CVS Flashcards
General inspection
Cyanosis: a bluish discolouration of the skin due to poor circulation
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).
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). c
Congestive heart failure
Conjunctival pallor: suggestive of underlying anaemia. Ask the patient to gently pull down their lower eyelid to allow you to inspect the conjunctiva.
Thoracic scars – Indicate cardiac surgery
Checking Hands/temp
Tar staining – caused by smoking, big RF for CVD
Xanthomata – Yellow cholesterol-rich deposits often on the palm and tendons of the wrist or elbow. May also appear around the eyes. High cholesterol RF for CVD
Finger clubbing – uniform soft tissue swelling resulting in a loss of normal angle between nail and nail bed.
Schamroth window test - Ask Pt to place nails of their index fingers back-to-back, in a healthy individual there should be a diamond shaped window you can see light through. Sign of endocarditis.
Temperature – Place dorsal aspect of hand onto Pts hands. Symmetrically walm indicates healthy perfusion. Cool hands suggest congestive cardiac failure. Cool but clammy suggests acute coronary syndrome.
CRT – Capillary refill time, Apply pressure to distal end of Pts finger for 5 seconds. If CRT takes more than 2 secs, suggests poor peripheral perfusion and congestive heart failure. Would then need to assess central capillary refill time.
What makes up a CVS exam
Checking pulses and getting HR
JVP
Auscultation
BP
Checking pulses
Assess the rate, the rhythm and the character of the: Radial
Carotid
Femoral
Tibial
Dorsalis pedis
Radial - radial delay * Aortic dissection
Radial femoral delay *aortic coarctation
Establish the rate in bpm by counting the number of beats over a 15 second period and multiplying by four.
Collapsing pulse - 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.
Meaning of HR:
Rate
Rhythm
Character
Rate - measure of the frequency of the heart’s contractions, bpm.
Rhythm - the regularity of the heartbeats. Normally, the heart beats in a regular pattern, with an evenly spaced time interval between each beat. However, sometimes the heart may beat irregularly or abnormally, which is referred to as an arrhythmia.
Determined as regular, regularly irregular, or irregularly irregular
Character - how strong, forceful, or full the pulse is.
Pulse characteristics include contour and amplitude of the pulse. Contour refers to the shape of the pressure wave; normally, it has a steep upward stroke and a smooth downward stroke. For example, a steep and robust upstroke is present in aortic regurgitation.
The amplitude of the pulse is the highest point of the upstroke. It can vary in congestive heart failure
Normal and abnormal HR
Normal resting HR should be between 60 and 100 beats per minute, need to decide if it is regular, irregularly irregular, or regularly irregular.
<60bpm = Bradycardia, healthy athletic individuals, side effect of medication or hypothyroidism, myocarditis
>100bpm = Tachycardia possible anxiety, hyperthyroidism
HR patho
A ‘slow-rising’ pulse has a delayed up-stroke and occurs in aortic stenosis.
A pulse is described as ‘bounding’ if it has an increased up-stroke and down-stroke. This may be a sign of CO2 retention.
A ‘jerky’ pulse is characteristic of hypertrophic cardiomyopathy, but this is unlikely to be detected peripherally.
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.
JVP
Position the patient in a semi-recumbent position (at 45°).
- Ask the patient to turn their head slightly to the left.
- Inspect for evidence of the IJV, running between the medial end of the clavicle and the ear lobe, under the medial aspect of the sternocleidomastoid (it may be visible between just above the clavicle between the sternal and clavicular heads of the sternocleidomastoid. The IJV has a double waveform pulsation, which helps to differentiate it from the pulsation of the external carotid artery.
- Measure the JVP by assessing the vertical distance between the sternal angle and the top of the pulsation point of the IJV (in healthy individuals, this should be no greater than 3 cm).
Causes of a raised JVP
A raised JVP indicates the presence of venous hypertension.
Right-sided heart failure
Tricuspid regurgitation
Constrictive pericarditis
Auscultation
Listening over the four valve areas shown below. With the diaphragm of the stethoscope. Murmurs should be considered in terms of timing, site of greatest intensity, character, loudness, and radiation.
Purpose is to characterise the hearts sounds and murmurs
Auscultation locations
Mitral valve: 5th intercostal space in the midclavicular line.
Tricuspid valve: 4th or 5th intercostal space at the lower left sternal edge.
Pulmonary valve: 2nd intercostal space at the left sternal edge.
Aortic valve: 2nd intercostal space at the right sternal edge.
Auscultate in the following order:
Mitral – Medicine
Tricuspid – Treats
Aortic – All
Pulmonary - Pts
Normal HR sounds
These consist of two sharp sounds, S1 and S2, which differentiate systole from diastole and no other significant sounds will be heard.
Auscultation patho
Must be able to pick up on mummers, Indicates a problem with valve function, chamber size and function, blood flow, and the overall health and function of the heart.
An enlarged left ventricle can produce a loud S4 sound, while a weakened left ventricle can result in a low-pitched S3 sound.
Sound of blood rushing through a narrowed aortic valve can produce a characteristic “whooshing” sound, known as an aortic stenosis murmur.
The sound of blood flowing backward through a leaky mitral valve during ventricular contraction can produce a characteristic “whooshing” sound, known as a mitral regurgitation murmur.
Pulmonary Stenosis - Maneuvers such as a heavy inspiration can increase the intensity of this murmur.
Blood pressure
An undersized cuff will overestimate the ABP and vice versa.
- Wrap the cuff around the upper arm, palpate the radial artery and make sure the arrow is inline and still within the size guide.
- Then inflate the cuff until the radial pulse can no longer be detected. The pressure at which the pulse is lost gives a rough estimate of the systolic blood pressure.
- Deflate the cuff and place your stethoscope over the brachial artery, which is situated in the antecubital fossa, just medial to the bicep’s tendon, midway between the medial and lateral epicondyles of the humerus.
- Reinflate the cuff to around 20mmHg above the estimated systolic blood pressure and then deflate it slowly (2-3mmHg per second) until a sound is first heard over the artery (Korotkoff 1). The pressure at which this occurs is the systolic blood pressure.
- Continue to deflate the cuff until the sounds disappears (Korotkoff V). The pressure at which this occurs is the diastolic blood pressure.
- Normal arterial blood pressure is defined as systolic blood pressure of less than 140mmHg and diastolic blood pressure of less than 90mmHg. Having measured the arterial blood pressure go on to
- Calculate the pulse pressure which is the difference between the systolic blood pressure and the diastolic blood pressure. The pulse pressure may be narrow in aortic stenosis and wide in aortic regurgitation.
Normal and abnormal BP
120/80 is healthy
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.
Severe if 180/120
Hypotension: blood pressure of less than 90/60 mmHg.
