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Clinical skills > Cardiovascular examination > Flashcards

Cardiovascular examination Flashcards

1
Q

What points of the chest does the left ventricle lie between?

A

The sternal end of the 2nd intercostal space inferolaterally to the apex of the heart (5th intercostal space, mid-axillary line)

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2
Q

Where is the right ventricle in the chest?

A

It sits deep to the sternum and extends out to the left towards the apex

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3
Q

Why might you not be able to palpate the apex beat in some patients?

A

Obesity and emphysema can make palpation difficult

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4
Q

What’s the correct procedure to palpate the apex beat in a woman?

A

Explain the process fully

Ask them to lift up their breast, or lift it up with the back of your hand, once you’ve received consent

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5
Q

What causes the S1 heart sound?

A

Closure of the mitral and tricuspid valves

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6
Q

What causes the S2 heart sound?

A

Closure of the aortic and pulmonary valves

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7
Q

What should you do while you auscultate the pulse in different regions of the chest?

A

Palpate the carotid pulse in the neck simultaneously

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8
Q

What’s the timings of S1 and S2 in relation to the pulse?

A

S1 comes just before the carotid pulse, marking the end of diastole (beginning of systole), and S2 just after, marking the end of systole

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9
Q

What makes the internal jugular vein unique?

A

There are no valves between it and the right atrium, so the height of the pulsation can be used as a direct correlate to the pressure in the right atrium

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10
Q

What can cause increased RA pressure and consequently JVP?

A

Volume overload, for example from an increased circulatory volume (hypervolaemia) or pump failure (heart failure)

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11
Q

What’s a normal JVP measurement?

A

<3cm

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12
Q

Name the 5 things to inspect for from the end of the bed to start a cardiovascular examination

A

Cyanosis- due to poor circulation or inadequate oxygenation of the blood
Shortness of breath- may indicate underlying CVD (CHF or pericarditis) or respiratory disease
Pallor- paleness of the skin that can indicate anaemia or poor perfusion
Malar flush- plum-red discolouration of the cheeks associated with mitral stenosis
Oedema- typically of the limbs or abdomen, can be caused by CHF

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13
Q

What objects do you look for on general inspection of the room?

A

Oxygen delivery devices, ECG leads, medications (GTN spray), vitals, drug charts

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14
Q

What is GTN spray?

A

Glyceryl trinitrate is a nitrate used to treat angina via sublingual administration. It’s only for adults. Pain should subside within 15 minutes

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15
Q

What is xanthomata?

A

Raised yellow cholesterol-rich deposits that are often noted on the palm, tendons of the wrist, and elbow. Xanthomata is associated with hyperlipidaemia, which is a risk factor for CVD

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16
Q

What is arachnodactyly?

A

‘Spider fingers’- abnormally long and slender fingers and toes in comparison to the palm and the arch of the foot. This is a feature of Marfan’s syndrome, which is associated with mitral/aortic valve prolapse and aortic dissection

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17
Q

What relevant disease processes can finger clubbing be related to?

A

Congenital cyanotic heart disease, infective endocarditis and atrial myxoma

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18
Q

What are splinter haemorrhages?

A

Lonngitudinal, red-brown haemorrhages under the nail that look like a wood splinter.. They indicate local trauma, infective endocarditis, sepsis, vasculatitis or psoriatic nail disease

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19
Q

What are Janeway lesions?

A

Non-tender, haemorrhages lesions that occur on the thenar and hypothenar eminences of the palms, which are typically associated with infective endocarditis

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20
Q

What are Osler’s nodes?

A

Red-purple, slightly raised, tender lumps, often with a pale centre, typically found on the fingers or toes. Typically associated with infective endocarditis

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21
Q

What do cool hands suggest?

A

Cool hands can indicate poor peripheral perfusion, caused by congestive heart failure or acute coronary syndrome. Cool and clammy hands are typically associated with acute coronary syndrome

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22
Q

What is acute coronary syndrome?

A

An umbrella term for a range of conditions associated with sudden reduced perfusion of the heart. Components are MI( STEMI or NSTEMI) and unstable angina

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23
Q

What are the possible causes of poor peripheral perfusion shown on examination of CRT?

A

Hypovolaemia or congestive heart failure

24
Q

What is radio-radial delay?

A

A loss of synchronicity between the radial pulse on each arm, resulting in the pulses occurring at different times

25
Q

What are 3 causes of radio-radial delay?

A

Subclavian artery stenosis
Aortic dissection
Aortic coarction

26
Q

What is aortic dissection?

A

A serious condition in which there’s a partial rupture of the aortic wall, resulting in good flowing into the tunica media, which becomes fatal if t. adventitia also ruptures

27
Q

What is aortic coarctation?

A

A congenital condition whereby the aorta is narrow, usually in the area where the ductus arteriosus (ligament arteriosum) inserts

28
Q

What is a collapsing pulse?

A

A forceful pulse that rapidly increases and subsequently collapses

29
Q

What are the 3 states that cause a collapsing pulse?

A

Normal physiological states like fever or pregnancy
Cardiac lesions like aortic regurgitation and patent ductus arteriosus
High output states like anaemia, arteriovenous fistula or thyrotoxicosis

30
Q

What’s a slow-rising charactered pulse?

A

A pulse with a slow upstroke, which is particularly prominent in the brachial and carotid pulses. It’s associated with aortic stenosis

31
Q

What’s a bounding pulse?

A

A pulse that feels as though the heart is pounding or racing. It’s associated with aortic regurgitation and CO2 retention

32
Q

What is a thready pulse?

A

A pulse that’s difficult to feel or obliterated easily with slight pressure. It’s associated with intravascular hypovolaemia in conditions such as sepsis, so it’s very serious

33
Q

What should you do prior to palpating the carotid pulse?

A

Auscultate to rule out the presence of a bruit, which would suggest underlying carotid stenosis, making palpation potentially dangerous

34
Q

What should the patient do while you auscultate the carotid pulse?

A

Take a deep breath in and hold it

35
Q

What’s the hepatojugular reflux test?

A

Where you apply pressure to the liver whilst observing for a sustained rise in JVP. In healthy individuals, the rise should last no longer than 2 cardiac cycles. If the JVP rises and is sustained at ≥4cm, this is a positive result.

36
Q

What does a positive hepatojugular reflux result indicate?

A

That the right ventricle is unable to accommodate an increased venous return. This can suggest RVF or LVF, constrictive pericarditis or restrictive cardiomyopathy

37
Q

What are Kayser-Fleischer rings?

A

Dark iron-coloured rings that encircle the iris, which are associated with Wilson’s disease

38
Q

What is Wilson’s disease?

A

A rare genetic disorder characterised by excess copper stored in various body tissues, particularly the liver, brain and eyes. It’s a progressive disease that can cause hepatic disease if left untreated

39
Q

What is angular stomatitis?

A

A common inflammatory condition affecting the corners of the mouth (oral commissures). The most common cause is Candida infection, but where there is crusting, secondary infection with Staphylococcus aureus must be considered

40
Q

What is poor dental hygiene a risk factor for?

A

Infective endocarditis

41
Q

What are Pectus excavatum and Pectus carniatum?

A

Pectus excavatum- a caved-in or sunken appearance of the chest
Pectus carniatum- protrusion of the sternum and ribs

42
Q

What does a median sternotomy scar indicate?

A

Cardiac valve replacement and CABG

43
Q

What does an anterolateral thoracotomy scar indicate and where is it?

A

Between the lateral border of the sternum and the mid-axillary line at the 4th or 5th intercostal space. It’s indicative of minimally invasive cardiac valve surgery

44
Q

What does an infraclavicular scar indicate?

A

Pacemaker insertion

45
Q

What does a left mid-axillary scar indicate?

A

The insertion of a subcutaneous implantable cardioverter-defibrillator (ICD)

46
Q

What causes apex beat displacement?

A

Ventricular hypertrophy

47
Q

What is a parasternal heave?

A

A precordial impulse that can be palpated and is associated with RV hypertrophy

48
Q

What is a thrill?

A

A palpable vibration (murmur) caused by turbulent blood flow through a heart valve

49
Q

How do you go about auscultating the 4 heart valves?

A

Start by palpating the carotid pulse. Then auscultate the aortic, pulmonary, tricuspid and mitral valves in that order, while palpating the pulse. Repeat with the bell of the stethoscope

50
Q

How do you accentuate for radiation of an ejection systolic murmur caused by aortic regurgitation?

A

Get the patient to hold their breath

51
Q

How do you accentuate for an early diastolic murmur caused by aortic regurgitation?

A

Sit the patient forwards and auscultate over the aortic area with the diaphragm of the stethoscope during expiration

52
Q

How do you accentuate for a pan systolic murmur caused by aortic regurgitation?

A

Get the patient to roll onto their left side, and listen over the mitral area during expiration

53
Q

How do you accentuate for a mid-diastolic murmur caused by mitral stenosis?

A

Roll the patient onto their left side and listen over the mitral area with the bell of the stethoscope during expiration

54
Q

What’s the difference between the bell and diaphragm of the stethoscope?

A

The bell is more effective at detecting low-frequency sounds and vice versa.

55
Q

What do you do when assessing the posterior chest wall?

A

Inspect for any deformities or scars, auscultate the lung fields for coarse crackles suggestive of pulmonary oedema. Press on the lower back for sacral oedema.

56
Q

What’s the final part of a cardiovascular examination?

A

Inspect the patient’s ankles and palpate them for evidence of pitting pedal oedema. Inspect the patient’s legs for evidence of saphenous vein harvesting for CABG

57
Q

Give 5 possible further assessments following a cardiovascular examination

A 
Measure blood pressure
Peripheral vascular examination
12-lead ECG
Dipstick urine test
Fingerpick blood glucose test

Clinical skills (10 decks)

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