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Clinical Examinations > Cardiovascular Examination > Flashcards

Cardiovascular Examination Flashcards

1
Q

State the 7 stages of your cardio examination

A
  1. Introduction
  2. General inspection
  3. Hands & arms
  4. Head & neck
  5. Chest
  6. Back
  7. Legs
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2
Q

Describe what you must do in the introduction stage of your cardio examination

A
  • Name
  • Role
  • Explain & gain informed consent
  • Check patients full details (Name & DOB)
  • Offer chaperone
  • Check for any pain- particulary in right shoulder
  • Wash hands
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3
Q

Describe what you must do in the general inspection stage of your cardio examination

A
  • Position & expose pt
  • Inspect surroundings: cardiac monitor, ECG, oxygen, GTN spray, nitrate infusion, pacing wires, warfarin yellow book
  • Inspect pt: comfortable at rest?, SOB, pallor, body habitus, scars
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4
Q

Describe what you must do in the hands & arms stage of your cardio examination

A
  • Check for tremor
  • Inspect hands: clubbing, tar staining, splinter haemorrhages, Osler’s nodes, Janeway lesions, peripheral cyanosis, xanthoma, radial artery/vein harvest scar
  • Capillary refill
  • Radial pulse (rate, rhythm)
  • Radio-radial delay
  • Offer radio-femoral delay
  • Collapsing pulse
  • Brachial pulse (volume & character) **NOTE: could just do carotid
  • Request bp in each arm
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5
Q

Describe what you must do in the head & neck stage of the cardio examination

A
  • Inspect eyes: malar flush, conjunctival pallor, xanthelasma, corneal arcus
  • Inspect mouth: central cyanosis, dental hygiene, high arched palate
  • Inspect neck: JVP (may do hepatojugular reflux to confirm)
  • Auscultate for carotid bruit
  • Carotid pulse bilaterally (volume & pulse)
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6
Q

Describe what you must do in the chest stage of your cardio examination

A
  • Inspection: scars, deformity (pectus excavatum or carinatum)
  • Palpate for pacemaker
  • Thrills & heaves
  • Palpate apex beat
  • Ausculate chest
  • Ausculate (radiation)
  • Ausculate (manoeuvres)
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7
Q

Describe what you must do in the back stage of your cardio examination

A
  • Inspect sacral oedema
  • Auscultate lung bases
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8
Q

Describe what you must do in the legs section of your cardio examination

A
  • Inspect: skin changes associated with peripheral vascular disease, vein harvest scar, pitting oedema
  • Check for pitting oedema
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9
Q

What position should you have your pt in for your cardio examination?

A

Led at 45 degrees with chest exposed

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10
Q

What 3 categories can we broadly split cardiac conditions into?

A
  • Arrhythmias
  • Heart failure
  • Ischaemia
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11
Q

What is normal capillary refill time?

A

< 3 secs

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12
Q

Why do some clinicians advocate auscultation prior to palpation of carotid?

A

Argue you should check for atherosclerotic disease prior to palpation as if disease if present palpation may produce atheromatous emboli and subsequent stroke

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13
Q

Describe how you would palpate for the apex beat

A
  • Start lateral
  • Work medially
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14
Q

Describe how you check for thrills

A
  • Fingers either side of sternum at around level of sternal angle in 2nd ICS
  • Push in quite firmly
  • Should feel pulse
  • If thrill is present will feel “vibration” as a thrill is a palpable murmur
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15
Q

Describe how you check for heaves

A
  • Place hands either side of sternum and see if feel movement with your hands
  • Place hand horizontally across chest (heel of hand around midline)

*Some people may like to check for apex beat after checking for heaves as it requires same hand positioning

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16
Q

Describe where you should auscultate on the chest

A

“Four basic points”

  • Over apex (mitral)
  • 4th ICS left (tricuspid)
  • 2nd ICS left sternal edge(pulmonary)
  • 2nd ICS right sternal edge (aortic)

*Palpate carotid pulse whilst auscultating

Auscultate for radiation?

  • ​Auscultate left axilla on expiration for mitral regurg/stenosis
  • Auscultate carotids with bell on expiration on expiration for aortic stenosis/regurg

Auscultation manoeuvres

  • Ask pt to roll to left and auscultate with bell on expiration to check for mitral stenosis
  • Ask pt to lean forwards and auscultate over tricuspid area for aortic regurg
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17
Q

State at least 3 things/appropriate next steps that you could suggest at the end of your cardio examination

A
  • ECG
  • Peripheral vascular examination
  • BP
  • Focused history
  • Observations
  • Abdominal examination (for hepatomegaly if tricuspid regug suspected and for hepatosplenomegaly if infective endocarditis suspected, for ascites if HF suspected)
  • Fundoscopy
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18
Q

Why would you like to do a fundoscopy following your cardio examination?

A

To check for:

  • Roth spots in infective endocarditis
  • Hypertensive retinopathy
  • Diabetic retinopathy
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19
Q

What does the image show?

A

Roth spots which are seen in infective endocarditis; retinal haemorrhages with white or pale centres

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20
Q

Clubbing is a non-specific sign of systemic disease; what cardiovascular diseases can it be indicative of?

A
  • Infection: endocarditis
  • Malignancy: mitral myxoma
  • Congenital: cyanotic heart disease
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21
Q

What does this image show?

What pathology can they indicate?

A
  • Splinter haemorrhages (capillary nail bed microemboli)
  • Pathology:
    • Infective endocarditis
    • Local inflammation e.g. psoriasis, lichen planus
    • Trauma
22
Q

What does this image show?

Where are these found?

Are they tender?

What pathology can they indicate?

A
  • Osler nodes
  • Red-purple, slightly raised, tender lumps often found on fingers and toes
  • Considred pathognomonic of subacute infective endocarditis
23
Q

What does this image show?

Where are they found?

Are they tender?

What pathology do they indicate?

A
  • Janeway lesions
  • Red, non-tender found commonly on palms and soles. Disappear after
24
Q

What 3 signs in hands are widely considered pathognomonic for subacute infective endocarditis?

A
  • Osler’s nodes
  • Janeway lesions
  • Roth’s spots
25
What does this image show? What pathology can it indicate?
* Tendon xanthoma *(accumulation of cholesterol/fat in tissue macrophages)* * Indicates raised serum lipids. This suggests risk of ischaemic heart disease, stroke, peripheral vascular disease as well as pancreatitis
26
What does this image show? What does in indicate?
* Radial artery harvest scar * Indicates CABG (although in UK saphenous vein is preferred)
27
What does this image show? What does it indicate?
* Xanthelasma * Hypercholesterolaemia
28
What does this image show? What does it indicate?
* Malar flush * Associated with mitral stenosis with reduced cardiac output. HOWEVER, can also be associated with rosacea, SLE, erysipelas, pulmonary hypertension due to COPD
29
What does this image show? What does it indicate?
* Corneal arcus * It is a degenerative change of peripheral cornea associated with natural aging however in those \<40yrs it may indicate raised serum lipoprotein levels
30
State some cardiac causes of central cyanosis
* Congenital * Tetralogy of fallot * Transposition of great arteries * AV septal defect * Tricuspid atresia * Eisenmenger syndrome * Acquuired congestive HF
31
What does this image show? What syndromes might it be seen in? Why is this relevant in cardio examination?
* High arched palate * May suggest **Marfan's syndrome** but it may also be associated with Ehlers-Danlos syndrome, Down syndrome or even just be a variant of normal * If it is **Marfan's syndrome** then pt is at risk of aortic root disease including aortic regurgitation, aneurysm dilation and aortic dissection
32
What does this image show?
* Dental caries/tooth decay * Risk of Streptococcus viridans associated infective endocarditis
33
State 3 possible causes of sacral oedema
* Right heart failure * Nephrotic syndrome * Liver failure
34
What does this image show? What does it indicate?
* Long saphenous vein harvest * CABG
35
Symmetrical bilateral pitting oedema is suggestve of either right heart failure, nephrotic syndrome or liver failure; give 2 possible causes of unilateral non-piting swelling and explain how to differentiate between the two
* Cellulitis: *warm, erythema* * DVT: *hard, erythema, not warm*
36
What does this image how? What disease is it seen in?
* Non-pitting, bilateral, yellowishb-brown to red-waxy papules * Graves disease
37
When commenting on pulse, what are the four facets to consider?
* Rate * Rhythm * Volume * Character *\*NOTE: you can only comment on volume and character for larger arteries*
38
How would you measure pulse if the pulse rate is regular? How would you measure pulse if the pulse rate is irregular?
* Regular: count over 30 secs and x2 * Irregular: count over 60 secs
39
A pulse can be described as... * Regularly irregular * Irregularly irregular ... what do we mean by this?
* Regularly irregular: pulse is 'abnormal' but it is consistently abnormal * Irregularly irregular: pulse is abnormal and isn't consistent
40
What is sinus arrythmia?
Sinus arrythmia is variation in rate with breathing: * Increase in rate on inspiration * Decrease in rate on expiration
41
Why do you get an increase in pulse rate on inspiration?
* Increase in pre-load to right atria * Detected by atrial pressure receptors * Activate bainbridge reflex *(increased CVP increase HR)*
42
Why do you get a decrease in pulse on expiration?
* Decrease in preload * Decrease response of atrial pressure receptors * Decrease/no bainbridge reflex
43
Where is the apex beat usually found?
Left 5th ICS, mid clavicular line
44
What does each side of the stethoscope detect?
* Diap**h**ragm: **h**igh frequency sounds * Be**ll**: **l**ow frequency sounds
45
In some patients you may hear a split S2 sound; it is physiologically normal in young patients. Explain why you may hear a split S2 sound
* S2 is due to closure of aortic & pulmonary valve * Aortic valve sometimes closes just before pulmonary valve as systemic circulation pressure is greater than pulmonary circulation pressure
46
What is pulsus paradoxus?
Opposite to sinus arrhythmia: * Heart rate slows on inspiration * Heart rate increases on expiration Pulsus paradox is defined as a drop in systolic BP of \>10mmHg on inspiration. Idea that inspiration compresses structures. Causes of pulsus paradox include pericardial disease (effusion or constrictive pericarditis) or extrinsic compression of heart (tension pneumothorax, severe asthma, COPD)
47
What does pulse volume refer to? State 4 words you can use to describe the pulse volume?
* Strength or intensity of pulse * Strong, weak or thready, bounding
48
State some situations in which you might find a bounding pulse
* Aortic regurgitation * Hyperdynamic circulation e.g. exercise, preg, anaemia, thryotoxicosis, Pagets disease
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Clinical Examinations (16 decks)

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