Cardiovascular Examination Flashcards

1
Q

Before exam

A
  • Wash hands
  • Introduce yourself
  • Consent
  • Comfortable position at 45 degrees and head supported
  • Inspect at side of bed
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2
Q

What should bedside inspection include?

A

-Build
-Colour
-Demeanour
=Relaxed?
=Appear breathless/ in pain?
=Oxygen/ IV/ ECG monitoring electrodes

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3
Q

What do we look for in the hands?

A
  • Tobacco staining
  • Tendon xanthomata
  • Pallor
  • Signs of endocarditis
  • Clubbing
  • Peripheral perfusion
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4
Q

What is finger clubbing?

A

Deformity of nail and soft tissues of terminal phalanx

-Associated with cardiovascular disease such as infective endocarditis and cyanotic congenital heart disease

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5
Q

What are the three main features of finger clubbing?

A

-Increased fluctuance of nail
-Loss of nail bed angle
-Increasing curvature of nail
=Advanced= drumstick
=Borderline clubbing unnecessary

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6
Q

How is nail bed fluctuance assessed?

A
  • Rest patient’s finger on your thumbs

- Gently palpate from side to side at the base of the nail bed

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7
Q

What is capillary refill time?

A

-Indicator of peripheral perfusion
=Pressure applied to blanch the nail for 5 seconds
=Release
=Normal colour should return in 2 seconds if perfusion is good

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8
Q

What are tendon xanthomata?

A

Cholesterol laden deposits present on extensor tendon of hands
-Diagnostic of familial hypercholesterolemia

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9
Q

What is pallor?

A
  • Diagnostic of anaemia

- Best assessed in hands by looking at the palmar creases

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10
Q

What are splinter haemrrhages?

A

-Linear lesions visible in nail bed
=Can signify endocarditis
=More common cause mechanical trauma

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11
Q

What are Osler’s nodes?

A

-Tender nodes at the fingertips

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12
Q

What are Janeway lesions?

A

Flat purple lesions on palms

-Uncommon signs of endocarditis

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13
Q

What pulse is checked at the wrist?

A

Radial pulse at lateral side of wrist using three fingers

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14
Q

What do we measure in taking the radial pulse?

A

-Rate
-Rhythm
-Synchrony
=Count number of pulses in 15 seconds x4
=Regular or irregular?
=Pulse volume better indicated at brachial pulse
=Compare both radial pulses simultaneously

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15
Q

What is a collapsing pulse a sign of?

A

Aortic regurgitation

=Pulse volume appears exaggerated when arm raised vertically as gravity dependent fall in diastolic pressure

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16
Q

What happens if there is a difference in timing or volume between radial pulses?

A
  • Blood pressure in both arms should be assessed
  • Unequal pulses often signs of peripheral vascular disease, can reflect important pathology such as aortic coarctation or dissection
17
Q

Why is the brachial pulse assessed?

A
  • Pulse volume and character

* Support patient’s arm with left hand, cup right fingers around elbow, thumb to pulse medial to biceps tendon

18
Q

What happens after we take radial and brachial pulses?

A

Blood pressure

19
Q

What do we examine in the neck?

A

*Relax head on pillow and turn slightly to the left
-Examine carotid arterial pulse
=Pulse volume and character
-Examine jugular venous pulse
=waveform and height of pressure, reflects pressure in right atrium
=First wave - pre-systolic caused by atrial contraction
=Second wave- systolic, in time with arterial pulse

20
Q

Why do we lower the bed?

A
  • JVP in health not visible at 45 degrees, so lowering my bring it into view
  • Help differentiate JVP from carotid arterial pulse which does not vary with posture
21
Q

What other manoeuvres may help take a JVP?

A
  • Abdominojugular test performed by placing hand over patients abdomen and pressing firmly to increase intra-abdominal pressure= increases venous return to RHS heart
  • Light pressure above clavicle will obliterate venous pulsation but not arterial pulsation
22
Q

How is pressure estimated?

A
  • Indirect measure of right atrial or central venous pressure
  • Expressed as vertical height (cm) from sternal angle to highest point of jugular waveform
  • Level normally less than 3cm so not always visible in healthy people
23
Q

What do we examine in the face?

A
  • Xanthelasma (around eyes and corneal arcus)
  • Corneal arcus
  • Jaundice
  • Pallor
  • Central cyanosis, reflected by blueish discolouration of mucus membranes
24
Q

How do we examine the chest/ precordium?

A
  • Shape (deformity)
  • Scars (surgery)
  • Pulsations
  • Apex beat
  • Thrills and heaves
  • Auscultation
25
Q

What scars are we looking for?

A
  • Sternotomy (midline over sternum)
  • Under clavicles (defibrillator scar)
  • In line with ribs (valvotomy scar, intercostal)
26
Q

Where do we palpate?

A

5th intercostal space= apex beat in midclavicular line

  • Roll onto left side if needed
  • Female- breast lifted up
  • Left ventricular hypertrophy= forceful apex beat
  • Displaced apex beat= left ventricular dilatation
27
Q

How do we palpate for a parasternal heave?

A
  • Sign of right ventricular enlargement
  • Heel of hand firmly over lower sternum
  • Heave present= hand moves up and down in time with heart
28
Q

What is a Thrill?

A
  • Vibration that can be felt with fingers
  • Occurs in association with cardiac murmur
  • Checked at apex over sternum and at aortic and pulmonary areas below clavicles
29
Q

What are the 4 main sites for auscultation?

A

-Aortic area
-Pulmonary area
-Lower left sternal border
-Apex
=Mitral, cuspid and aortic valves

30
Q

What is the bell of a stethoscope used for?

A

Low-pitched sounds like murmur of mitral stenosis

31
Q

What is the diaphragm of a stethoscope used for?

A

High-pitched sounds like the murmur of aortic stenosis

32
Q

What does the timings of the heart sounds tell us?

A

-Determines whether murmurs are systolic or diastolic

33
Q

When does the heart sound occur?

A

-First just before carotid upstroke
-Character
=Splitting, added sounds like third

34
Q

What are the other sites to hear a radiated systolic murmur?

A

-Axillar (mitral incompetence)
-Base of neck (murmur of aortic stenosis)
=Diaphragm
=Brewery= turbulence in artery

35
Q

What are the two manoeuvres that are used to accentuate the diastolic murmurs of mitral stenosis and aortic regurgitation?

A
  • Bell at apex (mitral stenosis) with patient on left side and breath held on expiration
  • Patient sitting forward using diaphragm side= aortic regurgitation at lower left sternal border with breath held on expiration
36
Q

How do we listen for pulmonary oedema?

A
  • Listen to lung bases on back when patient is still sat up

- Press of sacrum for pitting oedema

37
Q

What else can be looked at in an abdominal exam?

A
  • Distention due to ascites= sign of right sided cardiac failure
  • Right sided cardiac failure= hepatomegaly
  • Chronic endocarditis= splenomegaly
  • Pulsatile liver= severe tricuspid regurgitation