Clinical Skills - CV

Question 1

What is the normal range of systolic blood pressure? (1)

Answer 1

90-140mmHg

Question 2

What is the normal range of diastolic blood pressure? (1)

Answer 2

60-90mmHg

Question 3

What is the normal range for pulse? (1)

Answer 3

60-100bpm

Question 4

What is the reference range for temperature? (1)

Answer 4

36-37.5°C

Question 5

What is the reference range for respiratory rate? (1)

Answer 5

12-20 bpm

Question 6

What are the normal ranges for oxygen saturation? (2)

Answer 6

94-98%
89-92% (COPD)

Question 7

How is BP measured? (2)

Answer 7

Measured in mmHg.
Give as 2 figures: Systolic and Diastolic pressure.

Question 8

What is systolic pressure? (1)

Answer 8

Pressure when your heart pushes blood out.

Question 9

What is diastolic pressure? (1)

Answer 9

Pressure when your heart rests between beats.

Question 10

What systolic and diastolic range is considered as hypertensive? (2)

Answer 10

Systolic >140mmHg (either/or) Diastolic > 90mmHg

Question 11

What systolic and diastolic range is considered as hypotensive? (2)

Answer 11

Systolic <90mmHg (either/or)
Diastolic < 60mmHg

Question 12

How do you measure a cuff? (2)

Answer 12

Cuff bladder length = 80% of arm’s circumference.
Width of Bladder = 40% of arm’s circumference.

Question 13

Describe Phase 1’s Korotkoff’s sounds. (2)

Answer 13

Faint clear tapping sounds which gradually increases in intensity.

Systolic pressure heard for 2 consecutive beats. (Intra-arterial pressure)

Question 14

Describe Phase 2’s Korotkoff’s sounds. (1)

Answer 14

Softening sounds becomes swishing.

Question 15

Describe Phase 3’s Korotkoff’s sounds. (1)

Answer 15

Return of sharper sounds which becomes crisper but never fully regain intensity of phase 1 sounds.

Question 16

Describe Phase 4’s Korotkoff’s sounds. (1)

Answer 16

Distinct, abrupt, muffling sounds becomes soft and blowing.

Question 17

Describe Phase 5’s Korotkoff’s sounds. (1)

Answer 17

All sounds disappear completely.

Question 18

Explain the process of measuring a patient’s blood pressure. (14)

Answer 18

Ensure px is rested and comfortable. Consider caffeine, exercise and stress factors. Ensure seated if possible with legs uncrossed.

Check equipment + identify which arm is used.

Support px’s arm at about the level of the heart.

Select appropriate cuff size (80-40 rule)

Apply cuff to upper arm (2-3cm above brachial artery pulse)

Palpate brachial/radial artery and measure (30 sec x2 = regular, 60 sec = irregular) - record pulse rate.

Inflate cuff until pulse is impalpable.

Inflate cuff 10-20mmHg further.

Deflate cuff until pulse returns (rough estimate of systolic)

Allow rest for 15-30 seconds before reinflating cuff in step 7.

Place stethoscope over brachial artery (Diaphragm)

Deflate cuff slowly (2-3mmHg/sec) until regular sounds are heard - systolic pressure (Korotkoff’s sound phase 1 - note gauge)

Continue to deflate cuff until sounds disappear completely - diastolic pressure (Korotkoff’s sound phase 5 - note gauge). Record reading.

Deflate cuff completely + thank px.

Question 19

Outline the relevant parts of a cardiovascular examination. (10)
Task 2 in OSCE!!

Answer 19

General Inspection
Set of Basic observations (inc ECG)
Inspection of the Hands
Palpation of the Pulses
Inspection of the Face
Inspection of the JVP
Inspection of the Chest
Palpation of the Chest
Auscultation of the Heart
Additional Checks

Question 20

Perform a general inspection. (6)

Answer 20

Environment
General Health of the Patient
Obvious Pain
Colour (Pale - anaemia, flushed - raised BP/infection, cyanosed - hypoxia)
Weight (over/under)
Conditions associated with CVD (Marfans/Down Syndrome)

Question 21

Perform a hands inspection. (6)

Answer 21

Temp. (infection/perfusion)
Capillary refill (perfusion)
Splinter Haemorrhage (Infective endocarditis)
Clubbing (chronic disease/ IE)
Pale Palmar Creases (Anaemia)
Tar Staining (Smoking)

Question 22

Perform a pulse inspection. (6)

Answer 22

Radial Pulses
Brachial Pulses
Carotid Pulses (not together)
Dorsalid pedal
Posterior Tibial

(comparing both left to right for rate, rhythm and volume for 30 seconds x 2 = regular, 60 sec = irregular)

Question 23

Perform the inspection of the face. (6)

Answer 23

Xanthelasma
Corneal Arcus
Jaundice
Pale Conjunctiva
Mouth + Teeth for Infection
Central Cyanosis

Question 24

Perform the inspection of the JVP. (3)

Answer 24

Px lays at 45° angle.
Head positioned left lateral.
Identify JVP - if raised around +4cm (HF)

Question 25

Perform the inspection of the chest. (7)

Answer 25

Expose chest.
Inspect anterior (front) and lateral (side) of chest for:
Deformities,
Pacemakers,
Scars (Trauma/prev. surgery)
Bruising/trauma (chest wall injury)
Visible heaves (heart enlargement)

Question 26

Perform a chest palpation. (10)

Answer 26

Palpate for chest wall tenderness.

Apex beat (5th intercostal space midclavicular):
- Prominent beat (Left ventricular hypertrophy)
- Displaced laterally (pneumothorax)
- Difficulty detection (obesity/hyperinflation)

Heaves:
- Enlarged heart (R. ventricular hypertrophy)
- Felt on the left parasternal region.

Thrills: Palpable murmur
- Palpate across 4 heart valves
- Suggest palpable murmurs.

Question 27

Perform a heart auscultation. (8)

Answer 27

Listen with the diaphragm + bell.

Diaphragm - higher pitched sounds
Bell - lower pitched sounds

S1 = closure of the tricuspid + mitral valves
S2 = closure of the aortic + pulmonary valves
S3 + S4 = add. sounds

S1 & S2 = normal heart sounds (‘lub-dub’)
S3 & S4 = abnormal heart sounds (shouldn’t be hearing this e.g. splitting, murmurs an add. heart sounds)

Question 28

Name the 4 heart valves and locate each one. (4)

Answer 28

Aorta - 2nd intercostal space right sternal edge.
Pulmonary - 2nd intercostal space left sternal edge.
Tricuspid - between 4th + 5th intercostal space
Mitral - 5th intercostal space midclavicular line.

Question 29

Perform additional checks. (10)

Answer 29

Auscultate base of lungs (posterior)
Palpate for sacral oedema (HF)
Inspect both lower legs:
For DVT:
- Leg Swelling
- Palpate calves for tenderness DVT
- Increased temp. of leg
- Inflammation
For HF:
- Oedema in foot and ankle