Cardiovascular System 1 Flashcards
What method is used to assess pain?
SOCRATES
What does SOCRATES stand for?
S - Site - central/left/right
O - Onset - sudden/over time/ at rest/on exertion
C - Character - dull/sharp/aching/tightness/pleuritic
R - Radiation - spread to shoulder/jaw/neck/back
A - Alleviating factors - rest/position/pain relief
T - Time - duration of symptoms
E - Exacerbating factors - exertion/position/food
S - Severity 1-10
What are the 5 main presenting symptoms in cardiovascular disease?
Chest pain
- due to inadequate oxygen supply to the heart
Dyspnoea:
- breathlessness due to inadequate oxygen supply to the heart
Oedema:
- due to failure of pumping action of the heart
Palpitations:
- due to problems with electrical conduction
Syncope/Pre-syncope:
- due to inadequate cerebral perfusion
What topics should be asked about when assessing cardiovascular risk factors?
- diabetes
- smoking
- diet and exercise
- hypertension
- hyperlipidaemia
- family history
What other questions should be asked to complete the history?
- current medication
- any allergies
- do they drive?
- occupation
- alcohol consumption
In the cardiovascular examination, what 5 steps are involved in the general inspection?
bedside:
are there any treatments or adjuncts?
check the patient is comfortable at rest
malar flush:
plum red discolouration of cheeks
inspect chest:
are there any scars or visible pulsations?
inspect legs:
are there any scars from saphenous vein harvest for CAGB / peripheral oedema / missing limbs or toes
What may malar flush suggest?
plum red discolouration of cheeks may suggest mitral stenosis
What types of treatments or adjuncts should be looked for at the bedside?
GTN spray
oxygen
medication
mobility aids
When inspecting the chest for scars or pulsations, where else should you look?
look underneath the arms for thoracotomy scars and for small scars from minimally invasive surgery
In the cardiovascular examination what should be looked for on the dorsum of the hand?
splinter haemorrhages:
reddish/brown streaks on the nail bed suggest bacterial endocarditis
finger clubbing:
this is associated with infective endocarditis and cyanotic congenital heart disease
How is finger clubbing checked for?
using Schamroth’s window
a small diamond-shaped window should be observed when a patient places the nails of their index fingers back to back
when clubbing is present, the window is lost
What are the 8 things that should be looked for when a patient puts their hand out with their palms facing upwards?
- colour
- temperature
- sweaty/clammy
- Janeway lesions
- Osler’s nodes
- tar staining
- xanthomata
- capillary refill time
What specifically does looking at the colour of the palms assess?
dusky bluish colouration is seen in cyanosis
this suggests hypoxia
What specifically does looking at the temperature of the palms assess?
cool peripheries may suggest poor cardiac output/hypovolaemia
What can sweaty/clammy hands be associated with?
acute coronary syndrome
What are Janeway lesions ?
What are they associated with?
non-tender maculopapular erythematous palm pulp lesions
suggestive of bacterial endocarditis
What are Osler’s nodes?
What are they suggestive of?
tender red nodules on finger pulps/thenar eminence
they are suggestive of infective endocarditis
What is shown by tar staining?
this is seen in smokers
smoking is a risk factor for cardiovascular disease
What is xanthomata?
What is it associated with?
raised yellow lesions often seen on the tendons of the wrist
they are caused by hyperlipidaemia
What is normal capillary refill time?
What does it suggest if it is prolonged?
normal is < 2 seconds
prolonged refill time suggests hypovolaemia
What 6 pulses should be palpated in a cardiovascular examination?
- radial pulse
- radio-radial delay
- collapsing pulse
- brachial pulse
- blood pressure
- carotid pulse
How should the radial pulse be assessed?
assess rate and rhythm
What is radio-radial delay?
How is it measured and what is it associated with?
palpate both radial pulses simultaneously
in a healthy adult, they should occur at the same time
radio-radial delay can be associated with subclavian artery stenosis or aortic dissection
What commonly causes subclavian artery stenosis?
compression of the subclavian artery by a cervical rib
What is aortic dissection?
an injury to the innermost layer of the aorta allows blood to flow between the layers of the aortic wall, forcing the layers apart
How is collapsing pulse assessed?
- ensure the patient has no shoulder pain
- palpate the radial pulse with your hand wrapped around the wrist
- raise the arm above the head briskly
- feel for a tapping impulse through the muscle bulk of the arm as blood empties from the arm very quickly in diastole, resulting in the palpable sensation
What is the name of the “palpable sensation” felt when assessing collapsing pulse?
When does it occur?
water hammer pulse
normal physiological states:
- fever
- pregnancy
cardiac lesions:
- aortic regurgitation
- patent ductus arteriosus
high output states:
- anaemia
- atrioventricular fistula
- thyrotoxicosis
What is the main condition that a collapsing pulse is associated with?
aortic regurgitation
How is brachial pulse assessed?
assess volume and character
How is blood pressure measured?
What is wild and narrow pulse pressure associated with?
it is measured and any abnormalities are noted
narrow pulse pressure is associated with aortic stenosis
wide pulse pressure is associated with aortic regurgitation
How is carotid pulse assessed?
character and volume are assessed
e.g. slow rising character in aortic stenosis
What is it advised to do before palpating the carotid pulse?
auscultate the carotid artery for a bruit before palpating
theoretically, palpation may dislodge a plaque which could lead to a stroke
How is jugular venous pressure assessed?
- ensure patient is positioned at 45o
- ask patient to turn their head away from you
- observe the neck of the JVP
- measure the JVP
How is the JVP measured?
it is located inline with the sternocleidomastoid
the JVP is measured by the number of centimetres from the sternal angle to the upper border of pulsation
What may a raised JVP suggest?
- fluid overload
- right ventricular failure
- tricuspid regurgitation
How is the hepatojugular reflex tested?
- apply pressure to the liver and observe the JVP for a rise
in healthy individuals, the rise should last no longer than 1-2 cardiac cycles
if the rise is sustained and equal to or greater than 4cm, this is a positive result
What does a positive hepatojugular reflux sign suggest?
right-sided heart failure and/or tricuspid regurgitation
In the face part of the cardiovascular examination, how are the eyes assessed?
- conjunctival pallor
- corneal arcus
- xanthelasma
How is conjunctival pallor assessed?
What does it suggest?
ask the patient to gently pull down their lower eyelid
this is a sign of anaemia
What is corneal arcus?
What is it associated with?
yellowish/grey ring surrounding the iris
this shows hypercholesterolaemia
what is xanthelasma?
What is it associated with?
yellow raised lesions around the eyes
this occurs in hypercholesterolaemia
What signs are looked for when examining the mouth?
- central cyanosis
- angular stomatitis
- high arched palate
- dental hygiene
What is central cyanosis?
bluish discolouration of the lips and/or the tongue
What is angular stomatitis?
What is it associated with?
inflammation of the corners of the mouth
this is present in iron deficiency
What is high arched palate associated with?
it is suggestive of Marfan syndrome
there is an increased risk of aortic aneurysm/dissection
Why is dental hygiene considered?
it is important if you are considering sources for infective endocarditis
What scars are looked for when inspecting the chest?
- thoractomy - minimally invasive valve surgery
- sternotomy - valve surgery
- clavicular - pacemaker
- left mid-axillary line - subcutaenous implantable cardioverter defibrillator
Upon close inspection of the chest, what other factors should be looked for?
- chest wall deformities
- visible pulsations
Where is the apex beat palpated for?
it is located at the 5th intercostal space in the midclavicular line
it is palpated with the fingers placed horizontally across the chest
What does lateral displacement of the apex beat suggest?
cardiomegaly
What is a parasternal heave?
What is it associated with?
a precordial impulse that can be palpated
parasternal heaves are present in patients with right ventricular hypertrophy
How are heaves examined for?
the heel of the hand is placed parallel to the left sternal edge with the fingers vertical
if heaves are present, you should feel the heel of the hand being lifted during systole
What is a thrill?
a palpable vibration caused by turbulent blood flow through a heart valve
the thrill is a palpable murmur
How are thrills assessed for?
thrills are assessed for across each of the heart valves in turn
the hand is placed horizontally across the chest wall, with the flats of the fingers and palm over the valve to be assessed
Where are each of the heart valves auscultated for?
mitral valve:
midclavicular line - 5th intercostal space
tricuspid valve:
lower left sternal edge - 4th or 5th intercostal space
pulmonary valve:
left sternal edge - 2nd intercostal space
aortic valve:
right sternal edge - 2nd intercostal space
What are the 6 stages involved in auscultating the four valves?
- palpate the carotid pulse to determine the first heart sound
- auscultate ‘upwards’ through the valve areas using the diaphragm of the stethoscope
- repeat auscultation across the four valves with the bell of the stethoscope
- auscultate the carotid arteries with the patient holding their breath to check radiation of an aortic stenosis murmur
- sit the patient forwards and auscultate over the aortic area during expiration to listen for the murmur of aortic regurgitation
- roll the patient onto their left side and listen over the mitral area with the bell during expiration for mitral murmurs
What is looked for when auscultating the lung bases?
- crackles may suggest pulmonary oedema secondary to left ventricular failure
- if there are no other signs of fluid overload, consider chronic lung diseases
- sacral oedema or pedal oedema may suggest right ventricular failure
What are the following sites for ausculatation for heart sounds?
