Cardiovascular Examination Flashcards
Before exam
- Wash hands
- Introduce yourself
- Consent
- Comfortable position at 45 degrees and head supported
- Inspect at side of bed
What should bedside inspection include?
-Build
-Colour
-Demeanour
=Relaxed?
=Appear breathless/ in pain?
=Oxygen/ IV/ ECG monitoring electrodes
What do we look for in the hands?
- Tobacco staining
- Tendon xanthomata
- Pallor
- Signs of endocarditis
- Clubbing
- Peripheral perfusion
What is finger clubbing?
Deformity of nail and soft tissues of terminal phalanx
-Associated with cardiovascular disease such as infective endocarditis and cyanotic congenital heart disease
What are the three main features of finger clubbing?
-Increased fluctuance of nail
-Loss of nail bed angle
-Increasing curvature of nail
=Advanced= drumstick
=Borderline clubbing unnecessary
How is nail bed fluctuance assessed?
- Rest patient’s finger on your thumbs
- Gently palpate from side to side at the base of the nail bed
What is capillary refill time?
-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
What are tendon xanthomata?
Cholesterol laden deposits present on extensor tendon of hands
-Diagnostic of familial hypercholesterolemia
What is pallor?
- Diagnostic of anaemia
- Best assessed in hands by looking at the palmar creases
What are splinter haemrrhages?
-Linear lesions visible in nail bed
=Can signify endocarditis
=More common cause mechanical trauma
What are Osler’s nodes?
-Tender nodes at the fingertips
What are Janeway lesions?
Flat purple lesions on palms
-Uncommon signs of endocarditis
What pulse is checked at the wrist?
Radial pulse at lateral side of wrist using three fingers
What do we measure in taking the radial pulse?
-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
What is a collapsing pulse a sign of?
Aortic regurgitation
=Pulse volume appears exaggerated when arm raised vertically as gravity dependent fall in diastolic pressure
What happens if there is a difference in timing or volume between radial pulses?
- 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
Why is the brachial pulse assessed?
- Pulse volume and character
* Support patient’s arm with left hand, cup right fingers around elbow, thumb to pulse medial to biceps tendon
What happens after we take radial and brachial pulses?
Blood pressure
What do we examine in the neck?
*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
Why do we lower the bed?
- 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
What other manoeuvres may help take a JVP?
- 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
How is pressure estimated?
- 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
What do we examine in the face?
- Xanthelasma (around eyes and corneal arcus)
- Corneal arcus
- Jaundice
- Pallor
- Central cyanosis, reflected by blueish discolouration of mucus membranes
How do we examine the chest/ precordium?
- Shape (deformity)
- Scars (surgery)
- Pulsations
- Apex beat
- Thrills and heaves
- Auscultation
