Cardiovascular examination Flashcards
What points of the chest does the left ventricle lie between?
The sternal end of the 2nd intercostal space inferolaterally to the apex of the heart (5th intercostal space, mid-axillary line)
Where is the right ventricle in the chest?
It sits deep to the sternum and extends out to the left towards the apex
Why might you not be able to palpate the apex beat in some patients?
Obesity and emphysema can make palpation difficult
What’s the correct procedure to palpate the apex beat in a woman?
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
What causes the S1 heart sound?
Closure of the mitral and tricuspid valves
What causes the S2 heart sound?
Closure of the aortic and pulmonary valves
What should you do while you auscultate the pulse in different regions of the chest?
Palpate the carotid pulse in the neck simultaneously
What’s the timings of S1 and S2 in relation to the pulse?
S1 comes just before the carotid pulse, marking the end of diastole (beginning of systole), and S2 just after, marking the end of systole
What makes the internal jugular vein unique?
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
What can cause increased RA pressure and consequently JVP?
Volume overload, for example from an increased circulatory volume (hypervolaemia) or pump failure (heart failure)
What’s a normal JVP measurement?
<3cm
Name the 5 things to inspect for from the end of the bed to start a cardiovascular examination
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
What objects do you look for on general inspection of the room?
Oxygen delivery devices, ECG leads, medications (GTN spray), vitals, drug charts
What is GTN spray?
Glyceryl trinitrate is a nitrate used to treat angina via sublingual administration. It’s only for adults. Pain should subside within 15 minutes
What is xanthomata?
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
What is arachnodactyly?
‘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
What relevant disease processes can finger clubbing be related to?
Congenital cyanotic heart disease, infective endocarditis and atrial myxoma
What are splinter haemorrhages?
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
What are Janeway lesions?
Non-tender, haemorrhages lesions that occur on the thenar and hypothenar eminences of the palms, which are typically associated with infective endocarditis
What are Osler’s nodes?
Red-purple, slightly raised, tender lumps, often with a pale centre, typically found on the fingers or toes. Typically associated with infective endocarditis
What do cool hands suggest?
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
What is acute coronary syndrome?
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
What are the possible causes of poor peripheral perfusion shown on examination of CRT?
Hypovolaemia or congestive heart failure
What is radio-radial delay?
A loss of synchronicity between the radial pulse on each arm, resulting in the pulses occurring at different times
What are 3 causes of radio-radial delay?
Subclavian artery stenosis
Aortic dissection
Aortic coarction
What is aortic dissection?
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
What is aortic coarctation?
A congenital condition whereby the aorta is narrow, usually in the area where the ductus arteriosus (ligament arteriosum) inserts
What is a collapsing pulse?
A forceful pulse that rapidly increases and subsequently collapses
What are the 3 states that cause a collapsing pulse?
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
What’s a slow-rising charactered pulse?
A pulse with a slow upstroke, which is particularly prominent in the brachial and carotid pulses. It’s associated with aortic stenosis
What’s a bounding pulse?
A pulse that feels as though the heart is pounding or racing. It’s associated with aortic regurgitation and CO2 retention
What is a thready pulse?
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
What should you do prior to palpating the carotid pulse?
Auscultate to rule out the presence of a bruit, which would suggest underlying carotid stenosis, making palpation potentially dangerous
What should the patient do while you auscultate the carotid pulse?
Take a deep breath in and hold it
What’s the hepatojugular reflux test?
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.
What does a positive hepatojugular reflux result indicate?
That the right ventricle is unable to accommodate an increased venous return. This can suggest RVF or LVF, constrictive pericarditis or restrictive cardiomyopathy
What are Kayser-Fleischer rings?
Dark iron-coloured rings that encircle the iris, which are associated with Wilson’s disease
What is Wilson’s disease?
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
What is angular stomatitis?
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
What is poor dental hygiene a risk factor for?
Infective endocarditis
What are Pectus excavatum and Pectus carniatum?
Pectus excavatum- a caved-in or sunken appearance of the chest
Pectus carniatum- protrusion of the sternum and ribs
What does a median sternotomy scar indicate?
Cardiac valve replacement and CABG
What does an anterolateral thoracotomy scar indicate and where is it?
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
What does an infraclavicular scar indicate?
Pacemaker insertion
What does a left mid-axillary scar indicate?
The insertion of a subcutaneous implantable cardioverter-defibrillator (ICD)
What causes apex beat displacement?
Ventricular hypertrophy
What is a parasternal heave?
A precordial impulse that can be palpated and is associated with RV hypertrophy
What is a thrill?
A palpable vibration (murmur) caused by turbulent blood flow through a heart valve
How do you go about auscultating the 4 heart valves?
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
How do you accentuate for radiation of an ejection systolic murmur caused by aortic regurgitation?
Get the patient to hold their breath
How do you accentuate for an early diastolic murmur caused by aortic regurgitation?
Sit the patient forwards and auscultate over the aortic area with the diaphragm of the stethoscope during expiration
How do you accentuate for a pan systolic murmur caused by aortic regurgitation?
Get the patient to roll onto their left side, and listen over the mitral area during expiration
How do you accentuate for a mid-diastolic murmur caused by mitral stenosis?
Roll the patient onto their left side and listen over the mitral area with the bell of the stethoscope during expiration
What’s the difference between the bell and diaphragm of the stethoscope?
The bell is more effective at detecting low-frequency sounds and vice versa.
What do you do when assessing the posterior chest wall?
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.
What’s the final part of a cardiovascular examination?
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
Give 5 possible further assessments following a cardiovascular examination
Measure blood pressure Peripheral vascular examination 12-lead ECG Dipstick urine test Fingerpick blood glucose test
