Cardiovascular Examination Flashcards
How do you take a radial pulse, what do you look for and how long for?
Anatomy: lateral side of wrist in anatomical position (the thumb side)
Rate, rhythm, character & volume. (tachycardia, irregularity, shock, etc.)
Time for 15 secs.
Using which two instruments is blood pressure conventionally measured?
Conventionally measured in brachial artery, using sphygmomanometer & stethoscope.
Stethoscope: forks forward, usually diaphragm & bell.
Diaphragm: higher pitched sounds than bell.
o Used for most things.
From beginning to end, how do you measure a patient’s blood pressure?
Introduction, ask permission, wash hands.
Locate radial and brachial pulses.
Radial pulse as before. Just locate, no need for rate, rhythm character.
Brachial pulse is on medial side of arm, medial to biceps tendon. Sometimes difficult to locate: may need to press hard, or pull aside the biceps tendon. Different in different people.
Put on cuff correctly: you will have to come to teaching to find out how!
Pump up cuff until radial pulse disappears, and look at pressure: this is a rough estimate of systolic pressure.
Apply cuff, pump up until radial pulse no longer palpable: this is rough estimate of systolic blood pressure
Release pressure (you don’t have to do this if you are slick).
Put on stethoscope, apply diaphragm to where you palpated brachial pulse.
Pump up to about 20mm Hg above your estimate of systolic pressure. You should hear nothing! Slowly release. Sounds should appear: systolic pressure is pressure at which sounds appear. Continue to slowly release. Sounds will disappear. Pressure at which they disappear is the diastolic.
They are called Korotkoff sounds. They are not heart sounds: they are an artificial bruit generated when the artery is compressed.
How should a patient be positioned for the cardiovascular exam?
Lying on a couch, sitting at 45 degrees, exposed down to the waist
What is jugular venous pressure? What do you need to know about it? How can it be made visible? How can it be distinguished from the arterial pulsation?
Measurement of the pressure in the right atrium, measured in cms water (actually blood!)
You have to be able to say you can see it and be able to point it out.
Raised JVPs may be invisible in usual position because the height is above where the pulsation can be seen.
Can be made visible (augmented) by:
o Changing position of patient: in healthy person this will be lowering the angle of inclination.
o Raise legs.
o Press over liver (hepatojugular reflex)
o Get them to take deep breath in and out.
Distinguish venous from arterial pulsation: waveform, position, not palpable.
Where can the jugular venous pulse be found?
May be visible in Internal jugular vein, between two heads of sternocleidomastoid. May be easier to see with head turned to side (not too far! Do not make skin too tense!)
May also be visible in subclavian veins, just above the clavicle.
External jugular may also be visible (see picture in previous slide). Their visibility differs from person to person. Also in some people they are engorged all the time, because of kinking as they go through the fascia.
JVP can stand for Jugular venous pulse and jugular venous pressure.
You estimate the Jugular venous pressure by looking at the Jugular venous pulse.
All the veins in the body below a level just above the heart (5 cms or less in a healthy person) are full of blood, and distended.
Veins above this level are not distended, though they are not empty: there is blood running down them.
It is the vertical height between this level (between the distended and non-distended veins) and the Angle of Louis which is the Jugular venous pressure.
This level, between the distended and non-distended veins, jiggles up and down every cardiac cycle (a, c, & v waves) which causes a visible pulsation, the jugular venous pulse, and makes the level visible.
When is the JVP raised?
- Fluid overload, eg injudicious iv fluids.
- Right sided cardiac failure, due to:
a. Pulmonary hypertension, commonest cause Chronic Obstructive Pulmonary Disease, commonest cause smoking.
b. Tricuspid stenosis or regurgitation, both of which produce prominent waves in JVP (a in stenosis, v in regurgitation), and pulmonary valve disease.
c. Obstruction such as tamponade
d. Diseases of cardiac muscle.
e. Secondary to L. sided heart failure
How do you examine the praecordium?
Inspect praecordium: scars, visible pulsation, abnormal chest anatomy.
Palpate praecordium for heaves & thrills: now in first year material.
Palpate for apex beat: normal position is 5th intercostal space mid-clavicular line.
What heart sounds should you listen for?
Auscultate for heart sounds and murmurs.
Heart sounds traditionally rendered as “lub-dup”. First heart sound caused by closing of tricuspid and mitral valves at the beginning of ventricular systole. Second heart sound caused by closing of pulmonary and aortic valves at the end of ventricular systole. If the members of these pairs of valves close at slightly different times you get splitting of the sound.
You hear the same heart sounds in all the areas, so why listen in different places? It is to hear murmurs from the individual valves. Murmurs are turbulent flow, usually caused by partial blockage (stenosis) or by leak backwards (regurgitation) of a valve.
Where are the best places for hearing different parts of the heart?
Mitral murmurs is 5th intercostal space mid-clavicular line: the apex. This is where the heart sounds are loudest.
Tricuspid murmurs is 4th intercostal space beside the sternum on the L (or R).
Aortic murmurs is in 2nd intercostal space just to R of sternum.
Pulmonary murmurs is in 2nd intercostal space just to L of sternum.
Palpate carotid artery while auscultating at least one of the valves (mitral best, at apex). This enables you to distinguish the first from the 2nd heart sound. Pulse is on or just after first heart sound, medial to sternocleidomastoid.
There is more to it than this, but that is for year 2!
Which pathologies might cause a heart murmur?
Mitral regurgitation, aortic stenosis, tricuspid regurgitation and pulmonary stenosis all cause a systolic murmur.
Mitral stenosis, aortic regurgitation, tricuspid stenosis and pulmonary regurgitation all cause a diastolic murmur.
Look at the cardiac cycle and work out why.
There is more to it than this, but it is all second year stuff.
What should be examined in the foot to check for cardiovascular function?
Peripheral oedema: press firmly for up to 10 seconds with your thumb, then stroke across to see if you have left a dent.
Dorsalis pedis pulse: over dorsum of foot, overlying usually 1st or 2nd metatarsal, a bit variable. Gentle touch!
Posterior tibial pulse: posterior to medial malleolus. May have to dorsiflex foot gently to stretch artery, & press firmly with palpating fingers.
What is dependent oedema? What are its causes? What other symptoms may go with this?
This is the accumulation of fluid in the tissue spaces: extracellular and extravascular.
Its distribution is affected by gravity. In an ambulant (walking) person this will be the feet and ankles, extending up the legs as it worsens. In a bedbound person it will be over the sacrum.
There are many reasons for having dependent oedema, which we might go over in the lecture, but two of them are right sided heart failure and left sided heart failure.
Right sided heart failure causes raised JVP, enlarged liver (engorged with blood) and dependent oedema.
Left sided heart failure causes pulmonary oedema, and various consequences of poor perfusion of the tissues, including retention of salt and water with dependent oedema.
