Cardiovascular examination Flashcards
what clinical signs should be looked for in general inspection?
- cyanosis
- SOB
- pallor
- malar flush
- oedema
- comfort
- position
- build
what is cyanosis?
a bluish discolouration of the skin due to poor circulation (e.g. peripheral vasoconstriction secondary to hypovolaemia) or inadequate oxygenation of the blood (e.g. right to left cardiac shunting)
what is malar flush?
plum-red discolouration of the cheeks associated with mitral stenosis
what objects and equipment should be looked for in general inspection?
- oxygen delivery devices, ECG leads, medications, catheters (volume/colour of urine), IV access
- mobility aids
- how many pillows
- vital signs
- fluid balance
- prescriptions
what should be looked for in hand inspection?
- general observations
- finger clubbing
- signs in hands associated with endocarditis
what general observations should be looked for in hand inspection?
- colour
- vasodilation/constriction
- temperature
- xanthomata
- arachnodactyly
- sweating
- pallor of palmar creases
- peripheral cyanosis
- tendon xanthomas
what are xanthomata?
raised yellow cholesterol-rich deposits that are often noted on the palm, tendons of the wrist and elbow; associated with hyperlipidaemia
what is arachnodactyly?
fingers and toes are abnormally long and slender, in comparison to the palm of the hand and arch of the foot; is a feature of Marfan’s syndrome, which is associated with mitral/aortic prolapse and aortic dissection
what is finger clubbing? what is it associated with?
- involves uniform soft tissue swelling of the terminal phalanx of a digit with loss of the normal angle between the nail and the nail bed
- associated with underlying diseases, in CV OSCE they’re likely to include congenital cyanotic heart disease, infective endocarditis and atrial myxoma
how is finger clubbing tested for?
- ask patient to place the nails of their index fingers back to back
- in a healthy person, you should see a small diamond-shaped window (Schamroth’s window)
- when finger clubbing develops, this window is lost
what are signs in the hands associated with endocarditis?
- splinter haemorrhages
- Janeway lesions
- Osler’s nodes
- petechiae
what are splinter haemorrhages? what are they caused by?
- longitudinal, red-brown haemorrhages under nails that look like wood splinters
- causes include local trauma, infective endocarditis, sepsis, vasculitis, psoriatic nail disease
what are Janeway lesions?
non-tender, haemorrhagic lesions that occur on the thenar and hypothenar eminences of the palms and soles; associated with infective endocarditis
what are Osler’s nodes?
red-purple, slightly raised, tender lumps, often with a pale centre, typically found on fingers or toes; associated with infective endocarditis
what is palpated in the CV examination?
- temperature of hands
- capillary refill time
- radial pulse
- radio-radial delay
- collapsing pulse
- brachial pulse
- BP
- carotid pulse
- JVP
- hepatojugular reflex
how is the capillary refill time assessed?
- apply 5 seconds of pressure to the distal phalanx of one of the patient’s fingers and then release
- in healthy people, the initial pallor of the compressed area should return to its normal colour in less than 2 seconds
- a CRT >2seconds suggests poor peripheral perfusion and the need to assess central CRT
where is the radial pulse located? how is it assessed?
- palpate the radial pulse, located at the radial side of the wrist, with tips of your index and middle fingers aligned longitudinally over the artery
- assess rate and rhythm
- assess radio-radial delay
what is radio-radial delay?
a loss of synchronity between the radial pulse on each arm, resulting in pulses occurring at different times
how is radio-radial delay assessed?
- palpate both radial pulses simultaneously
2. should occur at same time
what are causes of radio-radial delay?
- subclavian artery stenosis
- aortic dissection
- aortic coarctation
how is collapsing pulse assessed?
- ask patient if they have any pain in their right shoulder, as you’ll have to move it briskly (if they do, avoid the assessment)
- palpate the radial pulse with your right hand wrapped around their wrist
- palpate the brachial pulse (medial to biceps brachii tendon) with your left hand, while supporting the patient’s elbow
- raise patient’s arm above the head briskly
- as blood rapidly empties from the arm in diastole, you should feel a tapping impulse through the muscle bulk; this is caused by the sudden retraction of the column of blood within the arm during diastole
what are causes of a collapsing pulse?
- normal physiological states (e.g. fever, pregnancy)
- cardiac lesions (e.g. aortic regurgitation, patent ductus arteriosus)
- high output states (e.g. anaemia, AV fistula, thyrotoxicosis)
how is the brachial pulse assessed?
- assess volume and character
- support the patient’s right forearm with your left hand
- position the patient so their upper arm is abducted, their elbow is partially flexed and their forearm is externally rotated
- with your right hand, palpate medial to the biceps brachii tendon and lateral to the medial epicondyle of the humerus; deeper palpation is required
what are the the types of pulse character?
- normal
- slow-rising (associated with aortic stenosis)
- bounding (associated with aortic regurg and CO2 retention)
- thready (associated with intravascular hypovolaemia in conditions e.g. sepsis)
what is a narrow pulse pressure?
less than 25mmHg of difference between the systolic and diastolic pulse pressure; causes include aortic stenosis, CHF, cardiac tamponade
what is a wide pulse pressure?
more than 100mmHg of difference between the systolic and diastolic blood pressure; causes include aortic regurg and aortic dissection
what difference in BP between arms is abnormal? what does it suggest?
more than 20mmHg; may suggest aortic dissection
how is the carotid artery auscultated?
- before palpating the carotid artery, you need to auscultate it to rule out a bruit (which suggests carotid stenosis), making palpation dangerous due to risk of dislodging a plaque and causing an ischaemic stroke
- place the diaphragm of your stethoscope between the larynx and the anterior border of the SCM muscle over the carotid pulse and ask patient to take a deep breath and hold whilst you listen
- presence of bruit may be a radiating carotid murmur
how is the carotid pulse palpated?
- if no bruits were identified in auscultation then it’s safe to palpate
- ensure patient is positioned safely on bed
- gently place your fingers between the larynx and the anterior border of the SCM to locate pulse
- assess character and volume
how is the JVP measured?
- position the patient in semi-recumbent position (45deg)
- ask patient to turn head slightly to left
- inspect for evidence of the IJV, running between the medial end of the clavicle and the ear lobe, under the medial aspect of the SCM
- measure JVP by assessing the vertical distance between the sternal angle and the top of the pulsation point of the IJV (should be no greater than 3cm)
what are cardiac causes of raised JCP?
- right-sided heart failure (left-sided heart failure, pulmonary hypertension, COPD, ILD)
- tricuspid regurgitation (causes are endocarditis and rheumatic heart disease)
- constrictive pericarditis (rheumatoid arthritis, TB, idiopathic)
how is the hepatojugular reflex elicited?
- there should be at least a 3cm distance from the upper margin of the baseline JVP to the angle of the mandible
- position the patient in a semi-recumbent position (45deg)
- apply direct pressure to the liver
- closely observe the IJV for a rise
- in healthy people the rise should last no longer than 1-2 cardiac cycles, then fall
- if the rise in JVP is sustained and equal to or greater than 4cm this is a positive result
- uncomfortable for patient
what is a positive result for the hepatojugular reflex?
rise in JVP is sustained and equal to or greater than 4cm
what can cause a positive hepatojugular reflex result?
positive result suggests right ventricle cannot accommodate an increased venous return, can be caused by:
- constrictive pericarditis
- right/left ventricular failure
- restrictive cardiomyopathy
what is looked for in eye inspection?
- conjunctival pallor
- corneal arcus
- xanthelasma
- Kayser-Fleischer rings
- malar flush
what is corneal arcus?
a hazy white, grey or blue opaque ring located in the peripheral cornea, typically occurring in patients over 60. in older patients it’s considered benign, in under 50s it suggests hypercholesterolaemia
what are Kayser-Fleischer rings?
dark rings encircling the iris in Wilson’s disease
what is looked for in mouth inspection?
- central cyanosis
- angular stomatitis
- high arched palate
- dental hygiene
what is looked for on the anterior chest?
- pectus excavatum
- pectus carniatum
- visible pulsations
- severe kyphoscoliosis
what is pectus excavatum?
a caved in or sunken appearance of the chest
what is pectus carniatum?
protrusion of the sternum and ribs
what types of thoracic scars should be looked for?
- median sternotomy scar
- anterolateral thoracotomy scar
- infraclavicular scar
- left mid-axillary scar
where is a median sternotomy scar located? what is it caused by?
- located in midline of thorax
- surgical approach is used for cardiac valve replacement and CABG
where is an anterolateral thoracotomy scar located? what is it caused by?
- located between lateral border of the sternum and the mid-axillary line at the 4th or 5th intercostal space
- surgical approach is used for minimally invasive cardiac valve surgery
where is an infraclavicular scar located? what is it caused by?
- located in the infraclavicular region
- surgical approach used for pacemaker insertion
where is a left mid-axillary scar located? what is it caused by?
surgical approach used for insertion of a subcutaneous ICD
what is assessed for in chest palpation?
- palpate apex beat
- heaves
- thrills
how is the apex beat palpated?
- palpate the apex beat with your fingers horizontally across the chest
- should be located in the 5th intercostal space in the midclavicular line
- displacement of apex beat from its usual location can occur due to ventricular hypertrophy
how are heaves palpated for?
- a parasternal heave is a precordial impulse that can be palpated
- place the heel of your hand parallel to the left sternal edge (fingers vertical)
- if heaves are present you should feel the heel of your hand being lifted with each systole
- typically associated with right ventricular hypertrophy
what is a parasternal heave?
precordial impulse that can be palpated
what is a thrill?
a palpable vibration caused by turbulent blood flow through a heart valve (palpable murmur)
how are thrills palpated for?
- assess for a thrill across each of the heart valves in turn
- place your hand horizontally across the chest wall, with the flats of your fingers and palm over the valve to be assessed
where are the 4 valves located?
- mitral valve: 5th intercostal space in the midclavicular line
- tricuspid valve: 4th or 5th intercostal space at the lower left sternal edge
- pulmonary valve: 2nd intercostal space at the left sternal edge
- aortic valve: 2nd intercostal space at the right sternal edge
how should the first heart sound be determined?
by palpating the carotid pulse
how do you auscultate the four heart valves?
- palpate the carotid pulse to determine the first heart sound
- auscultate upwards through the valve areas using the diaphragm whilst continuing to palpate the carotid pulse (mitral, tricuspid, pulmonary and aortic valves)
- repeat auscultation across the four valves with the bell of the stethoscope
- if extra sounds are heard, palpate the carotid pulse to time them with the first and second heart sounds; the start of the carotid pulsation will be synchronous with the first heart sound
what should be done if extra sounds are heard in auscultation?
if extra sounds are heard, palpate the carotid pulse to time them with the first and second heart sounds; the start of the carotid pulsation will be synchronous with the first heart sound
what are the accentuation manoeuvres?
- auscultate the carotid arteries using the diaphragm whilst the patient holds their breath to listen for radiation of an ejection systolic murmur in aortic stenosis
- sit the patient forwards and auscultate over the aortic area with the diaphragm during expiration to listen for early diastolic murmur caused by aortic regurgitation
- roll patient onto their left side and listen over the mitral area with the diaphragm during expiration to listen for a pansystolic murmur caused by mitral regurgitation; auscultate into the axilla to identify radiation
- on left side still, listen again over the mitral area using the bell during expiration for a mid-diastolic murmur in mitral stenosis
- switch back to the diaphragm, sit the patient forward and auscultate at the 4th/5th intercostal space to the left of the sternum on held expiration (aortic regurgitation)
- auscultate lung bases, assess for sacral oedema; if coarctation is suspected, auscultate to the left of the spine in the 3rd/4th intercostal space
- sit the patient back and auscultate the carotids for bruits or a transmitted systolic murmur
- lay the patient flat, if they can tolerate it, and palpate for hepatomegaly; if the liver is enlarged, feel for pulsation (tricuspid regurgitation)
what are the accentuation manoeuvres for aortic stenosis?
- auscultate the carotid arteries using the diaphragm whilst the patient holds their breath to listen for radiation of an ejection systolic murmur caused by aortic stenosis
what are the accentuation manoeuvres for aortic regurgitation?
- sit the patient forwards and auscultate over the aortic area with the diaphragm during expiration to listen for an early diastolic murmur caused by aortic regurgitation
- using the diaphragm, sit the patient forward and auscultate at the 4th/5th intercostal space to the left of the sternum on held expiration
what are the accentuation manoeuvres for mitral regurgitation?
- roll the patient onto their left side and listen over the mitral area with the diaphragm during expiration to listen for a pansystolic murmur caused by mitral regurgitation; continue to auscultate into the axilla to identify radiation
what are the accentuation manoeuvres for mitral stenosis?
- with patient still on their left side, listen again over the mitral area using the bell during expiration for a mid-diastolic murmur caused by mitral stenosis
what are the accentuation manoeuvres for tricuspid regurgitation?
- lay the patient flat, if they can tolerate it, and palpate for hepatomegaly; if the liver is enlarged, feel for pulsation
what murmurs are heard during systole?
- aortic and pulmonary stenosis
- mitral and tricuspid regurgitation
- mitral valve prolapse causes a systolic murmur with an opening click
what murmurs are heard during early diastole?
aortic and pulmonary regurgitation
what murmurs are heard during mid/late diastole?
mitral and tricuspid stenosis
what are the characteristics of aortic and pulmonary stenosis?
ejection systolic (crescendo-decrescendo)
what are the characteristics of mitral and tricuspid regurgitation?
pansystolic
what are characteristics of aortic sclerosis and HOCM?
- both are loudest in aortic valve area, during expiration
- aortic stenosis radiates to the carotids, whereas HOCM and aortic sclerosis does not
what are characteristics of atrial septal defects and pulmonary stenosis?
- both are loudest in the pulmonary region
- ASDs cause wide and fixed splitting of S2 whereas pulmonary stenosis does not
where are murmurs heard the loudest?
in the region of the valve affected:
- aortic area (2nd intercostal space right sternal edge)
- pulmonary area (2nd intercostal space left sternal edge)
- tricuspid area (4th intercostal space left sternal edge)
- mitral area (cardiac apex; usually 5th intercostal space in the left midclavicular line)
what manoeuvres exaggerate aortic murmurs?
sitting forwards brings aortic valve closer to the chest wall, so they’re heard louder while they’re sitting forwards
what manoeuvres exaggerate mitral murmurs?
the left lateral decubitus position brings apex of the heart closer to the chest wall, so they’re heard loudest in this position
what heart murmurs are heard loudest on inspiration? why?
- during inspiration, the intrathoracic pressure reduces, so more blood flows into the right heart chambers
- right-sided valve lesions (pulmonary and tricuspid valves) are loudest during inspiration
what heart murmurs are heard loudest on expiration? why?
- during expiration intrathoracic pressure increases, forcing pulmonary vessels to constrict, so blood is forced from pulmonary veins into the left atrium and through the left side of the heart
- left-sided heart valve lesions (aortic and mitral valves) are loudest during expiration
where does aortic stenosis radiate to?
carotid artery
where does mitral regurgitation radiate to?
axilla
where does aortic regurgitation radiate to?
left sternal edge
where does pulmonary stenosis radiate to?
left shoulder/infraclavicular region
what are typical clinical features of aortic stenosis?
- ejection systolic murmur
- heard loudest over the aortic area
- radiates to the carotid arteries
- loudest on expiration and when the patient is sitting forwards
- slow rising pulse with narrow pulse pressure
- non-displaced, heaving apex beat (if present indicates left ventricular hypertrophy)
- reduced or absent S2
- reverse splitting of S2 - aortic valve closes after pulmonary valve
what are the causes of aortic stenosis?
- degenerative age-related calcification
- bicuspid aortic valve
what are typical clinical features of mitral regurgitation?
- pansystolic murmur
- heard loudest over mitral area
- radiates to axilla
- heard loudest using bell of stethoscope
- loudest on expiration in the left lateral decubitus position
- displaced, hyperdynamic apex beat
what are causes of mitral regurgitation?
- degenerative
- left ventricular dilatation
- ruptured chordae tendinae
- papillary muscle rupture
- rheumatic heart disease
- infective endocarditis
- mitral valve prolapse
- connective tissue disease
what are typical clinical features of aortic regurgitation?
- decrescendo early diastolic murmur
- heard loudest at left sternal edge and sometimes over aortic area
- collapsing pulse
- displaced, hyperdynamic apex beat
- Austin-Flint murmur
what is an Austin-Flint murmur?
- low pitched rumbling mid-diastolic murmur heard best at the apex
- caused by the regurgitated blood through the aortic valve mixing with blood from left atrium, during atrial contraction
- sign of severe aortic regurgitation
what is Corrigan’s sign?
visible distention and collapse of carotid arteries in the neck
what is De Musset’s sign?
head bobbing with each heartbeat
what is Quincke’s sign?
pulsations are seen in the nail bed with each heartbeat when the nail bed is lightly compressed
what is Duroziez’s sign?
- a stethoscope is placed over the femoral arteries
- when gentle pressure is applied proximal to the stethoscope a systolic murmur is heard
- when gentle pressure is applied distal to the stethoscope a diastolic murmur is heard
what is Traube’s sign?
pistol shot sound heard when stethoscope placed over the femoral artery during systole and diastole
what is Muller’s sign?
uvula pulsations are seen with each heartbeat
what are causes of aortic regurgitation?
- ascending aortic arch dissection
- infective endocarditis
- chest trauma
- prosthetic aortic valve failure
- connective tissue disease
- rheumatological disorders
- syphilis
what are typical clinical features of mitral stenosis?
- snapping sound (opening click when mitral valve opens)
- loud S1 with tapping apex beat
- Graham Steel murmur
- low-pitched, rumbling mid-diastolic murmur with an opening click
- heard loudest over the apex
- loudest in left lateral decubitus position on expiration
- low-volume pulse which may be irregularly irregular
what is a Graham Steel murmur?
early decrescendo murmur heard in pulmonary area due to pulmonary incompetence - a sign of pulmonary hypertension
what are causes of mitral stenosis?
- rheumatic heart disease
- congenital
- left atrial myxoma
- connective tissue disorders
- mucopolysaccharidosis
what are typical clinical features of mitral valve prolapse?
- mid-systolic click
- followed by a mid or late-systolic murmur
- heard loudest at the apex
- loudest in expiration
what are causes of mitral valve prolapse?
- rheumatic heart disease
- connective tissue disorders
- Ebstein anomaly
- associated with ASD and patent ductus arteriosus
- SLE
what are typical clinical features of tricuspid regurgitation?
- pansystolic murmur
- heard loudest over tricuspid region
- loudest during inspiration
- large V waves in jugular veins
- visible/palpable hepatic pulsations
- signs of right-sided heart failure
what are causes of tricuspid regurgitation?
- right ventricular dilatation
- rheumatic fever
- infective endocarditis
- carcinoid syndrome
- congenital (ASD, AV canal, Ebstein anomaly)
what are typical clinical features of pulmonary stenosis?
- ejection systolic murmur
- heard loudest over pulmonary area
- loudest during inspiration
- radiates to left shoulder/left infraclavicular region
- prominent a waves in jugular veins
- widely split S2
- P2 may be soft and inaudible
- right ventricular heave, tricuspid regurgitation, peripheral signs of RHF
what are causes of pulmonary stenosis?
- Turner’s, Noonan’s, Williams, tetralogy of Fallot
- rheumatic fever
- carcinoid syndrome
what are typical clinical features of pulmonary regurgitation?
- early decrescendo murmur
- heard loudest over the left sternal edge
- loudest during inspiration
- usually due to pulmonary hypertension
what are typical clinical features of tricuspid stenosis?
- mid-diastolic murmur (rarely audible)
- loudest at 3rd-4th intercostal space at the left sternal edge
- loudest during inspiration
- signs of right atrial enlargement
what are causes of tricuspid stenosis?
- rheumatic fever
- congenital disease
- infective endocarditis
what is the bell of the stethoscope more effective for?
detecting low-frequency sounds, including the mid-diastolic murmur of mitral stenosis
what is the diaphragm of the stethoscope more effective for?
detecting high-frequency sounds, including the ejection systolic murmur of aortic stenosis, early diastolic murmur of aortic regurgitation and pansystolic murmur of mitral regurgitation
what is done to finish off a cardiovascular examination?
- posterior chest wall inspection
- auscultation of posterior cehst wall
- sacral/pitting oedema
- leg inspection
- test for shifting dullness if ascites is suspected
what further assessments and investigations should be suggested at the end of a cardiovascular exam?
- measure BP in both arms, lying and standing
- peripheral vascular examination
- 12-lead ECG
- urine dipstick
- bedside capillary blood glucose
- fundoscopy
- opthalmoscopy
