Clinical Skills - Cardiovascular Flashcards
Where do you feel for a radial pulse? What features do you look for (and why)? How long do you time it for?
Lateral side of wrist in anatomical position (thumb side)
Rate, rhythm, character & volume. (tachycardia, irregularity, shock, etc.)
Time for 15 secs
Where is blood pressure conventionally measured? What instruments are used to do this, and how are they used?
Measured in brachial artery
Sphygmomanometer and stethoscope used
Stethoscope: forks forward, usually diaphragm (higher pitched sounds - used for most things) and bell
What is the first step for any examination?
Introduction, ask permission, wash hands
What two pulses are required for a blood pressure examination?
Radial and brachial pulses.
Radial pulse located as normal - just locate it, no need for rate, rhythm character, etc.
Brachial pulse is on medial side of arm, medial to biceps tendon - sometimes difficult to locate so may need to press hard, or pull aside the biceps tendon, but different people vary.
What are the steps to take blood pressure once the cuff has been put on?
- Pump up cuff until radial pulse disappears and look at pressure: this is a rough estimate of systolic pressure
- Release pressure (you don’t have to do this if you are slick)
- Put on stethoscope, apply diaphragm to where you palpated brachial pulse.
- Pump up to about 20mm Hg above your estimate of systolic pressure. You should hear nothing! Slowly release. Sounds should appear: systolic pressure is pressure at which sounds appear. Continue to slowly release. Sounds will disappear. Pressure at which they disappear is the diastolic. They are called Korotkoff sounds. They are not heart sounds: they are an artificial bruit generated when the artery is compressed.
How should a patient be positioned to take jugular venous pressure?
Lying on couch, sitting up at 45 degrees, exposed down to the waist
What do you need to know about the JVP? What are the problems with this, and how can these be resolved? How can you distinguish venous from arterial pulsation?
You have to be able to say you can see it and be able to point it out.
Raised JVPs may be invisible in usual position because the height is above where the pulsation can be seen.
Can be made visible (augmented) by:
o Changing position of patient: in healthy person this will be lowering the angle of inclination.
o Raise legs.
o Press over liver (hepatojugular reflex)
o Get them to take deep breath in and out.
Distinguish venous from arterial pulsation: waveform, position, not palpable.
Where can we see the jugular venous pulse?
May be visible in Internal jugular vein, between two heads of sternocleidomastoid. May be easier to see with head turned to side (not too far! Do not make skin too tense!)
May also be visible in subclavian veins, just above the clavicle.
External jugular may also be visible (see picture in previous slide). Their visibility differs from person to person. Also in some people they are engorged all the time, because of kinking as they go through the fascia.
What can JVP stand for?
Jugular venous pulse or jugular venous pressure
How do you estimate the jugular venous pressure?
By looking at the jugular venous pulse
Which veins are distended, and which are not? How does this relate to jugular venous pressure?
All the veins in the body below a level just above the heart (5 cms or less in a healthy person) are full of blood, and distended.
Veins above this level are not distended, though they are not empty: there is blood running down them.
It is the vertical height between this level (between the distended and non-distended veins) and the Angle of Louis which is the Jugular venous pressure.
This level, between the distended and non-distended veins, jiggles up and down every cardiac cycle (a, c, & v waves) which causes a visible pulsation, the jugular venous pulse, and makes the level visible.
When is the JVP raised?
- Fluid overload, eg injudicious iv fluids.
- Right sided cardiac failure, due to:
a. Pulmonary hypertension, commonest cause Chronic Obstructive Pulmonary Disease, commonest cause smoking.
b. Tricuspid stenosis or regurgitation, both of which produce prominent waves in JVP (a in stenosis, v in regurgitation), and pulmonary valve disease.
c. Obstruction such as tamponade
d. Diseases of cardiac muscle.
e. Secondary to L. sided heart failure
How should you examine the praecordium (portion of body over heart and lower chest)?
Inspect praecordium: scars, visible pulsation, abnormal chest anatomy.
Palpate praecordium for heaves & thrills: now in first year material.
Palpate for apex beat: normal position is 5th intercostal space mid-clavicular line
What sounds should be auscultated for? What do they normally sound like, and why? Why do you listen in different places?
Auscultate for heart sounds and murmurs.
Heart sounds traditionally rendered as “lub-dup”. First heart sound caused by closing of tricuspid and mitral valves at the beginning of ventricular systole. Second heart sound caused by closing of pulmonary and aortic valves at the end of ventricular systole. If the members of these pairs of valves close at slightly different times you get splitting of the sound.
You hear the same heart sounds in all the areas, so why listen in different places? It is to hear murmurs from the individual valves. Murmurs are turbulent flow, usually caused by partial blockage (stenosis) or by leak backwards (regurgitation) of a valve.
What is the place to hear a mitral murmur?
5th intercostal space mid-clavicular line: the apex
This is where heart sounds are loudest
