Clinical 11: Cardiovascular examination Flashcards
How should the patient be positioned for the cardiovascular examination?
Expose the chest, keep bra on
Ask patient to lie at 45 degrees.
What is part of the general inspection of surrounding and upper limb during the cardiovascular examination?
Consider surroundings - oxygen mask, walking aids etc
Patient - pale, cyanosed, breathless, obses, cachectic.
Hands - pallor, cyanosis, staining, clubbing, splinter haemorrhages, temp, cap refill, xanthotamata, osler nodes and janeway lesions,
Wrist - radial pulse rate, rhythm, character (at periph and central), radial-radial delay, radial-femoral delay, raise wrist vertically to check for collapsing pulse
Blood pressure
Arms - xanthomata, track marks of IV drug use
What is jugular venous pressure?
Measured as the vertical heigh (cm) of the jugular venous pulsation above the sternal angle
Best seen when patient at 45 degrees
Not normally visible or is very slight under the supraclavicular fossa.
Direct measurement of right atrial pressure as there are no valves in this part of the system.
How can we make the JVP easier to see?
Lie that patient down or press gently on the right upper quadrant of the abdomen (hepatojugular reflux means pressure is transmitted directly to the RA)
What makes up the Precordial (chest) examination?
I - chest shape, scars, abnormal movements aka visible apex beat
Palpate - midlines for thrills, left later for thrills, locate apex beat
Percuss - no
Ausculate - locate systole by palpating the carotid or supraclavicular puse as you listen. And heart valves, listen over axilla and carotid pulse for mutmus.
How should you ausculate for the different heart valves?
Aortic valve - 2nd right ICS
Pulmonary valve - 2nd left ICD
Tricuspid valve - lest left sternal edge 4th ICD
Mitrial valve - apex, 5th ICS mcl.
What are the two main heart sounds?
S1 - lub - closing of mitral and tricuspid vales
S2 - dub - closing of semilunar valves. (aortic and pulmonary)
Why does S2 sound split during inspiration?
In inspiration, S2 splits into two sounds, diaphragm lowers causing negative pressure in chest increases venous return to the right atrium, so more blood in the right ventricle, this increases the time the ventricle needs to eject all the blood so deleted closing of the valve
What is the S3 heart sound?
Produced by tautening of papillar muscles at end of rapid diastolic filling
Rapid ventricular filling
Occurs in early diastole
Louder at apex - cadence as Kentuck when in gallop rhythm
Physiological in children nd young adults
Pathological causes include cardiac failure, artic regurgitation, mitral regurgitation, PDA
What is the fourth heart sound?
When contraction of atrial forces blood into non compliant ventricles.
Late diastole
Cadence as Tennessee in gallop rhythm
Left V S4 - systemic hypertension, aortic stenosis, Acute MI/MR, advanced age
Right V S4 - pulmonary stenosis, pulmonary hypertension.
What should you examine on the the back for the cardiovascular examination?
Examine the back of the chest for scars
Palpate for sacral oedema
Percusss lung bases if effusion suspected
Ausculate for crackles of pulmonary odema at bases
What should you examine in the abdomen during the cardiovascular exam?
Inspect for ascities
Enlarged liver
Palpate for AAA
Consider listening for bruits
What should you examine for in the legs during the cardiovascular examination?
Peripheral vascular disease - pallor, pulselness, cold etc
Skin changes related to venous insufficiency - hair distribution, hyperpigmentation etc
Dorsal pedis pulses
Peripheral Oedema
What vein is used to measure jugular venous pressure?
Right internal jugular vein
What should you look for in the face and neck during the cardiovascular examination?
Eyes - conjucitive palloe, corneal arcus, central cyanosis, malar flush
Mouth - tongue colour, mucous membranes,,
Neck - carotid pulse, jugular venous pressure, listen for carotid bruits (ask to hold breath).
