Cardiovascular Examination Flashcards
1
Q
Cardiovascular examination
A
General inspection, inspect the hands, take the pulse and blood pressure, inspect the face and neck, assess carotid pulse and JVP, palpation of the praecordium, auscultation, peripheral examintaion and anything else.
2
Q
General examination
A
- Breathlessness and peripheral cyanosis can be due to heart failure or rarely congenital heart disease.
- Xanthomata – yellow nodules in skin or tendons (patella or Achilles) indicative of hyperlipidaemia.
- Petachiae – haemorrhages on the legs and conjunctivae caused by vasculitis in infective endocarditis.
- Cafe au lait spots – light brown areas often found on the chest that indicate bacterial endocarditis.
- Hydration status – assess ankles for peripheral oedema and lung bases for pulmonary oedema.
3
Q
Inspection of the hands
A
- Osler’s nodes – painful, raised lesions on fingers or toes caused by immune complex in endocarditis.
- Janeway lesions – non-tender erythematous lesions on palms and soles in bacterial endocarditis.
- Splinter haemorrhages – multiple, linear reddish-brown marks along the axis of the fingernails or toenails – a sign of infective endocarditis caused by circulating immune complexes.
- Capillary refill time – normal time < 2 seconds – a measure of hydration and peripheral perfusion
- Clubbing – a rare feature in chronic bacterial endocarditis
- Tobacco staining – yellowish discolouration of the hands and nails
4
Q
Pulse - rate
A
Will vary depending on the patients but bradycardia is <60 bpm and tachycardia is >100 bpm.
- Causes of bradycardia – sleep, athletic training, hypothyroidism, drugs (e.g. β blockers, digoxin, verapamil or diltiazem), carotid sinus hypersensitivity, sick sinus syndrome or heart block.
- Causes of tachycardia – exercise, pain, anxiety, fever, hyperthyroidism, AF or atrial flutter, drugs (e.g. sympathomimetics or vasodilators), supraventricular or ventricular tachycardia.
5
Q
Pulse - rhythm
A
Should be regular sinus rhythm but varies with respiration (rate increases during inspiration). Can be regularly irregular due to ectopic beats occurring or can be irregularly irregular due to AF.
- Causes of AF – hypertension, myocardial infarction, heart failure, thyrotoxicosis, alcohol related heart disease, mitral valve disease, infection e.g. respiratory or urinary or after surgery.
6
Q
Pulse - volume
A
Refers to the degree of pulsation and reflects the pulse pressure.
- Causes of increased volume – physiological in exercise, pregnancy, increased temperature or advancing age. Pathological in peripheral vascular disease, hypertension, fever, thyrotoxicosis, anaemia, aortic regurgitation, Paget’s disease of the bone or a peripheral AV shunt.
- Causes of decreased volume – left ventricular failure, hypovolaemia or atherosclerosis.
- Pulses paradoxus – exaggeration of the normal variability of pulse volume with respiration (normally decreases with inspiration) e.g. with cardiac tamponade or acute severe asthma.
7
Q
Pulse - character
A
Refers to the waveform or shape of the arterial pulse.
- Collapsing pulse – the peak of the pulse arrives early and is followed by a rapid descent. It can be exaggerated by raising the arm above the level of the heart – occurs in aortic regurgitation.
- Slow rising pulse – a gradual upstroke with a peak late in systole – occurs in aortic stenosis.
- Bisferiens pulse – 2 systolic peaks separated by diastolic dip with regurgitation and stenosis.
8
Q
Pulse - delay
A
Radio-radial or radio-femoral may occur in aortic co-arctation (depends in site of the lesion).
9
Q
Blood Pressure
A
- The bladder should be placed over brachial artery when the anticubital fossa at the level of the heart.
- Inflate the cuff until radial pulse disappears, increase by 30mmHg and decrease at intervals of 5mmHg.
- Place diaphragm over brachial artery – systolic when Korotkoff appear and diastolic when disappear.
10
Q
Inspect the face and the neck
A
- Corneal arcus – creamy yellow or bluish discolouration at the iris/corneal boundary caused by cholesterol crystals – this can also occur in patients aged >50 years with no hyperlipidaemia.
- Xanthelasma – yellowish cholesterol plaques that are found around the eyelids and periorbital area.
- Malar flush – mitral stenosis due to rheumatic heart disease, infective endocarditis, lupus, pregnancy
- Central cyanosis – reduced CO caused by HF or hypovolaemia or arterial or venous obstruction
- Roth spots – flame shaped retinal haemorrhages seen on ophthalmoscopy in infective endocarditis.
- Pallor of the lower eyelid or tongue – indicates the presence of anaemia
11
Q
Carotid vs venous pulsation
A
- Carotid pulse - rapid outward movement, one peak per heartbeat, palpable, unaffected by pressure at the root of the neck, independent of respiration, independent of the position of the patient and independent of hepato-jugular reflex.
- Jugular venous pressure - rapid inward movement, two peaks per heartbeat, impalpable, diminished by pressure at the root of the neck, height of pulsation varies with respiration, varies with the position of the patient and rises with the hepato-jugular reflex.
12
Q
JVP components
A
- A wave = RA contraction
- X descent = RA relaxation
- C wave = RV contraction
- X1 descent = RA relaxation
- V wave = RA filling
- Y descent = Triscuspid opening
13
Q
Causes of raised JVP
A
Heart failure, pulmonary embolism, pericardial effusion (prominent Y descent), pericardial constriction, superior vena cava obstruction (loss of pulsation), atrial fibrillation (absent a waves), tricuspid stenosis (giant a waves) or regurgitation (giant v waves) or heart block.
14
Q
Assess the praecordium
A
- Assess the praecordium – feel apex beat – should be in the 5th left IC space in the mid clavicular line.
- Heaves – at apex due to LVH or aortic stenosis or at left sternal edge due to pulmonary HTN and RVH.
- Thrills – a vibration at the apex due to aortic stenosis or at the sternal edges due to a septal defect.
15
Q
Auscultation
A
- Listen for bruits in carotid with the bell and the diaphragm – ask the patient to hold their breath.
- Heart sounds - listen at the right then left (aortic then pulmonary) 2nd ICS near the sternum, with the diaphragm and bell at left 3rd, 4th, and 5th (tricuspid) ICS near the sternum and at the apex (mitral).
- Have the patient roll onto left side and listen with bell at the apex (mitral murmur). Have patient sit up and hold breath in exhalation - listen with diaphragm at left 3rd and 4th IC space (aortic murmurs)
