CVS Flashcards
Give one risk factor for cardiac chest pain
High bp
What does SOCRATES stand for
Site = central, left, right
Onset = sudden, over time, at rest, on exertion
Character = dull, sharp, aching, pressure, heaviness, tightness, pleuritic
Radiation= shoulder, jaw, neck, back
Alleviating factors =rest, position, pain relief,
Time = duration of symptoms
Exacerbating factors = exertion, position, food
Severity = 1-10
Where does cardiac chest pain classically radiate to
The jaw or left arm
What can be given to treat angina symptoms
GTN spray = Glyceryl Trinitrate Spray
What is the classical cardiac chest pain in terms of SOCRATES
S. Centre of the chest 0. Sudden onset C. Dull or crushing R. Left arm, neck, jaw A. Nausea, sweating, breathlessness T. 10 mins to an hour E. Exertion, cold air, relieved by rest, GTN spray S. Mild to v severe (can be angina attack, severe angina attack, MI)
Many people, esp women, can present with atypical symptoms
What is stable angina usually brought on by
Exertion
What can unstable angina be brought on by
At rest
How is angina relieved
Rest
GTN spray
When can acute coronary syndrome come on
At rest or exertion
What might chest pain that is NOT relived by rest or GTN spray be caused by
Acute coronary syndrome
What is acute coronary syndrome
A range of conditions associated with sudden, reduced blood flow to the heart. Eg, an MI
What is angina
Chest pain caused by reduced blood flow to the heart muscles, not usually life threatening but could be a warning sign that you are at risk of heart attack or stroke
What kind of presentation would point towards acute coronary syndrome rather than angina
Last longer than usually angina symptoms More severe pain More associated symptoms Not relieved by rest of GTN spray Can come on at rest/ exertion
What is dyspnoea
Breathlessness
What is orthopnoea
Breathlessness lying flat
Can ask about how many pillows a patient sleeps on
What is paroxysmal nocturnal dyspnoea
Sudden breathlessness waking up from sleep
Classical sign of heart failure
What kind of oedema may be present in patients with heart disease
Pitting
If patient is more mobile where might an oedema collect
Ankle
If less mobile, oedema may collect in sacral area, or abdominal wall
How may patients describe their palpitations
Rapid, regular, irregular,
Slow, feeling of missed beats, sudden thumping
What other common presenting symptoms in CVS disease should you ask about
Dyspnoea
Oedema
Palpitations
Syncope/ presyncope
What is the brief structure of a history
- History of presenting complaint and related SE
- Past medical history: active (eg, also has DM) and inactive problems (has previously had gall bladder removed with no current problems)
- Systematic enquiry - build this around the active problems eg, is DM well controlled
- Drug history - how they receive meds, allergies = and ask about the reaction
- Social history = eg, drugs, work, how mobile,
Consider risk factors
Non CVS causes of chest pain related to respiratory system
cough, temperature, haemoptysis, risk factors for PE
Non CVS causes of chest pain related to GI
pain related to eating, reflux, burning, indigestion, swallowing difficulty, vomiting regurgitation
Non CVS causes of chest pain related to musculophrenic-skeletal system
Recent falls/ injury/ trauma
Psychological factors that can cause chest pain
Anxiety, stress, recent life events
Give 6 cardiovascular risk factors
Diabetes Smoking Diet and exercise Hypertension Hyperlipidaemia Family history (eg, of heart disease, and ask specifically about sudden death)
What clinical observations and heart sounds and chest auscultation would support a diagnosis of angina
Normal for all
What 4 main things should you check when carrying out a CVS examination
Hands
Face
Chest/body
Legs
What might you be looking out for when examining hands during a CVS examination
Nicotine staining
Finger clubbing
Signs of endocarditis
What might you be looking out for when examining the face during a CVS examination
Malar flush
Corneal Arcus (signs of hypercholestrolemia)
Xanthalasma (signs of hypercholestrolaemia)
What can malar flush be a sign of
Mitral stenosis
What might you be looking out for when examining chest/ body during a CVS examination
Scars
Chest wall abnormalities
What might you be looking out for when examining legs during a CVS examination
Pitting oedema
Scars
What is the first heart sound produced by
Closing of the mitral and tricuspid valve leaflets
What is the second heart sound produced by
Closing of the aortic and pulmonic valve leaflets
When are the first and second heart sounds heard in relation to the carotid pulse
When you feel the pulse on fingers = hear the first heart sound
When pulse draws away = second heart sound
What are murmurs
Absence of silence between the heart sounds
Can happen in systole or diastole
Where can the aortic valve be auscultated
2nd- 3rd right interspace
Where can the pulmonic valve be auscultated
2nd - 3rd left interspace
Where can the tricuspid valve be ausculatated
Left sternal border
Where can the mitral valve be auscultated
Apex
Why is it important to palpate the carotid pulse whilst auscultating the heart sounds
Because if an added sound is present to determine if this is occurring in diastole or systole by timing with the carotid pulse
How to begin a CVS examination
Greet your patient
Introduce yourself and your role
Explain what you are going to do and why, and gain consent to proceed with the examination
Clean your hands
Ongoing communication to patient involves clear instructions and attention to your patient’s comfort
Demonstrate a Professional manner throughout
Examination method is structured and performed fluently and in a logical order
What should you make a general observation of at the start of a CVS examination
of patient (colour, conscious level, any pain or breathing difficulty, build) of bedside (oxygen or other bedside equipment, GTN spray/medication)
What to look for in hands and nails in CVS examination
clubbing, nicotine staining, splinter haemorrhages, tendon xanthoma, Janeway lesions, Osler’s nodes, pale palmar creases, palpate to ascertain capillary refill time which should be < 2 seconds
How to take a pulse and what to look out for and report
palpate for 30 secs (60 secs if pulse irregular)
report rate, rhythm & character
Check for radio-radial delay and radio-femoral delay (aortic stenosis)
Ensure your patient does not suffer with arm or shoulder pain before examining for a collapsing pulse (present in aortic regurgitation)
What is pallor of conjunctiva
Pale appearance of the conjunctiva - can be a sign of anaemia
What is a corneal arcus
Deposit of cholesterol, phospholipids, and triglycerides in an ‘arc’ on either the top or bottom side of the iris inside the cornea
What to look for in eyes, lips and tongue in CVS exam
Look in the eyes for xanthelasma, a corneal arcus and for pallor of conjunctivae.
Look at the lips for peripheral cyanosis and under the tongue for central cyanosis. Ascertain general dental hygiene.
High-arched palate suggestive of Marfan’s syndrome
What is xanthelasma
Soft, yellowish fatty deposit that forms under the skin and can be seen around the eyes/ eyelids area
What to observe in the neck in a CVS exam
Carotid pulse:palpate and listen for bruits
JVP:should be examined and measured with the patient rested at 45 degrees. (know how to demonstrate hepato-jugular reflux which may be useful in clinical practice but is not routinely performed in an OSCE)
What to observe around chest/ praecordium during a CVS exam
look for scars (sternotomy, thoracotomy), a pacemaker, and for visible pulsations or heaves
What to palpate during a CVS exam
Locate the Apex Beat (should know expected site is 5th intercostal space, mid-clavicular line
Heaves – use the flat of the hand to feel for parasternal heaves indicative of LVH or RVH
Thrills – use the lateral border of the hand to palpate all 4 valve areas for palpable murmurs
What to ausculutate during a CVS exam
Auscultate all 4 valve areas (Aortic, Pulmonary, Tricuspid and Mitral) and carotid arteries with the diaphragm of the stethoscope – ascertain the heart sounds and for any added heart sounds or murmurs.
How to listen for a murmur
If a murmur is present try to ascertain at which valve area it is heard and whether there is any radiation, for example into the carotids or into the apex.
Listen at the mitral area with the bell and the patient leaning onto their left hand side – this makes it easier to listen for the low pitched diastolic murmur of mitral stenosis.
Listen at the tricuspid area with the diaphragm of the stethoscope and your patient sat forward in held expiration which will intensify a murmur due to aortic regurgitation.
Auscultate the lungs, particularly looking for fluid at the bases which may be due to heart failure.
What might sacral or ankle oedema indicate?
Right sided heart failure
How to determine whether an oedema is a pitting oedema
You should press into the area of oedema for 5 seconds to establish whether an indentation remains which indicates pitting oedema.
What other things would complete a CVS exam
Lying and standing BP
Abdomen
Observation
Palpation :
— Organomegaly – hepatosplenomegaly can occur due to engorgement from right sided heart failure
Abdominal Aortic Aneurysm – expansile (aorta can be palpable in thin individuals and is pulsatile)
Palpate femoral pulses
Auscultation - for renal and femoral bruits
Vascular exam of lower limbs
Fundoscopy- to check for hypertensive and diabetic retinopathy
Thank and explain
What might be the cause of hepatosplenomegaly
Engorgement from right sided heart failure
