Cardiovascular PE Flashcards
Your next patient is a 45 year old man who has come to the ED complaining of acute onset chest pain. His chest pain started 30 minutes ago and is radiating to the tip of his left shoulder. He is also sweating and has nausea. He is feeling better now and his vitals are stable. +/- Pain is better on leaning forward. (Gives idea case is pericarditis)
Task:
Explain physical examination to your medical student with anatomical landmarks
Chest Pain Examination
I. Hemodynamic Stability
- Even if vitals are stable, because the patient is having chest pain, it would be helpful to say: “Before I start examination, I would like to move the patient to the resuscitation cubicle, attach the cardiac monitor and constantly monitor his vital signs”
II. Introduction (WIPE)
- Introduce yourself
- Explain steps: I would like to take a look at the chest, feel the chest, and listen to the chest
- Get consent: if you’re happy to proceed with the examination, I would like you to remove your shirt for proper exposure
- I will position him in a semi-sitting position at a 45 degree angle
- I would offer a dose of painkillers if the patient would want to take some
- I’ll then wash my hands before I start examination
III. General Appearance
- Respiratory distress and cyanosis
- Check level of consciousness: if patient’s alert or drowsy
- Distress due to pain
- Cachexia (severe heart failure)
- BMI and waist circumference
IV. Hands, Pulse, Blood Pressure
- Inspect hands for nicotine/tar stains suggestive of chronic smoking
- Check for xanthomas, the yellow raised plaques on the palms which are chronic fat infiltrations
- Check the capillary refill time - do this by pressing on the nails and see the time it takes to get the color back to normal, normally this is less than 2 seconds
- Check for clubbing - disappearance of the diamond-shaped space when the nails are facing each other
- Check for signs of infective endocarditis
○ Splinter hemorrhages which are linear discoloration along the long axis of the nails
○ Osler nodes and Janeway lesions which are hemorrhages, dermatological signs
- Palpate the radial pulse
○ Count the rate in 60 seconds
○ Check the rhythm for irregularities
○ Check for radioradio and radiofemoral delay to rule out aortic dissection. Do this by feeling both radial pulses at the same time and check for any asymmetry, and feel the radial pulse and femoral pulse at the same time and also check for asymmetry
- Check the Blood Pressure
○ Palpatory - get the systolic pressure by attaching the cuff, inflate the cuff while palpating the radial pulse. The moment I don’t feel the pulse, gently deflate the cuff until the pulse is felt again. This is the systolic pressure
○ Auscultatory - completely deflate the cuff then inflate higher than the systolic BP we got earlier, then gently deflate the cuff until you hear the 1st Korotkoff sound, this is the systolic BP, then continue deflating until the sound disappears, this is the 5th Korotkoff sound which is the diastolic BP.
○ Check for pulsus paradoxus to rule out pericarditis. This is a fall in BP on inspiration of more than 10mm with a paradoxical rise in PR. You do this by inflating the cuff above systolic BP, gently deflate until you hear the 1st Korotkoff sound intermittently then check the BP. Continue deflating until you hear the 1st Korotkoff sound continuously then check the BP. The difference between the 2 measurements should be less than 10mmHg. It is abnormal if it is more than 10mmHg.
V. Face
- Check the eyes
○ for arcus senilis, a silverish ring around the cornea (associated with increased risk of CVD)
○ Xanthelasma, yellowish patches around the eye which are also chronic fat infiltrations
○ Conjunctival pallor - ask the patient to look up, pull down on the eyelid and check the color of the palpebral conjunctiva (Anemia - stable angina)
○ Jaundice - ask the patient to look up and look for yellowing of the sclera
- Ask the patient to open the mouth and check the lips and tongue for central cyanosis
VI. Neck
- JVP
○ This is where the 45 degree angle position is very important to check the JVP, indicative of the right atrial pressure (in heart failure, this is elevated)
○ Ask the patient to look to the left side to check the right JVP. This is preferable as the right JVP is directly above the right atrium
○ If the JVP is elevated, check the vertical height from the sternum, normally this is less than 3cm
- Carotid bruit - with the bell of the stethoscope over the side of the trachea, listen for bruits
- Check for tracheal displacement by placing your 2nd and 3rd fingers over the sternal notch then push back and upwards to check if the trachea is in midline to look for tracheal shift which we can see in tension pneumothorax
VII. Core Cardiovascular PE
A. Inspection
- Check for chest wall deformities such as pectus carinatum, pectus excavatum, kyphoscolosis
- CABG scars
- Rash of Herpes Zoster
- Visible Apex beat which is suggestive of cardiomegaly (heart failure)
B. Palpation
- Check for a displaced apex beat - palpate for the apex beat at the left lower side of the chest, if palpable, locate it by counting from the 2nd ICS. Normally it is at the 5th ICS left MCL (cardiomegaly / tension pneumothorax / increased pressure in mediastinum)
- Feel for parasternal heave - use the heel of your hand and palpate the left sternal edge for a rumbling sensation or impulse
- At the location of the 4 valves, using the flat of your hand, feel for palpable thrills
§ Mitral - 5th ICS, left MCL
§ Tricuspid - 4th/5th ICS, left lower sternal border
§ Pulmonic - 2nd ICS, left sternal border
§ Aortic - 2nd ICS, right sternal border
C. Auscultation
- At the location of the 4 valves I explained earlier, listen for the normal heart sounds the S1 and S2, any added sounds the S3 and S4 or gallop rhythm, murmurs, and pericardial friction rub (pericarditis)
§ Mitral - start with the bell, then diaphragm (use both bell and diaphragm because the frequency of some murmurs is different in the mitral valve region)
§ Tricuspid, pulmonic, aortic - listen with the diaphragm
VIII. Respiratory Exam
A. Inspection
- Check for symmetry of chest wall movement (upper lobes - look from above at the level of the clavicles; lower lobes - look from behind)
B. Palpation
- Check for chest expansion - place your hands on the sides of the chest with the thumbs lifted off and ask the patient to breathe in and out and feel for the symmetric expansion of the chest
C. Auscultation
- Absent breathing sounds (pneumothorax)
IX. Musculoskeletal Exam
- Palpate for tenderness suggestive of costochondritis, or with trauma, fractures
X. Upper Abdomen
- Palpate the upper abdomen, superficial and deep palpation for tenderness, liver size for hepatomegaly
XI. Lower limb Exam
- Check for swelling, if present check if pitting or non-pitting
- Check for signs of DVT like calf tenderness, size difference, which can cause pulmonary embolism
Your next patient is a 47 year old man who is admitted in the ED due to shortness of breath. His shortness of breath is worse on lying down. He is a known case of hypertension and a past history of CABG 12 months ago. His temperature is 36.3.
Task:
Explain your physical examination to the medical student with anatomical landmarks
Heart Failure Examination
Keypoints:
- JVP, Hepatojugular reflux (Heart Failure)
- Visible / Displaced Apex beat
- Gallop rhythm on auscultation
- Bibasal crepitations (Pulmonary Edema)
- Hepatomegaly
- Lower limb edema
I. Hemodynamic Stability - Before we start the examination, I would like to move this patient to the resuscitation cubicle, attach the cardiac monitor and continuously monitor his vital signs II. Introduction - Introduce yourself - Explain steps: I would look at his chest, feel his chest, and listen to his chest with my stethoscope - Gain consent - Ask patient to remove his shirt for proper exposure - Position the patient at a semi-sitting position at 45 degrees - I will wash my hands before I begin the examination III. Flagging - My provisional diagnosis in this case is heart failure or congestive heart failure. The reason I am thinking about this is the patient has orthopnea and major cardiovascular risk factors. - I will be doing a CVS examination looking for a raised JVP, gallop rhythm, displaced apex beat, bibasal crepitation, hepatomegaly and edema IV. General Appearance - Respiratory distress (accessory muscle use, paradoxical movement of the abdomen on inspiration, tracheal tug, noisy breathing, if able to speak in sentences), cyanosis - Level of consciousness - if alert or drowsy - Cachexia (severe heart failure) - BMI and waist circumference V. Vital Signs - Because complaint is shortness of breath, check RR in 1 minute and O2 saturation VI. Hands - Nails ○ Clubbing ○ Cyanosis ○ Nicotine stains ○ Xanthomas - Pulse ○ Assess radial pulse on the lateral part of the wrist, count the rate, assess the rhythm - Blood pressure ○ Put the cuff on the arm, inflate while palpating the radial pulse, once I don't feel the pulse anymore, slowly deflate and when the pulse is felt again, that will be the systolic BP ○ I will then place the stethoscope under the cuff and inflate above the systolic BP. I will slowly deflate, the 1st sound I hear is the systolic BP, the last sound I hear before it disappears is the diastolic BP VII. Face - Eyes ○ Jaundice (Hepatic congestion due to heart failure) ○ Xanthelasma ○ Arcus senilis - Central cyanosis - open the mouth and check for bluish discoloration on the lips and tongue VIII. Neck - JVP ○ Position patient at 45 degrees. Expect a raised JVP in heart failure ○ Hepatojugular reflux. Expect a sustained rise in JVP in heart failure - Carotid bruit ○ Place the bell on the side of the trachea and auscultate for bruits - Tracheal shift ○ Forefingers in the suprasternal notch, check if trachea is in midline IX. Core Cardiovascular Examination A. Inspection - Visible Apex beat. Expect to see in heart failure with cardiomegaly - Chest wall deformities - Visible scars - CABG B. Palpation - Displaced Apex beat - place my hand on the left lower side of the chest. If I feel the apex beat, I will locate it. Normally, it is at the 5th ICS MCL. But in the case of heart failure and cardiomegaly, it is displaced - Parasternal heave - Palpable thrills - 4 valvular areas C. Auscultation - 4 valvular areas § Mitral valve - bell then diaphragm § Tricuspid, Pulmonic, Aortic § Listen for the normal S1 and S2 § Listen for murmurs § Listen for added sounds, specifically gallop rhythm X. Respiratory Exam A. Inspection - Check for symmetric chest wall movements B. Palpation - Check for chest expansion. I am looking for symmetric thumb movements of at least 5 cm C. Percussion - Strike firmly on the middle phalanx of 3rd finger on both sides (important because heart failure can lead to pleural effusion which can give dullness on percussion) D. Auscultation - Auscultate the apexes with the bell - Auscultate the other levels with the diaphragm - Listen for bibasal crepitations / crackles XI. Abdominal Exam - Check for hepatomegaly - Start with deep palpation the RLQ moving to the RUQ to check for the liver edge XII. Lower limb Exam - Check for edema - if unilateral or bilateral, upto which level, pitting or non-pitting
Acute Rheumatic Fever Examination
Case: 5 year old has presented to the ED unwell. His mother gives a history of sore throat 3 weeks ago. His BP 80/50, PR 100, RR 12, Temp 38.5.
Chest x-ray: Cardiomegaly
Tasks:
1. Explain your physical examination to the medical student with anatomical landmarks
2. You will be given PE findings at 7 minutes
3. Explain your diagnosis
RED CASE!
Infective Endocarditis signs (splinter hemorrhages, osler’s nodes, janeway lesions)
Pulse volume (dehydration), Pulse rhythm
FULL joint exam (Arthritis - ARF)
Subcutaneous nodules (ARF)
Chorea (ARF)
Rash of erythema marginatum (ARF)
Fundoscopy - Roth’s spots (Infective endocarditis)
Throat exam (exudates on tonsils, petechiae in palate and buccal mucosa - infective endocarditis)
Raised JVP + Hepatojugular reflux (cardiomegaly - sign of cardiac decompensation)
Visible and Displaced apex beat (cardiomegaly)
Parasternal heave (cardiomegaly)
Gallop rhythm (Valvulitis in Carditis)
pericardial friction rub (Carditis)
Murmurs - mitral and aortic maneuvers (Valvulitis)
Bibasal crepitations (Cardiac decompensation)
Hepatomegaly (Cardiac decompensation)
Lower limb edema (Cardiac decompentation)
Diagnosis: ARF leading to Carditis and decompensated heart failure
Pediatrics Murmur Examination
Case: Your next patient is a 5 year old child who had otitis media 2 weeks ago (some stems: had a cold) and was treated with azithromycin. He had a murmur on examination but you failed to examine the child as he was crying. Today they have come back for a follow-up and the child is cooperative for examination.
Tasks:
1. Explain the steps to the mother
2. Explain examination to the medical student stating what you are looking for
3. After 6 minutes for the first 2 tasks, you will be given PE findings
4. Explain diagnosis
RED CASE!
Pallor (Anemia)
Infective endocarditis signs (splinter hemorrhages, osler nodes, janeway lesions)
JVP, Carotid bruits (part of murmur exam as aortic stenosis radiates to the carotids)
Clubbing (Congenital heart disease)
Murmur characteristics: area of greatest intensity, timing of murmurs (systolic, diastolic, pansystolic), intensity or loudness grade 1 to 6, radiation, character
Murmur maneuvers: mitral, valsalva, aortic, isometric exercise, standing to squatting, respiration
Peripheral Vascular Disease Examination
Case: Your next patient is a 50 year old man who presented to you complaining of pain in his legs. The pain is worse on walking uphill and better with rest. His pain free walking distance has been decreasing. He is a known case of hypertension, a chronic smoker and is on beta blockers.
Task:
1. Explain your physical examination to the medical student.
Inspection - arterial (atrophic skin changes, hair loss, pallor, ulcers, evidence of amputation/scars)
Inspection - venous (varicose veins, hyperpigmentation, lipodermatosclerosis)
Pulses - femoral, popliteal, dorsalis pedis, posterior tibialis
Special test: Buerger’s test, Bruits, Ankle Brachial test
Dizziness Examination
Your next patient is a 60 year old man who has presented to your general practice complaining of dizziness and lightheadedness after changing his position.
Task:
1. Explain cardiovascular examination to your medical student
2. Explain how to check the blood pressure in detail using the automated device
Postural hypotension (lying - standing or sitting - standing)
Taking proper BP measurement guidelines
DVT Examination
Features of DVT (size difference)
Respiratory exam (pulmonary emboli)
Risk factors for DVT
Ulcers Examination
Your next patient has presented to your general practice for a painful ulcer on his leg (most likely chronic ulcer)
Task:
1. Explain your physical examination to the medical student
Inspection (TIME)
Arterial vs Venous Ulcers
Palpation - Pulses
Special tests: Buerger’s, bruits, ABI
Differentials: PVD, neuropathic, malignancy,
Varicose Veins Examination
Flagging: 2 major groups in venous system. SFJ anatomy
Inspection: venous insufficiency findings
Special tests: cough test, tap test, Trendelenburg test, Perthes test, Bruits, Beurger’s test
Abdominal Aortic Aneurysm
Hand: CRT, Pulse
Abdominal Examination:
Inspection: Ecchymosis
Palpation: How to palpate for AAA
Auscultation: aortic and renal artery bruits
Quick vascular and cardio PE
