CVS Flashcards
general inspection
cyanosis SOB pallor malar flush - mitral stenosis oedeoma
assess environment around patient
medical equipment - ECG leads, O2, GTN spray mobility aids pillows vital signs fluid balance prescriptions
hands inspection
colour - peripheral cyanosis tar staining xanthomata arachnodactyly - spider fingers (Marfans) finger clubbing pale palmar creases
hands signs associated with endocarditis
splinter haemorrhages
Janeway lesions - thenar and hypothenar
Olser’s nodes - front of fingers
2 main systolic murmurs
aortic stenosis
mitral regurgitation = whoosh whoosh
2 main diastolic murmurs
aortic regurgitation
mitral stenosis
hands palpation
temp - bilateral, check symmetry
CRT
pulses - rate, rhythm and character
radial
check radio-radial delay - aortic dissection, aortic coarctation, subclavian artery stenosis
check radio-femoral delay collapsing pulse brachial carotid - palpate and listen for bruits JVP hepato-jugular reflux?
JVP
patient positioned at 45 degrees, vertical distance between sternal angle and top of pulsation point on IJV, should not be more than 3cm, internal jugular vein only
eyes exam
conjunctival pallor = anaemia
corneal arcus = high cholesteral
xanthelesma
Kayer-Fleishcer rings = Wilson’ disease > copper
mouth exam
central cyanosis
angular stomatitis > iron deficiency
high arched palate > Marfans syndrome
dental hygiene
anterior chest inspection
scars chest wall deformities pectus excavatum pectus carinatum visible pulsations or heaves pacemaker?
chest palpation
apex beat = 5th intercostal space, mid-clavicular line
parasternal heaves = flat of hand, LVH or RVH
thrills each heart valve = lateral border of hand
auscultation of 4 heart valves
right - left top
right - left bottom
aortic - pulmonary = 2nd intercostal space sternal edge
tricuspid - mitral (apex) = 5th intercostal space, mitral is midclavicular line
posterior chest wall inspection
deformities or scars
posterior chest wall ausultation
coarse crackles
dull percussion
leg exam
oedema
saphenous vein harvesting
sacral oedema
check bottom of back for pitting oedema
further investigations
measure BP peripheral vascular exam record an ECG urine dipstick test bedside CBG fundoscopy
order of exam
intro general inspection bedside environment hands neck - JVP face - eyes, mouth, cheeks anterior chest posterior chest sacrum legs final assessments
pallor
pale skin - underlying anaemia, haemorrhage, chronic disease, poor perfusion
malar flush = butterfly rash as seen in SLE
nose and across cheeks
plum-red cheek discolouration = mitral stenosis
oedema indicates
congestive heart failure
pillows?
congestive heart failure patients often have orthopnoea so use pillows to prop themselves up
xanthomata
raised yellow cholesterol deposits on palm, tendons of hand and elbow
arachnodactyly
spider fingers = abnormally long and slender, feature of Marfan’s syndrome
Marfan’s syndrome associated with
mitral/aortic valve prolapse and aortic dissection
finger clubbing indicates … in CVS
congenital cyanotic heart disease, infective endocarditis and atrial myxoma
finger clubbing assessment
look for Schamroth’s window, clubbing has loss of normal angle between nail and nail bed
splinter haemorrhages
longitudinal red-brown haemorrhage under nail looks like wood splinters > infective endocarditis, sepsis, vasculitis
Janeway lesions
non-tender haemorrhagic lesions on thenar and hypothenar eminences of palms and soles > infective endocarditis
Osler’s nodes
red-purple slightly raised lumps often with pale centre on fingers and toes > infective endocarditis
temp hand assessment
dorsal aspect
symmetry
warm or cold
dry or clammy
CRT procedure
5 seconds of pressure to end of finger
how long to return to initial pallor should be less than 2 seconds
CRT greater than 2 secs
poor peripheral perfusion - hypovolaemia, congestive heart failure
healthy adult PR
60-100bpm
tachycardic PR
> 100bpm
irregular PR measure
have to record pulse for full 60 seconds
AF indicated
radio-radial delay
loss of synchronicity between radial pulse on each arm
causes of radio-radial delay
subclavian artery stenosis, aortic dissection, aortic coarctation
collapsing pulse
aortic valve regurgitation = leaking
think of blood going back into valve
reduced pulse with arm up
in health should be the same
palpate radial pulse with right hand wrapped around patients wrist
palpate brachial pulse with left hand
raise patients arm above head briskly
should feel a tapping impulse in muscle bulk of arm as blood empties
collapsing pulse = when arm is raised and pulse is a lot weaker
pulse rhythms = check rate and rhythm
regular
regularly irregular
irregularly irregular
CVS causes of collapsing pulse
aortic regurgitation, patent ductus arteriosus, anaemia
slow rising pulse indicates
aortic stenosis
bounding pulse indicates
aortic regurgitation and co2 retention
thready pulse indicates
intravascular hypovolaemia - sepsis
first step in investigating carotid pulse
auscultate artery to detect presence of a bruit - indicates carotid stenosis which makes palpation of vessel dangerous due to dislodging of carotid plaque causing an ischaemic stroke
raised JVP indicates
venous hypertension - right sided HF, tricuspid regurgitation, constrictive pericarditis
conjunctival pallor
underlying anaemia
corneal arcus
hazy white/grey/yellow/blue opaque ring around cornea
xanthelasma
yellow cholesterol rich deposits around eyes
Kayser-Fleischer rings
dark rings around iris in Wilson’s disease = abnormal processing of copper in liver results in deposition
angular stomatits
inflammation around sides of mouth
anaemia
high arched palate
feature of Marfan syndrome
poor dental hygiene can be a risk factor for
infective endocarditis
infective endocarditis
infective of heart valves or endocardium
pectus excavatum
caved in/sunken chest
pectus carinatum
protrusion of sternum and ribs
saphenous vein harvesting leg inspection
performed as part of coronary artery bypass graft
mitral valve located
5th intercostal space at midclavicular line
tricuspid valve located
4th or 5th intercostal space at lower left sternal edge
aortic valve located
2nd intercostal space at right sternal edge
pulmonary valve located
2nd intercostal space at left sternal edge
thrill
palpable murmur = turbulent blood flow,
test each valve by placing horizontal hand across chest wall above
how to assess for parasternal heave
heel of hand parallel to LHS/RHS of sternal angle, if there is a heave then should feel hand being lifted - right ventricular hypertrophy
apex beat bottom corner of heart
5th intercostal space midclavicular line
normally next to nipple
hepatojugular reflux test
pressure on liver whilst observing JVP
positive result = if JVP rise is sustained and equal to or greater than 4cm
irregularly irregular pulse caused by
AF - often patients go in and out of fibrillation, when heart gets back into rhythm can fire off clots
ventricular fibrillation
cardiac arrest = no pulse
regularly irregular pulse caused by
arrhythmias:
ectopics = missed heart beat
bigeminy
trigeminy
JVP
right sided heart problem - fluid backs up
shown in raised JVP
how visible is the vein
pulse in a vein?
veins should never have a pulse!
you can press them and it should stop filling
sternotomy scar
down the sternum = open heart surgery
infraclavicular scar
pacemaker insertion
GTN spray
for angina
displacement of apex beat
lots of reasons for big floppy heart can find apex beat in midclavicular line (in line under armpit)
narrow or regurgitation in valve causes
thrill = where you can feel murmur with your hand over the valve heave = can feel how hard heart is having to pump with hand due to narrowing (aortic stenosis with LV pumping against resistance)
cardiac cycle revision = 3 stages
- Atrial and Ventricular diastole (chambers are relaxed and filling with blood)
- Atrial systole (atria contract and remaining blood is pushed into ventricles)
- Ventricular systole (ventricles contract and push blood out through aorta and pulmonary artery)
murmur is caused by
turbulence in valve as blood struggles to go through
murmur is caused by
turbulence in valve as blood struggles to go through
mitral regurgitation murmur
pansystolic murmur
back pressure from ventricles damages and weakens mitral valve, blood leaks back into atria
turbulence around valve during whole of systole phase
mitral regurgitation valve murmurs pitch
often higher pitched so can use bell of stethoscope to hear better if needed
aortic stenosis murmur
ejection systolic = crescendo-decrescendo
aortic regurgitation murmur
early diastolic murmur
mitral stenosis murmur
mid-diastolic murmur
systolic murmur
aortic and pulmonary stenosis
mitral and tricuspid regurgitation
early diastolic murmur
aortic or pulmonary regurgitation
murmurs that radiate
aortic stenosis = radiates to carotid arteries
mitral regurgitation = radiates to axilla
ventricular systole
contraction and ejection
ventricular diastole
relaxation and filling
s1 heart sound
lub = closure of mitral and tricuspid valves
signals start of systole
s2 heart sound
dub = closure of aortic and pulmonary valves
signals end of systole
mid-late diastolic murmur
mitral or tricuspid stenosis
murmurs heard better on expiration = increased intrathoracic pressure
inc pressure constricts pulmonary vessels so blood is forced into left atrium and through left side of heart so aortic and mitral valves heard better
murmurs heard better on inspiration = decreased intrathoracic pressure
right side heart fills with more blood so can hear pulmonary and tricuspid valves better
tendon xanthoma
papules and nodules found in the tendons of the hands, feet, and heel. Also associated with familial hypercholesterolemia (FH)
end pieces
Fundoscopy: this is to check for hypertensive and diabetic retinopathy
Ausculation for renal and femoral bruits
Palpate: AAA, organomegaly (liver + spleen enlarged from right sided heart failure), femoral pulses
