CVS Flashcards
What clinical signs do you look for at the beginning of the cardio examination (5)
Give an explanation for each
Cyanosis: a bluish discolouration of the skin due to poor circulation (e.g. peripheral vasoconstriction secondary to hypovolaemia) or inadequate oxygenation of the blood (e.g. right-to-left cardiac shunting).
Shortness of breath: may indicate underlying cardiovascular (e.g. congestive heart failure, pericarditis) or respiratory disease (e.g. pneumonia, pulmonary embolism).
Pallor: a pale colour of the skin that can suggest underlying anaemia (e.g. haemorrhage, chronic disease) or poor perfusion (e.g. congestive cardiac failure). It should be noted that a healthy individual may have a pale complexion that mimics pallor, however, pathological causes should be ruled out.
Malar flush: plum-red discolouration of the cheeks associated with mitral stenosis.
Oedema: typically presents with swelling of the limbs (e.g. pedal oedema) or abdomen (i.e. ascites). There are many causes of oedema, but in the context of a cardiovascular examination OSCE station, congestive heart failure is the most likely culprit.
What peripheral equipment/ objects do you look for around the patient at the beginning of the CV exam (6)
What could each indicate?
Medical equipment: note any oxygen delivery devices, ECG leads, medications (e.g. glyceryl trinitrate spray), catheters (note volume/colour of urine) and intravenous access.
Mobility aids: items such as wheelchairs and walking aids give an indication of the patient’s current mobility status.
Pillows: patients with congestive heart failure typically suffer from orthopnoea, preventing them from being able to lie flat. As a result, they often use multiple pillows to prop themselves up.
Vital signs: charts on which vital signs are recorded will give an indication of the patient’s current clinical status and how their physiological parameters have changed over time.
Fluid balance: fluid balance charts will give an indication of the patient’s current fluid status which may be relevant if a patient appears fluid overloaded or dehydrated.
Prescriptions: prescribing charts or personal prescriptions can provide useful information about the patient’s recent medications.
What is the order of the CV exam
Introduction (WIPERQQ)
General inspection
Hands
Arms/ axillae
Face
Neck
Chest
Abdominal IPPA
Legs
Further assessment suggestions
What is the WIPERQQ for CV exam
Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Confirm the patient’s name and date of birth.
Briefly explain what the examination will involve using patient-friendly language.
Gain consent to proceed with the examination.
Adjust the head of the bed to a 45° angle.
Adequately expose the patient’s chest for the examination (offer a blanket to allow exposure only when required and if appropriate, inform patients they do not need to remove their bra). Exposure of the patient’s lower legs is also helpful to assess for peripheral oedema and signs of peripheral vascular disease.
Ask the patient if they have any pain before proceeding with the clinical examination.
What does the hand part of the CV exam entail
General observations
Finger clubbing
Signs in the hands associated with endocarditis
Palpation (Temp and Capillary refill time (CRT))
What are you looking for in the general inspection of hands part CV exam
Colour: pallor suggests poor peripheral perfusion (e.g. congestive heart failure) and cyanosis may indicate underlying hypoxaemia.
Tar staining: caused by smoking, a significant risk factor for cardiovascular disease (e.g. coronary artery disease, hypertension).
Xanthomata: raised yellow cholesterol-rich deposits that are often noted on the palm, tendons of the wrist and elbow. Xanthomata are associated with hyperlipidaemia (typically familial hypercholesterolaemia), another important risk factor for cardiovascular disease (e.g. coronary artery disease, hypertension).
Arachnodactyly (‘spider fingers’): fingers and toes are abnormally long and slender, in comparison to the palm of the hand and arch of the foot. Arachnodactyly is a feature of Marfan’s syndrome, which is associated with mitral/aortic valve prolapse and aortic dissection
What is finger clubbing
Finger clubbing involves uniform soft tissue swelling of the terminal phalanx of a digit with subsequent loss of the normal angle between the nail and the nail bed. Finger clubbing is associated with several underlying disease processes, but those most likely to appear in a cardiovascular OSCE station include congenital cyanotic heart disease, infective endocarditis and atrial myxoma (very rare).
Which hand signs indicate endocarditis
Splinter haemorrhages: a longitudinal, red-brown haemorrhage under a nail that looks like a wood splinter. Causes include local trauma, infective endocarditis, sepsis, vasculitis and psoriatic nail disease.
Janeway lesions: non-tender, haemorrhagic lesions that occur on the thenar and hypothenar eminences of the palms (and soles). Janeway lesions are typically associated with infective endocarditis.
Osler’s nodes: red-purple, slightly raised, tender lumps, often with a pale centre, typically found on the fingers or toes. They are typically associated with infective endocarditis.
What do you assess for in palpation of the hands in CV exam
Temperature
Place the dorsal aspect of your hand onto the patient’s to assess temperature:
In healthy individuals, the hands should be symmetrically warm, suggesting adequate perfusion.
Cool hands may suggest poor peripheral perfusion (e.g. congestive cardiac failure, acute coronary syndrome).
Cool and sweaty/clammy hands are typically associated with acute coronary syndrome.
Capillary refill time (CRT)
Measuring capillary refill time (CRT) in the hands is a useful way of assessing peripheral perfusion:
Apply five seconds of pressure to the distal phalanx of one of a patient’s fingers and then release.
In healthy individuals, the initial pallor of the area you compressed should return to its normal colour in less than two seconds.
A CRT that is greater than two seconds suggests poor peripheral perfusion (e.g. hypovolaemia, congestive heart failure) and the need to assess central capillary refill time.
What pulses do you assess for in the CV exam
radial
heart rate
radio-radial delay
Collapsing pulse
Brachial pulse
Blood pressure
Carotid pulse
JVP
What do you assess from the radial pulse in the CV
rate and rhythm
What does the radio-radial delay describe
Causes of radio-radial delay include? (3)
a loss of synchronicity between the radial pulse on each arm, resulting in the pulses occurring at different times.
Subclavian artery stenosis (e.g. compression by a cervical rib)
Aortic dissection
Aortic coarctation
To assess for radio-radial delay:
Palpate both radial pulses simultaneously.
In healthy individuals, the pulses should occur at the same time.
If the radial pulses are out of sync, this would be described as radio-radial delay.
What is a collapsing pulse
A collapsing pulse is a forceful pulse that rapidly increases and subsequently collapses. It is also sometimes referred to as a ‘water hammer pulse’.
How do you check for a collapsing pulse
Ask the patient if they have any pain in their right shoulder, as you will need to move it briskly as part of the assessment for a collapsing pulse (if they do, this assessment should be avoided).
Palpate the radial pulse with your right hand wrapped around the patient’s wrist.
Palpate the brachial pulse (medial to the biceps brachii tendon) with your left hand, whilst also supporting the patient’s elbow.
Raise the patient’s arm above their head briskly.
Palpate for a collapsing pulse: As blood rapidly empties from the arm in diastole, you should be able to feel a tapping impulse through the muscle bulk of the arm. This is caused by the sudden retraction of the column of blood within the arm during diastole.
Give the Causes of a collapsing pulse
Normal physiological states (e.g. fever, pregnancy)
Cardiac lesions (e.g. aortic regurgitation, patent ductus arteriosus)
High output states (e.g. anaemia, arteriovenous fistula, thyrotoxicosis)
How do you assess the brachial pulse?
What are you assessing for?
Palpate the brachial pulse in their right arm, assessing volume and character:
- Support the patient’s right forearm with your left hand.
- Position the patient so that their upper arm is abducted, their elbow is partially flexed and their forearm is externally rotated.
- With your right hand, palpate medial to the biceps brachii tendon and lateral to the medial epicondyle of the humerus. Deeper palpation is required (compared to radial pulse palpation) due to the location of the brachial artery
What are the types of pulse character
Normal
Slow-rising (associated with aortic stenosis)
Bounding (associated with aortic regurgitation as well as CO2 retention)
Thready (associated with intravascular hypovolaemia in conditions such as sepsis)
What are the types of pulse character
Normal
Slow-rising (associated with aortic stenosis)
Bounding (associated with aortic regurgitation as well as CO2 retention)
Thready (associated with intravascular hypovolaemia in conditions such as sepsis)
What blood pressure abnormalities should you be aware of in a CVS examination (4)
Hypertension: blood pressure of greater than or equal to 140/90 mmHg if under 80 years old or greater than or equal to 150/90 mmHg if you’re over 80 years old.
Hypotension: blood pressure of less than 90/60 mmHg.
Narrow pulse pressure: less than 25 mmHg of difference between the systolic and diastolic blood pressure. Causes include aortic stenosis, congestive heart failure and cardiac tamponade.
Wide pulse pressure: more than 100 mmHg of difference between systolic and diastolic blood pressure. Causes include aortic regurgitation and aortic dissection.
Difference between arms: more than 20 mmHg difference in blood pressure between each arm is abnormal and may suggest aortic dissection.
Where is the carotid pulse located
The carotid pulse can be located between the larynx and the anterior border of the sternocleidomastoid muscle.
What do you do with the carotid artery in the CVS examination
Auscultate
Palpate
Prior to palpating the carotid artery, you need to auscultate the vessel to rule out the presence of a bruit. The presence of a bruit suggests underlying carotid stenosis, making palpation of the vessel potentially dangerous due to the risk of dislodging a carotid plaque and causing an ischaemic stroke.
How do you auscultate the carotid pulse
Place the diaphragm of your stethoscope between the larynx and the anterior border of the sternocleidomastoid muscle over the carotid pulse and ask the patient to take a deep breath and then hold it whilst you listen.
Be aware that at this point in the examination, the presence of a ‘carotid bruit’ may, in fact, be a radiating cardiac murmur (e.g. aortic stenosis).
Then Palpate the carotid pulse
What does the presence of a bruit in the carotid artery suggest
underlying carotid stenosis, making palpation of the vessel potentially dangerous due to the risk of dislodging a carotid plaque and causing an ischaemic stroke.
How do you palpate the carotid pulse
- Ensure the patient is positioned safely on the bed, as there is a risk of inducing reflex bradycardia when palpating the carotid artery (potentially causing a syncopal episode).
- Gently place your fingers between the larynx and the anterior border of the sternocleidomastoid muscle to locate the carotid pulse.
- Assess the character (e.g. slow-rising, thready) and volume of the pulse.
What does the JVP measure
Why is this
Jugular venous pressure (JVP) provides an indirect measure of central venous pressure. This is possible because the internal jugular vein (IJV) connects to the right atrium without any intervening valves, resulting in a continuous column of blood.
he presence of this continuous column of blood means that changes in right atrial pressure are reflected in the IJV (e.g. raised right atrial pressure results in distension of the IJV).
Where does the IJV run
The IJV runs between the medial end of the clavicle and the ear lobe, under the medial aspect of the sternocleidomastoid, making it difficult to visualise (its double waveform pulsation is, however, sometimes visible due to transmission through the sternocleidomastoid muscle).
