Clinical skills: cardiovascular exam Flashcards
What are the components of the cardiovascular exam?
Initial approach
General inspection
Vital signs
Upper limb (hands, wrists, elbows/arms)
Face
Neck
Chest
Lungs
Liver
Lower limb
Conclude exam
INITIAL APPROACH:
What do you need to do?
7 normal steps
Ask if they’re in any pain or discomfort before beginning the exam, and ask throughout
GENERAL INSPECTION:
What to look for?
Body build
Comfort
Congenital abnormality
Dyspnoea
Distress/pain
Debility
Hydration
What are the 3 congential abnormalities and their features?
Why is it relevant to CVD?
Turner’s syndrome: webbed neck, short
Marfan syndrome: tall, skinny, long limbs/fingers, kyphosis
Down syndrome: almond shaped eyes
As they confer increased risk to CVD
VITAL SIGNS
- What are they?
- Do you have to perform them in the APEX?
Respiratory rate
Pulse: radial pulse rate and rhythm
Blood pressure
Temperature
No - can say you’d ordinarily do them but skipping today
UPPER LIMB: HANDS
- What are you looking for?
- What are you feeling for?
LOOK
General:
- Clubbing
- Peripheral cyanosis
Lesions (pictured!)
- Janeway lesions
- Osler nodes
- Splinter haemorrhage
- Tar staining
- Xanthomata
FEEL
- Cold
- Sweat
- Capillary refill
What is endocarditis?
What is its usual cause?
How does it contribute to Janeway lesions, Osler nodes, splinter hemorrhage?
Inflammation of the inner lining of the heart’s chambers and valves.
Due to infection.
Infective emboli go from heart and are deposited in capillaries
Are Janeway lesions and Osler nodes rare?
Yes
Difference between Janeway lesiosn and Osler nodes? How to remember?
Janeway lesions: palpable but not painful.
Osler nodes: palpable and painful (O for ouch/oh that hurts)
UPPER LIMBS: WRISTS
What to do?
Is it okay to skip?
Radio-radio delay
Radio-femoral delay
Yes - if you acknowledge
UPPER LIMBS: ELBOWS AND ARMS
What to do?
Xanthomata
Brachial pulse
Xanthomata
- What is the singular name?
- What are they?
- What are they caused by?
Xanthoma
Yellow skin lesions
Fat within macrophages is deposited in the skin. Usually due to primary lipid disorders.
Xanthomata
- What is the singular name?
- What are they?
- What are they caused by?
Xanthoma
Yellow skin lesions
Fat within macrophages is deposited in the skin. Usually due to primary lipid disorders.
FACE
What 3 parts of the face do you look at?
Cheeks
Eyes
Mouth
FACE
Overall, what do you look for?
Cheeks: mitral facies
Eyes:
- Jaundice (whites)
- Pallour (conjunctiva)
- Corneal arcus/arcus senilis
- Xanthelasma
Mouth
- Lips: central cyanosis, petechiae
- Tongue: central cyanosis
- High arched palate
- Teeth and gums
FACE
What does conjunctival pallour indicate?
Xanthelasma are ________ but around the eyelids
What are petechiae and their causes?
Where should you look on the tongue for central cyanosis?
High arched palate is a sign of
Anemia
Xanthomata
Red dots, due to capillaries bursting. Due to impaired blood clotting/vascular integrity
Underneath
Marfan syndrome
FACE
Mitral facies
-What is the cause?
- What is the effect?
Severe mitral valve stenosis –> cutaneous vasodilation –> abnormal flushing of the cheeks
FACE
Corneal arcus
- What causes it?
- Is it normal in older people? What is it called?
- Is it normal in younger people? What is its cause?
- Deposits of lipids around the corneal margin, forming an arc (thus the name)
- Yes, arcus senilis
- No, lipid metabolism disorders
NECK
- What must you do before the tests?
- Make table 45 degrees
NECK
What are the tests
Internal jugular vein:
- Jugular venous pressure
- Abdominojugular reflex
Carotid artery
- Palpation (2 fingers)
- Thrills (palm of hand)
- Bruits (auscultate)
NECK
Jugular venous pressure
- What does it approximate?
- How to locate the internal jugular vein?
central venous pressure
Turn head 45 degrees to the left
Should see double flickering - if not, light and abdominojugular reflex can help
NECK
Jugular venous pressure
- How to measure
Measure vertically from the sternal angle to the top of the jugular vein.
With ruler going up, stick going across.
NECK
Jugular venous pressure
- What is normal?
- What does above and below this mean?
3-4cm is normal
Above: elevated central venous pressure
Less: dehydration, low blood volume
NECK
Abdominojugular reflex
- How to conduct?
- Normal and abnormal results?
Place hand firmly in middle part of upper abdomen, then look at internal jugular vein.
Normal: temporary jugular vein distension
Abnormal: persistent distension
NECK
- When should you palpate both carotids at once?
- Carotid bruits: when do they occur? NOrmal and abnormal findings?
- Never
- During turbulent flow. So don’t hear normally, only during narrowing
CHEST
What are the 4 parts of the chest exam?
Inspect
Palpate
Auscultate
Specialised manouevres
CHEST
Inspect: what do you inspect for?
Skin:
- Scars
- Rashes
CVS:
- Apex beat
- Abnormal pulsation
- Breathing pattern
Other deformities
- Skeletal deformities (barrel chest, funnel chest, pigeon chest)
- Sacral oedema
- Pacemaker
CHEST
Inspect: do you know what barrel chest, pigeon chest, funnel chest deformities look like?
Yes
CHEST
Palpate: what 3 things do you palpate for?
Apex beat
Heaves
Thrills
CHEST
Palpate:
- How do you palpate the apex?
- Is it palpable in all people?
- Who is it harder to palpate in?
With fingertips
Not all - 50%
Women, larger people
CHEST
Palpate: heaves
-How do you do heaves?
- Where do you palpate?
Palpate the left of the sternum with the heel (H for heaves and heel) of your hand
CHEST
Palpate: thirlls
- How do you palpate thrills?
- Where do you palpate thrills?
with palm of hand
Over aortic, pulmonary, tricuspid, mitral areas
CHEST
Palplate: where is the
- Base
- Apex
- Aortic area
- Pulmonary area
- Tricuspid area
- Mitral area
CHEST
Auscultate
- Which areas do you ausculate and with bell, diaphragm, or both?
- What additional step must you complete?
- Aortic: diaphragm only
- Pulmonary: diaphragm only
- Tricuspid: diaphragm only
- Mitral: diaphragm and bell
Comment on heart sounds S1 (lub) and S2 (dub), and additional sounds
CHEST
Special manoeuvres
What are the 5 you must perform? With bell, diaphragm, or both?
Left lateral decubitus: lie on left side. Auscultate with bell over the mitral valve.
aOrtic: get patient to breathe Out, hold breath, auscultate with diaphragm over aortic area
Pulmonary: get patient to breathe in, hold breath, auscultate with diaphragm over the pulmonary area
Tricuspid: get patient to breathe in, hold breath, auscultate with diaphragm over the tricuspid area
Leaning fOrward: get patient to lean fOrward, breathe Out, hold breath, auscultate with diaphragm over 3rd left intercostal space.
CHEST
What are some symptoms of right heart failure
Lower limb pitting odema
Sacral odema
GI tract congestion (abdominal pain, anorexia, weight loss)
Hepatomegaly
CHEST
What are some symptoms of left heart failure
Decreased CO –> cyanosis, decreased exercise tolerance
Fluid in lungs:
- Orthopnoea, paroxysmal nocturnal dyspnoea
- Cough with frothy sputum
- Cyanosis, hypoxia
LUNGS
Percussion (generally): what structures lead to dull sounds? Resonant sounds?
Solid/liquid structures
Gas structures
LUNGS
Auscultation of lungs
- What leads to normal breath sounds? Crackles? No breath sounds?
Normal lungs, pulmonary oedema, loss of lung tissue (eg. pleural effusion which pushes lungs up)
LUNGS
Complete the table
LUNGS
- What positiondoes the patient need to be at?
- What two steps need to be done (in how many places?)
Sitting up
Percuss (4 spots)
Auscultate (4 spots)
LIVER
- What position/angle should the patient be at?
- What two steps do you need to do?
- What is the goal of these steps?
Flat/0 degrees
Palpate
Percuss
Determining liver size - hepatomegaly may indicate right heart failure
LIVER
How to palpate the liver?
Get patient to breathe in and out
During out breaths, move, fingers up. Should be able to feel the curvature of the liver just under the right ribcage.
LIVER
How to percuss the liver?
What percussion sound should it be?
Go straight up then diagonally up
Dull
LOWER LIMB
What should you look for?
Achilles tendon xanthomata
Colour change/cyanosis
Clubbing of toenails
Hair loss
Janeway lesions
Osler nodes
Pitting oedema
Ulcers
Varicose veins
LOWER LIMB
What should you feel for?
Pitting odema
Temperature
Capillary refill
Pulses - femoral, popliteal, posterior tibial, dorsalis femoris
BEFORE FINISHING THE EXAM
- What two things could you consider examining?
Urinanalysis for assessment of white blood cells if endocarditis is suspected
Examine the fundi for vascular changes if appropriate
FINISHING THE EXAM
What 3 steps?
- Report findings to supervising clinician
- Ask if they have any questions
- Thank patient for their time
