CLIN SKILLS: CVS Exam Flashcards
1
Q
general CVS exam process
A
- introduction
- inspection of hands and wrists
- inspection of face (eyes, cheeks, mouth)
- neck (JVP, carotid)
- precordium inspection
- palpation
- auscultation
- lower limb inspection + palpation
2
Q
CVS inspection
A
- general appearance
- hands/wrists/arms
- pulse
- face (eyes, cheeks, mouth)
- neck (carotid + JVP)
3
Q
Marfan’s syndrome
- what is it
- signs
- what are you at risk of
A
- genetic connective tissue disorder
- Sx: high-arched palate, funnel/pigeon chest
- risk of aortic dissection and regurgitation
4
Q
Turner’s syndrome
A
- genetic disease in females only (45, X(O))
- aortic coarctation
5
Q
main DVT Sx
A
- sharp pain on dorsiflexion
- ankle or calf oedema (usually unilateral)
6
Q
what to look for in hands for CVS inspection
A
- temperature
- Osler’s nodes
- Janeway lesions
- splinter haemorrhages
- peripheral cyanosis
- tar staining
- surgical scars
- tendon xanthomata
- clubbing of fingers
- capillary refill
7
Q
signs of infective endocarditis
A
- splinter haemorrhages
- Osler’s nodes: painful red nodules on pads of fingers
- Janeway lesions (laneway = fun = not painful): non-painful red flat lesions on palms
8
Q
how to do pulse
A
- rate (feel for 30 secs and then x2 - count for 1 min if irregular)
- rhythm (regular/irregular) and strength
- radio-radial delay (thoracic outlet syndrome, subclavian artery stenosis)
- radio-femoral delay: aortic coarctation or dissection
9
Q
what to look for in eyes
A
- conjunctival pallor: ask Pt to look up and lift lower eyelid down, should be pink (if white = anaemia)
- jaundice: ask Pt to look down and lift upper eyelid up, check for yellowing (RHF can cause liver congestion = post-hepatic jaundice)
- arcus senilis: grey rings around iris (old age/hypercholesterolaemia)
- xanthelasma = yellow deposits around eyelids = hypercholesterolaemia
10
Q
what to look for in cheeks
A
- mitral flush: rosy flushed cheeks w/ dilated capillaries (mitral stenosis)
11
Q
what to look for in mouth
A
- central cyanosis: check lips and tongue using torch + tongue depressor
- high-arched palate - Marfan’s syndrome
- petechiae - on the inside of the lips (small red spots that look like eczema)
- teeth: overall appearance
12
Q
what do you check for in the carotid arteries?
A
- palpate carotid arteries (one at a time), comment on rhythm and strength
- auscultate for bruits (take a deep breath in and hold it)
- DONT press on carotid sinus (top of thyroid cartilage) b/c may result in reflex bradycardia and hypotension
13
Q
how to examine JVP
A
- recline Pt to 45˚ and turn head to the L, JVP is just above clavicle, near clavicle + SCM. If cant find: say you would lie them down further than 45 deg to elevate it
- measure: one ruler perpendicular to sternal angle and another pointing at the JVP (should be <3cm)
- hepatojugular reflux: press over liver (R side of abdomen, just under ribs), JVP should rise then fall. +ve test if JVP stays elevated the whole time.
14
Q
why do we prefer the right IJV for JVP?
A
b/c in line w/ SVC and R atrium
15
Q
why do we need 45 degrees for JVP?
A
(bigger angle = can’t see JVP, smaller angle = would appear elevated
16
Q
what could an elevated JVP indicate?
A
- R heart failure
- pulmonary HTN
- tricuspid regurgitation
17
Q
JVP waveform: label each component
A
- A: tricuspid valve is already open, RA contracts to actively push blood into RV
- X descent: RA relaxation
- C: tricuspid valve Closure (invisible O/E) + RV systole
- X’ descent: passive RA filling
- V: RA filling from SVC/IVC (tricuspid valve closed)
- Y: tricuspid valve opens, blood PASSIVELY moves from RA > RV
18
Q
precordium inspection
A
- breathing rate and pattern
- skin: scars (clavicle, sternum, lateral chest) and rashes
- pacemaker
- chest abnormalities
19
Q
3 types of chest deformities
A
- barrel chest (anteroposterior diameter of the thorax is more than the transverse diameter)
- pigeon chest (anterior sternal protrusion - childhood respiratory disease, rickets)
- funnel chest (depression on inferior end of sternum)
20
Q
palpation of precordium
A
- palpate apex beat w/ fingertips and locate position (normal = L 5th intercostal space, mid-clavicular line) - can ask Pt to lie on L side (tell them if you need to move breast: use the back of one hand to move breast up)
- describe type: normal, heaving (fingers will move), tapping, double impulse
- palpate for thrills (palpable murmurs) with a flat hand over the 4 areas
- palpate for heaves with the heel of the hand over the 4 areas
21
Q
what does a heaving, tapping or double impulse apex beat indicate?
A
- heaving: L ventricular hypertrophy - fingers will move
- tapping: mitral stenosis
- double impulse: hypertrophic cardiomyopathy - S4/double heart sound
22
Q
4 auscultation areas
A
- mitral: 5th L midclavicular
- tricuspid: 4th L sternal border
- pulmonary: 2nd L sternal border
- aortic: 2nd R sternal border
23
Q
what does S1 and S2 mean?
A
- S1: closure of AV valves
- S2: closure of SL valves
24
Q
4 rounds of auscultation
A
- 1st round: all 4 sites @ 45˚ - mitral (both diaphragm and bell) and all others (diaphragm only). comment on: S1 and S2, murmurs, additional/abnormal sounds
- 2nd round: lying on L side w/ bell for mitral
- 3rd round: sitting fully upright. Ask Pt to breathe in and hold their breath TWO TIMES for R sided heart murmurs (tricuspid, pulmonary). Ask Pt to breathe out and hold their breath TWO TIMES for L sided heart murmurs (mitral, aortic)
- 4th round: leaning forward, breathe out and hold their breath, listen over Erb’s point (3rd left intercostal space, parasternal) and aortic area
25
why do we get the Pt to lean forward to listen over Era's point?
- reduces thickness of lung = louder murmur to better hear aortic regurg
26
inspection of lower limb (CVS)
- absence of hair
- skin discolouration
- splinter haemorrhages
- osler’s nodes (pads of toes)
- janeway lesions (palms)
- varicose veins
- cyanosis
- clubbing of toes
- achilles tendon xanthomata
27
palpation of lower limb (CVS)
- temperature
- sacral oedema - ask them to lean forward, feel for pitting oedema
- pitting oedema in distal shaft of tibia
- capillary refill
