Cardiovascular Examination Flashcards
To remember the stages of a cardiology examination and learn the underlying pathology
What are you looking out for when ‘inspecting from the end of the bed’?
GTN spray ECG leads Pacemaker Oxygen Pillows (HF or pulmonary oedema) Catheter bags IV fluids Cigarettes
What signs on the patient should be observed from general inspections
Anaemia Visible pulsations SOB Pallor Oedema Cyanosis Malar rash Oedema Nutritional state Syndromic features (Down’s, Marfan’s) Scars- Mitral valvotomy, Thoracotomy
What would shortness of breath be indicative of?
Cardiac problems: Congestive heart failure Pericarditis Respiratory problems: Infection (pneumonia) Pulmonary embolism
What would cyanosis be suggestive of? (Name 2 things)
Hypovolemia Inadequate oxygenation (right to left shifting)
What is pallor indicative of?
Poor perfusion -> congestive heart failure Anaemia -> haemorrhage, chronic disease
What would pillows, to prop up the patient during sleep, suggest?
Orthopnoea (congestive heart failure)
What are you looking for when inspecting the dorsum of the hands and what are these signs indicative of?
Splinter haemorrhages- micro emboli suggestive of infective endocarditis Peripheral cyanosis- suggestive of heart failure or congenital heart failure
What are you looking for when inspecting the palmar side of the hands?
Tar staining Xanthomata Osler’s nodes (node); Janeway lesions (non tender on thenar and hypothenar areas) Clubbing
What is xanthomata and what does it suggest?
Yellowish cholesterol deposits under the skin around tendons, indicative of hyperlipidemia/familial hypercholestremia
How long should capillary refill time be?
<3 seconds
Describe the characteristics, pathophysiology and pain associated with Osler’s nodes
Tender, red palpable lesions on fingers caused by immune complex deposition in infective endocarditis
Describe the characteristics, pathophysiology and pain associated with Janeway lesions
Non-tender, red lesions caused by deposition of septic emboli and microabscess formation in infective endocarditis
What cardiovascular diseases could clubbing of the fingers be suggestive of?
Atrial myxoma Congential cyanotic heart disease Endocarditis (subacute)
Give three signs of infective endocarditis
Clubbing Poor dentition Splinter haemorrhages
What is CO2 retention flap and how do you test for it?
Ask patient to cock hands up and hold in place. Must complete for 30 seconds to say not present. Hypercapnic patients experience tremors
What is atrial myxoma?
A non-cancerous tumour in one of the atria of the heart
What should you look for when assessing the radial pulse?
Rate- Brady<60bpm and tacky >100bpm Character - bounding? radio-radial delay? collapsing pulse? Volume (thready - sepsis, hypovolemia)
What may cause bradycardia?
Heart block Heart rhythms
What may cause tachycardia?
Supraventricular arrhthmias Sepsis Phaeochromocytoma Anxiety
State two irregular rhythms
irregularly irregular- Atrial Fibrillation regularly irregular - Heart block
State reasons for radio-radial delay
Stenosis of subclavian artery Aortic coarctation
How do you assess for a collapsing pulse and what does it suggest?
Feel radial pulse Feel brachial pulse Don’t do it if they have pain in their arm Large volume “collapsing”pulse indicates Aortic regurgitation
What is a “Waterhammer” pulse and how do you test for it?
Aortic insufficiency leads to increased end-diastolic volume. By Starling’s law this increases cardiac output leading to a bounding pulse. There is a rapid reduction in BP during diastole due to incompetent aortic valve.
What might a difference of more than 20mmHg in BP between two arms suggest?
Aortic dissection above the level of the left subclavian Atherosclerosis
Narrow pulse pressure (between systolic and diastolic)
<25mmHg difference may suggest Aortic stenosis or congestive heart failure
What may cause a wide pulse pressure?
Aortic regurgitation Aortic dissection
What does a radio-femoral delay suggest?
distal coarctation
What are the effects of Turners syndrome on the cardiovascular system?
45 X Cooarctation of aorta Bicuspid instead of tricuspid valve
What heart conditions are associated with Marfan’s syndrome?
Aortic aneurysm mitral valve prolapse Cardial myopathy Lots of heart problems Cataracts Subluxation
What is JVP a measure of?
Indirect measure of right atrial and central venous pressure because the IJV connects to the right atrium without a valve
How do you measure for JVP?
- Position patient at 45 degrees looking left for muscle relaxation 2. Look between the two heads of SCM muscle 3. Look for a rapid double/ triple waveform with each heart beat and identify highest point 4. Try pressing on abdomen at liver and see if JVP comes up- hepatojugular reflex 5. Using an imaginary horizontal line from this point, measure vertically from sternal angle which is about 5cm above the right atrium 6. JVP < 4cm in normal healthy adult
What would a raised JVP be caused by?
Right heart failure Tricuspid valvular disease Fluid overload
What are the features of a normal JVP waveform
a wave: Caused by atrial contraction c point: slight AV-ring bulge during ventricular contractionx descent: atrial relaxation v wave: tricuspid closure and atrial filling y descent: ventricular filling as tricuspid valve opens
What should you look for in the face and what are they sign of?
Conjunctival pallor– Anaemia Xanthelasma- Hyperlipidaemia Corneal arcus -Hyperlipidaemia Malar flush –Mitral stenosis High arched palate –Marfan’s syndrome Dental caries –Infective endocarditis Central cyanosis –Hypoxia
What can malar flush be indicative of?
Mitral stenosis SLE
What is mitral stenosis?
Narrowing of the mitral valve (LA to LV)
What kinds of scars would you find on the chest (and axilla) and what would they suggest?
Median sternotomy i. Coronary artery bypass graft –Look for graft harvesting scar on medial leg ii. Valve replacementii. Left inframammary i. Mitral valvotomy Infraclavicular i. Pacemaker
Where do you palpate for the apex beat
5th intercostal space at mid-clavicular line. Start at the axillary line and migrate to the sternum.
Reasons for apex beat displacement
Ventricular hypertrophy
What is a heave and how do you feel for it?
Pulsation felt through chest wall indicative of ventricular hypertrophy. Fell with a flat hand just on the left of the sternum
What is a thrill and how do you feel for it?
Palpable murmur- felt due to turbulent blood flow through valves Felt using flat hand (perpendicular to sternum) in valve areas.
Where should you listen for valve sounds?
- 2ndintercostal space at right sternal edge–Aortic area 2. 2ndintercostal space at left sternal edge–Pulmonary area 3. 5thintercostal space at left sternal edge–Tricuspid area 4. Apex–Mitral area All Prostitues Take Money
What are the murmurs heard during systole?
Mitral stenosis Aortic regurgitation
Acronym for remembering the heart murmurs heard during systole
MRS ASS Mitral Regurgitation Systole Aortic Stenosis Systole
How should you manouvre the patient to accentuate murmurs?
Roll onto left side to accentuate mitral stenosis; use bell (low frequency) to auscultate in expiration at apex Auscultate in a leaning forward position to accentuate Aortic regurgitation (loudest in the 3-4thintercostal space at the left sternal edge in expiration) Auscultate in inspiration to accentuate right sided murmurs (Tricuspid and Pulmonary) and in expiration to accentuate left sided murmurs (Mitral and Aortic) MRS ASS- Mitral Regurg
Aortic stenosis
radiates to carotides peripheral pulses often weak and delayed ‘cresendo and descendo)
Mitral stenosis
‘loud 51 type sound) early diastolic flap rumbling diastolic murmur rheumatic heart disease complciations: pulmonary HTN ??
Aortic regurgitation
Flowing heard at axilla
Where would you find oedema that may suggest cardiovascular issues?
Pitting oedema at ankles and sacrum (right HF)
What should you look for on assessment of the carotid pulse
Volume Character Slow rising –Aortic stenosis Pulsus bisferens –Aortic stenosis and regurgitation Jerky –Hypertrophic cardiomyopathy
What should you assess on the patients back?
Percuss and auscultate the lung bases i.Left ventricular failure ii.Pleural effusion
What are some appropriate follow up examinations?
i. Urinanalysis –haematuria in infective endocarditis ii.Temperature chart –Infective endocarditis iii.Examine the fundi 1.Roth spots –Infective endocarditis 2.Hypertensive changes 3.Diabetic changes iv. Examine the abdomen for AAA (abdominal aortic aneurysm)
