Cardiovascular system exam and anatomy Flashcards
What are the margins needed to mark the surface outline of the heart?
3rd CC
6th CC
2nd Inter costal space
5th intercostal space at Mid clavicular line
How do you find and palpate the apex beat of the heart
Use 4 finger excluding thumb and line them across 4th, 5th and 6th ICS and move them from right of the patient to left
Where can the apex beat be found in adults and children
Adult: 5th ICS along mid clavicular line.
Females- beneath the breast along its lower border a sbreats extend from 2nd to 6th ICS
Children: slightly higher on the 5th rib
What does a shift in the apex beat laterally or inferiorly mean?
Normally cardiomegaly OR Occasionally chest wall deformity, mediastinal shift or underlying pleural or lung disease
what is a thrill and how can you examine it?
it is a hyperkinetic and more sustained beat.
You can palpate it by placing the flat of hand at the apex and upper precordium
A palpable vibration will be felt under your hands
What is a “thrill” a characteristic of? When may it occur?
Volume overload
May occur in heart failure and mitral or aortic regurgitation
N.B aortic regurgitation sound here
What may result in a “heave”
Describe how you would palpate for it?
Hypertrophy of left ventricle- this heave may extend out towards axillary
Heaves are palpated by placing you hand vertically on the left of the sternum, a heave will lift the heel of you hand with each beat.
Where can the apex beat be palpable in dextrocardia?
Right side of the sternum
In what patients may apex beat not be palpable?
Thick chest wall, emphysema, pericardial effusion and shock
What are the heart valves you need to auscultate and where can you find them? IN ORDER
Mitral - left 5th ICS at mid clavicular line
Tricuspid- left 5th ICS near sternum
Pulmonary - left 2nd or 3rd ICS near sternum
Aortic - right 2nd ICS near sternum
What produces the first large sound (lub) of the heart?
The closing of the tricuspid and mitral valves
What produces the 2nd quieter sound (dub) of the heart
The closing of the pulmonary and aortic valve
What are the order in which the valves are arranged?
During palpation of arterial pulses what can you evaluate?
Pulse rate- right radial pulse
Rhythm- right radial pulse; abnormal during atrial fibrillation or ectopic beats
Character and volume- right carotid
Symmetry- brachial, femoral, radial of both hands
Radio-femoral delay
What are the sites of palpating arterial pulses in upper limb
Radial pulse Ulnar pulse Axillary pulse Cubital fossa pulse Brachial artery pulse Subclavian pulse
What are the sites of palpating arterial pulses in head and neck
Carotid artery pulse Superficial temporal
What is the most common site for venepuncture? How do you discern it?
Median cubittal vein
Encircle patient middle hand and ask them to close and open fist quickly.
Outline the procedure for palpating the apex beat
You should use your palm and 4 fingers of your right hand to palpate. You should align your fingers along the left 4th, 5th and 6th intercostal spaces.
You should start palpation from the left lateral chest wall (near the mid-axillary line), and move to the anterior chest wall (towards the mid-clavicular line).
If you find the apex beat difficult to palpate in your colleague, a brisk “jogging on the spot” by your colleague (for 1 minute) may increase the heart rate and strength of the heart beat that enables easier palpation.
In females, the examiner’s hand should be laid beneath the breast along its lower border (a mitral valvotomy scar could be missed if the apex beat is not visualised).
What are the Abnormalities of the apex beat and explain what it connotes
Shift laterally and inferiorly- means left ventricular hypertrophy or cardiomegaly
Any shift due to:
- Chest wall deformity
- mediastinal shift
- underlying pleural or lung disease
Shift to the right side of the body- dextrocardia
Not palpabel ins ome pts due to?
Summarise the cardio exam we need to know for the CPA
Position and Exposure
- Patient lying down at 45 degrees
- Patient adequately exposed from the waist upwards
Inspection
- General inspection- look for scars, lateral thoractomy, ICDs
Palpation
- Palpation of the radial artery including rate and rhythm
- Palpation of the ulnar artery
- Palpation of the brachial artery
- Palpation of the common carotid artery
- Palpation of the apex beat
- Palpation of heaves
- Palpation of thrills
Percussion
- N/a
Auscultation
- Auscultation of the aortic valve
- Auscultation of the pulmonary valve
- Auscultation of the tricuspid valve
- Auscultation of the mitral valve
what causes this heart sound and where do you auscultate for it?
Aortic stenosis-
ausculate at carotid artery
it is a early crescendo decresndo murmur
what causes this heart sound and where do you auscultate for it?
Aortic regurgitation
Ausculatate at aortic valve with pt leaniong forward
it is an early diastolic murmur
where do you auscultate to ascertain a mitral valve stenosis or mitral valve regurgitation murmur
Mitral valve sound position when pts lie on the left side
what does this echocardiogram show and give relevant symptoms or signs
Calcific aortic stenosis
Signs:
- Echogenic and immobile aortic valcve leeaflet
- Turbulent flow and reduced opening of valve
- Ejection systolic murmur radiating to carotid
- Slow risingg pulse felt on carotid and narrow pulse pressure
what are all the clinical manifestation of valve disease
Mild- moderate aortic valve- asymptomatic
Ejection systolic murmur with chestpain, SOB and dizziness/syncope shows severe aortic stenosis
Decompensated heart failure
- Exertional heart failure with
- SOB (bi-basal crepitations) and
- pitting oedema
- and other signs
if you suspect valve disease, what are the relevant Ixs you should order
Echocardiogram- gold standard as it allows evaluation of flow and pressure across valve and asseses overall cardiac function
CXR and ECG are very useful before getting to echo
Cardiac catherisation- diagnostic test for CHD.
Cardiac Angiography
what is the ankle brachial pulse index and how is it significant in Peripheral artery disease?
ABPI is a ratio of the brachial systolic BP.
Can be measured using a sphygmomanometer and a hand held dopple device
in peripheral artery disease the ABPI is very low (0.4) in affected leg. The lower the number the more severe the disease
Can be normal in unaffected leg
if pts has symptoms and exams suggestive of peripheral artery disease, what are the Ixs and in what order?
Give advantage and disadvantage of each
CT angiography - very accesible in hospital
DS angiography- gold standard but had to do as it requires an interventional radiologist
USS Doppler- look for blood flow and hence can see stenosis. Very accesible for primary care
MRI angio-
if someone has intermittent claudication due to peripheral artery disease, what is very important to discern
Claudication distance- can tell severity
what are the main symptoms suggestive of aortic dissection?
what BP readings can occur
Sudden severe chest pain (could be in abdo). it can be sharp or ripping or tearing pain
Radiate to the back
May faint
There could be very huge discrepancy between right and left brachial BP depending on site of aortic dissection
Describe the microanatomy of aortic dissection
A tear in the tunica intima of aorta
Hence lead to creation of false lumen.
Lead to ischaemia
if a pt is unstable (fainted) but you have collected collateral Hx with symptoms suggested of aortic dissection, what is the first Ixs afrter stabilising pt
Urgent Coronal CT
N.B: can see line in aorta which shows dissection
What are the clinical manifestation of the types of aortic dissection in terms of pain
Type A (both type 1 and 2)
- Anterior chest pain - 70%
- Posterior back pain - 30%
Type B (3)
- Back pain (64%) then followed by chest (60%) and /orabdominal pain (40%)
There are several sites of aortic dissection, what does it mean for the symptoms depending on site
Can present with stroke, neuro symptoms if less blood goes to carotids
End organ ischaemia (could be bowel or liver)
Contrast the 3 Stanford classification of aortic dissection?
Type A- (1)
- Affects aortic arch and body
- most common
- Can have neuro symptoms
Tye A (2)
- Affects only arch
- Can have neuro symptoms
Type B (3)
- Common in older people
- Arch not affected
- Caused by High BP
- No need for surgery - treat conservativey with BBs
- No neuro symptoms
what is the surgical treatment for Aortic dissectio?
In surgical treatment, the area of the aorta with the intimal tear is usually resected and replaced with a Dacron graft.
Discern this heart sound
Mitral stenosis
Mid-diastolic murmur
Discern this heart sound
Mitral regurgitation
Pan-sytolic murmur
