the sternocleidomastoid muscles?
common carotid arteries
What feeling the carotid pulse wave form what three characteristics are important?
the amplitude, the shape and volume of the pulse wave
What can the carotid pulse wave form be used for?
diagnosis of underlying cardiac diseases and assessment of their severity
What type of pulse wave forms may be apparent in aortic stenosis?
- anacrotic (small volume, slow uptake, nothced wave on upstroke)
- plateau (slow upstroke)
- Small volume
Aortic stenosis AND regurg: Bisferiens (Anacrotic and collapsing)
Anacrotic pulse wave forms of carotid artery suggests what pathology?
Aortic stenosis
Bisferiens carotid pulse waveform suggests what pathology?
Aortic stenosis and regurgitation
A collapsing carotid pulse wave form suggests what causes?
- aortic regurgitation
- Hyperdynamic circulation
- patent ductus arteriosus
- peripheral arteriovenous fistula
- arteriosclerotic aorta (elderly patients in particular)
Left ventricular failure may manifest in what carotid pulse wave form?
Alternans: alternating strong and weak beats
Aortic regurgitation has what type of carotid pulse wave form?
Collapsing
Carotid pulse wave form tells us about pathology in what part of the thoracic anatomy?
Aorta and left ventricular function
Jugular venous pressure tells us about function in which part of the heart?
Right atrium and right ventricular function
If the patient’s head is rotated too far to one side during measurement of the JVP what makes assessment difficult?
The sternocleidomastoid muscle will contract and obscure the view
Name the 4 ways in which jugular venous pulsation can be distinguished from the arterial pulse:
- it is visible but not palpable and has a more prominent inward movement than the artery
- it has a complex wave form, usually seen to flicker twice with each cardiac cycle (if in sinus rhythm)
- it moves on respiration (normally the JVP decreases on inspiration)
- it is at first obliterated and then filled from above when light pressure is applied at the base of the neck
What two characteristics are assessed when measuring the JVP?
Height and character of the wave form.
What does an increased JVP suggest?
Right ventricular failure, volume overload, or some types of pericardial disease (eg constrictive pericarditis, cardiac tamponade)
What are the two positive waves in a normal JVP?
a wave and v wave
The a wave in a normal JVP coincides with that?
- right atrial systole/atrial contraction
- first heart sound
- precedes carotid pulsation
The v wave in a normal JVP coincides with what?
- atrial filling in the period when the tricuspid valve remains closed during ventricular systole
- second heart sound
What occurs between the a and v waves of a normal JVP?
an x descent, which corresponds to atrial relaxation
(the x descent is interrupted after the a wave by the c point, which is due to transmitted carotid pulsation and coincides with the tricuspid valve closure- it is not usualy visible)
Following the v wave in a normal JVP, the tricuspid valve opens and rapid ventricular filling occurs; what is the name of this part of the wave form?
What is Kussmaul’s sign and when is it best elicited?
Elevated JVP due to limited right ventircular filling is more marked on inspiration when venous return to the heart increases.
The increase on inspiration is called Kussmaul’s sign.
List 6 causes of an elevated central venous pressure:
- right ventricular failure
- tricuspid stenosis or regurgitation
- pericardial effusion or constrictive pericarditis
- superior vena caval obstruction
- fluid overload
- hyperdynamic circulation
List three causes of a dominant a wave:
- tricuspid stenosis
- pulmonary stenosis
- pulmonary hypertension
What are cannon a waves?
An abnormal jugular venous pressure curve with an accentuated ‘a’ wave of sufficient intensity to cause the earlobes to ‘flap’, due to decreased right ventricular compliance, tricuspid stenosis or an arrhythmia in which the atrium contracts against a closed or stenosed tricuspid valve; a less ‘explosive’ but still prominent ‘a’ wave may by associated with pulmonary hypertension. Cannon ‘a’ waves may be regular—as are AV junctional rhythms, in which an ‘a’ wave occurs every 2nd beat in a 2:1 block—or irregular, which is more common and may occur in complete heart blocks without atrial fibrillation, ventricular tachycardia, or AV dissociation
List three causes of cannon a waves
Name one cause of a dominant v wave
tricuspid regurgitation
Name one condition is which the x descent may be absent and two when it may be exaggerated
in atrial fibrillation
List two causes for a sharp y descent and two causes for a slow y descent
Sharp: severe tricuspid regurgitation and constrictive pericarditis
slow: tricuspid stenosis and right atrial myxoma
What does a positive abdominojugular reflux test/hepatojulgular reflux test suggest?
Right or left ventricular failure or reduced right ventricular compliance
What are giant a waves and when do they occur?
Giant a waves are large but not explosive a waves with each beat. They occur when right atrial pressures are raised because of elevated pressures in the pulmonary circulation or obstruction to outflow (tricuspid stenosis).
What are large v waves and when do they occur?
Large v waves of tricuspid regurgitation should never be missed. They are a reliable sign of tricuspid regurgitation and are visible welling up into the neck during each ventricular systole.
Left or even right sided lateral thoracotomy scars indicate what type of surger?
Previous closed mitral valvotomy.
In this operation, a stenoised mitral valve is opened through an incision made in the left atrial appendage. Cardiopulmonary bypass is not required.
A median sternotomy scar can indicate what type of past surgery?
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.)
What are skeletal abnormalities such as pectus excavatum or kyphoscoliosis be relevant to a cardiovascular examination
Skeletal abnormalities can cause distortion of the position of the heart and great vessels in the chest and thus alter the position of the apex beat. Severe deformity can interfere with pulmonary function and cause pulmonary hypertension
What intervention, if present, is mobile under the skin and palpable under the right or left pectoral muscle just under the clavicle?
A pacemaker or cardioverter-defibrillator box (larger than pacemakers 10x5x1cm).
It feels obviously metallic.
The pacemaker leads may be palpable under the skin, leading from the top of the box.
Fixation of a pacemaker box or stretching or skin over the box is an indication for what?
Repositioning
Erosion of the box through the skin is at risk of what serious complication?
Infection
(Rare:) Muscle twitching of the chest wall around the (pacemaker) box can occur. What is the cause?
What could be the cause of diaphragmatic contractions (hiccups) at a disconcerting pace in a patient with a pacemaker?
Penetration of the right ventricular lead into or through the right ventricular wall
What causes the apex beat?
Primarily, the recoil of the heart as blood is expelled during systole.
Visible pulsation over the pulmonary artery suggests what pathology?
severe pulmonary hypertension
The apex beat is palpable is what proportion of adults?
0.5 (50%)
Is the palpable apex beat the same as the anatomical apex of the heart?
No
…
The palpable apex beat is a point above the actual apex of the heart.
At the time the apex beat is palpable, the heart is assuming a more spherical shape and the apex is twisting away from the chest wall. The area above the apex, however, is moving closer to the chest and is palpable.
If the apex beat is displaced laterally or inferiorly (or both), it usually indicated enlargement.
However, sometimes is may be due to:
(3)
- chest wall deformity
- pleural disease
- pulmonary disease
List 5 types of abnormal apex beats:
- forceful and sustained impulse
- displaced, diffuse, non-sustained impluse
- uncoordinated impluse felt over a larger area than normal in the praecordium
- two distinct impulses felt with each systole
- palpable first heart sound
A forceful and sustained apex beat occurs in what pathology?
Aortic stenosis
(called “Pressure loaded/heaving/hyperdynamic/systolic overloaded” apex beat)
A displaced, diffuse, non-sustained apex beat occurs in what pathology?
Advanced mitral regurgitation or dilated cardiomyopathy
(called the “volume loaded/thrusting” apex beat)
An uncoordinated impulse felt over a larger area than normal is usually due to what pathology?
left ventricular dysfunction eg in anterior myocardial infarction
(known as dyskinetic apex beat)
An apex beat with two distinct impulses felt with each systole is characteristic of what pathology?
Hypertrophic cardiomyopathy
(called a double impulse apex beat)
A palpable first heart sound indicates what pathology?
mitral or very rarely tricuspid stenosis
(called a tapping apex beat)
The character or the apex beat (not the position) may be more easily assessed in what position?
When the patient lies on their left side
List 5 reasons the apex beat might not be palpable
Most often due to:
- thick chest wall
- emphysema
- pericardial effusion
- shock (or death)
rarely:
- dextrocardia ( inversion of the heart and great vessels; beat will be palpable to the right of sterum in many cases)
How and why is a parasternal impulse felt?
When the heel of the hand is rested just to the left of the sternum wiht the fingers lifted slightly off the chest. Normally no impulse of slight inward impulse is felt.
In cases of right ventricular enlargement or severe left atrial enlargement where the right ventricle is pushed anteriorly, the heel of the hand is lifted off the chest wall with each systole.
A palpable tale over the pulmonary area is due to what and occurs when?
A palpable P2 is the tap of pulmonary valve closure and occurs in cases of pulmonary hypertension
What are thrills?
Palpable turbulent blood flow (also shown as murmers on ausculation)
The praecordium should be systematically palpated for thrills with the flat of the hand in what locations?
- apex
- left sternal edge
- base of heart (the upper part of the chest which includes the aortic and pulmonary areas)
Thrills are best felt in what position and why?
With the patient sitting up, leaning forward and in full expiration.
In this position, the base of the heart is moved closer to the chest wall.
Aprical thrills can be more easily felt with the patient in what position?
Left lateral position (rolled onto left side)
Thrills that coincide with the apex beat are called _____________.
Thrills that do not are called ______________.
Systolic thrills
Diastolic thrills
The presence of a thrill usually indicates what?
An organic lesion
FYI from Talley:
It is possible to define the cardiac outline by means of percussion, but this is not routine.
Percussion is most accurate when performed in the fifth intercostal space. The patient should lie supine and the examiner percusses from the anterior axillary line towards the sternum. The point at which the percussion note becomes dull represents the left heart border. A distance of more than 10.5 centimetres between the border of the heart and the middle of the sternum indicates cardiomegaly. The sign is not useful in the presence of lung disease.
The bell of the stethoscope, designed as a resonating chamber, is particularly efficient are amplifying what types of sounds?
Low pitched sounds such as the diastolic murmur of mitral stenosis or a third heart sound
Forceful application of the bell of the stethoscope causes what?
It stretches the skin under the bell so that it forms a diaphragm.
Therefore - apply lightly to chest wall
The diaphragm of the stethocope best reproduces what type of sounds?
Higher pitched sounds - such as the systolic murmur of mitral reguritation or a fourth heart sound.
What does the first heart sound correspond to and indicate?
The first heart sound (S1) has two components corresponding to mitral and tricuspid valve closure. Mitral closure occurs slightly before tricuspid, but usually only one sound is audible. The first heart sound indicates the beginning of ventricular systole.
What does the second heart sound correspond to and indicate?
S2 is softer, shorter and at a slightly higher pitch than S! and marks the end of systole. It is made up of sounds arising from aortic and pulmonary valve closures.
Why is the second heart sound be split?
In normal cases, although left and right ventricular systole end at the same time, the lower pressure in the pulmonary circulation compared with the aorta means that flow continues into the pulmonary artery after the end of left ventricular systole.
As a result, closure of the pulmonary valve occurs later than that of the aortic valve. These components are usually (in 70% of normal adults), sufficiently separated in time so that splitting of the second hear sound is audible.
Pulmonary valve closure is further delayed (by 20-30 milliseconds) with inspiration because of increased venous return to the right ventricle; thus splitting of the second heart sound is wider on inspiration.
The second heart sound marks the beginning of diastole, which is usually longer than systole.
Where is splitting of the second heart sound best auscultated?
Because the pulmonary component of the second heart sound (P2) may not be audible throughout the praecordium, splitting of the second heart sound may best be appreciated in the pulmonary area and along the left sternal edge.
In what percentage of normal adults is the splitting of the second heart sound audible?
70%
Normal mitral valve cusps drift back towards the closed position at the end of diastole as ventricular filling slows down.
Why might first heart sounds be louder than normal?
S1 is loud when mitral or tricuspid valve cusps remain wide open at the end of diastole and shut forcefully with the onset of ventricular systole.
This occurs in mitral stenosis because of the narrowed valve orifice limiting ventricular filling so that there is no decrease in flow towards the end of diastole.
Other causes of a loud S1 are related to reduced diastolic filling time (eg tachycardia or any cause of a short atrioventricular conduction time)
Why might the first heart sound be softer than normal?
Soft first heart sounds can be due to prolonged diastolic filling time (as with first degree heart block) or a delayed onset of left ventricular systole (as with left bundle branch block), or a failure of the leaflets to coapt normally (as in mitral regurgitation).
A loud aortic component (A2) of S2 may occur in patients with what pathology?
Systemic hypertension
Loud A2 component of S2 may occur in patients with systemic hypertension, how does HTN lead to loud heart sounds?
P2 of S2 is said to be loud in what pathology?
Pulmonary hypertension where the valve closure is forceful becuase of high pulmonary pressure.
Note: A palpable P2 correlated better with raised pulmonary pressures than a loud P2
When might a soft A2 of S2 be heard?
When the aortic valve is calcified and leaflet movement is reduced, and in aortic regurgitation when the leaflets cannot coapt.
Splitting of the first heart sound is not usually detectable clinically; however, when it does occur, it is most often due to what?
the cardiac conduction block known as complete right bundle block
Increased normal splitting (wider on inspiration) of S2 occurs when?
When there is any delay in right ventricular emptying, as in:
- RBBB (delayed RV depolarisation)
-
pulmonary stenosis (delayed right ventricular ejection)
- ventricular septal defect (increased RV volume load)
- mitral regurgitation (because of earlier aortic valve closure, due to more rapid LV emptying).
What is fixed splitting and what causes it?
Fixed splitting of the second heart sound is where there is no respiratory variation and splitting tends to be wide.
This is calused by an atrial septal defect where equalisation of volume loads between the two atria occurs through the defect. This results in the atria acting as a common chamber.
What is reversed splitting and what causes it?
Reversed splitting is present when P2 occurs first and splitting occurs in expiration.
This can be due to:
- delayed left ventricular depolarisation (LBBB)
- delayed left ventricular emptying (severe aortic stenosis, coarctation of the aorta)
- increased left ventricular volume load (large patent ductus arteriosus; note the loud machinery murmur means that in this case, S2 is usually not heard)
What is the third heart sound?
S3:
a low pitched (20-70Hz) mid diastolic sound
What is a gallop rhythm?
Rhythm with appreciable S3 or S4
(Ken-tuck-y) or (Ten-nes-see)
How is S3 more easily heard?
- listen for a triple rhythm rather than individual heart sounds
- use the bell (low pitched)
What is the cause of S3?
A pathological S3 is due to what?
Probably caused by tautening of the mitral or tricuspid papillary muscles at the end of rapid diastolic filling when blood flow temporarily stops.
A pathological S3 is due to reduced ventricular compliance, so that a filling sound is produced even when diastolic filling is not especially rapid.
S3 is strongly associated with what?
increased atrial and ventricular end-diastolic pressure
When is a left ventricular S3 physiological?
When it is due to very rapid diastolic filling associated with increased cardiac output as occurs in pregnancy and thyrotoxicosis and in some children.
When and where is a left ventricular S3 loudest?
At the apex and on expiration
Left ventricular S3 is an important sign of:
(1)
and can also occur in:
(5)
- left ventricular failure and dilation
Also in:
- aortic regurgitation
- mitral regurgitation
- ventricular septal defect
- patent ductus arteriosus
When and where is a right ventricular S3 loudest?
At the left sternal edge and on inspiration.
Two causes of a right ventricular S3:
- right ventricular failure
- constrictive pericarditis
What is a fouth heart sound?
S4:
a late diastolic sound pitched slightly higher than S3
What is S4 due to?
S4 is due to a high-pressure atrial wave reflected back from a poorly compliant ventricle.
It depends on effective atrial conduction.
Can S4 be heard in patients with AF?
No.
S4 requires effective atrial contraction.
A left ventricular S4 may be the only physical sign of what condition?
During an episode of angina or with a myocardial infarction.
Left ventricular S4 may be audible when?
When LV compliance is reduced due to:
- aortic stenosis
- actue mitral regurgitation
- systemic hypertension
- ischaemic heart disease
- advanced age
A right ventricular S4 occurs when:
when right ventricular compliance is reduced as a result of pulmonary hypertension or pulmonary stenosis
S3 and S4 may be superimposed in what cardiac state?
Tachycardia (>120bpm)
What is a summation gallop?
A tachycardia with S3 and S4 superimposed.
The two inaudible sounds may combine to produce an audible one.
What is the name of the rhythm when both S3 and S4 are present?
What does this imply?
Quadruple rhythm.
It usually implies severe ventricular dysfunction.
Does a summation gallop imply ventricular stress?
Only if one or both extra heart sounds persist when the HR slows or is slowed by carotid sinus massage.
What is an opening snap and when does it occur?
An opening snap is a hitch pitched sound that occurs in mitral stenosis at a variable distance after S2 before the diastolic murmer of mitral stenosis
What causes an opening snap?
The sudden opening of the mitral valve.
What can an opening snap be difficult to distinguish from?
A widely split S2
Use of the term opening snap implies diagnosis of?
mitral stenosis (rarely tricuspid stenosis)
What is a systolic ejection click and when is it heard?
An early systolic high-pitched sound that is heard over the aortic or pulmonary and left sternal edge areas, before the systolic ejection murmer of aortic or pulmonary stenosis.
In what abnormalities does a systolic ejection click occur and what causes the sound?
A systolic ejection click may occur in cases of congenital aortic or pulmonary stensosis where the valve remains mobile. It is due to the abrupt doming of the abnormal valve early in systole.
What is a non-ejection systolic click and when does it occur?
A non-ejection systolic click is a high pitched sound heard during systolic that is best apprecitaed at the mitral area. It is a common finding. It may be followed by a systolic murmer.
What is a non-ejection systolic click due to?
It may be due to prolapse of one or more redundant mitral valve leaflets during systole. Non-ejection systolic clicks may aslo be heard in patients with atrial septal defects of Ebstein’s anomaly/
What is a tummour plop?
An early diastolic plopping heard in 10% of patients with an atrial myxoma (very rare tumour of atrium)
What is a diastolic pericardial knock?
A sound that occurs when there is sudden cessation of ventricular filling because of constrictive percardial disease
What is the pacemaker sound?
The late diastolic high-pitched click due to contraction of the chest wall muscles in patients with right ventricular pacemakers.
How fast does normal blood flow through cardiac valves?
1 metre per second!
What are murmurs?
Continuous sounds caused by turbulent blood flow
List two causes of increased turbulance across normal valves:
Anaemia and thyrotoxicosis
What needs to be consdiered in order to assess the origin of a cardiac murmur (5)?
- associated features (peripheral signs)
- timing
- area of greatest intensity
- loudness/pitch
- effect of dynamic manoeuvres (respiration and valsalva)
List four cardiac leasons that will cause a pansystolic murmur
Mitral regurgitation
Tricuspid regurgitation
Ventricular septal defect
Aortopulmonary shunts
List the three types of systolic murmers based on when they occur during systole
Pansystolic
Midsystolic (Ejection systolic)
Late systolic
Describe pansystolic murmers
Extend throughout systole, beginning with the first heart sound going right up to the second heart sound. Its loudness and pitch do not vary during systole.
Why do pansystolic murmurs occur?
Pansystolic murmurs occur when a ventricle leaks to a lower pressure chamber or vessel (
