Examination of the Cardiovascular System Flashcards
Learning outcomes
- To demonstrate understanding of the fundamentals of cardiovascular examination
- To identify physical signs of cardiovascular disease
- To relate clinical signs to underlying pathology
- Recognise the importance of using history & examination findings to help reach a diagnosis
OSCE CVS examination list
What are the 7 stages of a CVS examination
- CVS examination steps:
1) Introduction and explanation
2) Inspection (general and close)
3) Palpation
4) (Percussion)
5) Auscultation (listening to sounds from heart)
6) Other areas
7) Conclusion
What 7 things do we do during the introduction of the CVS examination?
- Introduction of the CVS examination:
1) Ensure adequate hygiene of hands and stethoscope.
2) Introduce yourself.
3) Confirm patient’s name and date of birth.
4) Ask if patient is in any discomfort.
5) Explain the procedure.
6) Seek permission to examine.
7) Position patient at 45 degrees with chest adequately exposed.
What 5 things do we do during general inspection?
- During general inspection:
1) Stand at end of bed.
2) Look around the patient. Any medications, oxygen, cigarettes, sublingual spray (e.g for pain/medicine)
3) Look at patient.
4) Does patient look unwell?
5) Any suggestion breathlessness, discomfort, pain?
What 7 things do we do look for with the hands during close inspection?
- During close inspection:
- Examine hands to assess circulation through warmth and assessment capillary refill time (capillary refill time less then 2 seconds is normal)
- In the hands, we are looking for signs of:
1) Peripheral cyanosis
* Blue discolouration
* Can be normal when we get cold
* Inability to deliver oxygen rich blood to peripheral tissues
* Can be caused due to slowing of blood
2) Tar staining (from smoking)
3) Clubbing
* Nails curve downwards
* Last part of nail may seem bulging
* Caused by disorders of deoxygenated haemoglobin and disorders of abnormal haemoglobin
* Clubbing often occurs in heart and lung diseases that reduce the amount of oxygen in the blood.
* Related to many CVS conditions e.g infective endocarditis
* Most common cause of clubbing is lung cancer
4) Splinter haemorrhages
* red/brownish lines under nails
* Can be associated with infection of the heart valves (endocarditis)
* May be caused by vessel damage from swelling of blood vessels (vasculitis) or tiny clots that damage the small capillaries (microemboli)
5) Janeway lesions
* Rare, irregular, nontender haemorrhagic macules (flat, distinct, discoloured skin)
* Located on the hands and feet
* Painless
* Caused by septic emboli that deposit bacteria, leading to microabesses
* Associated with infective endocarditis
6) Osler’s nodes
* Painful Red lesions usually found on distal pads of digits of hands and feet
* Associated with infective endocarditis
7) Koilonychia
* Manifestation of iron deficiency anaemia leading to spoon shaped nails
What 6 things do we look for with the face, eyes, and mouth during close inspection?
- During close inspection:
- We look at the face, eyes, and mouth for signs of:
1) Malar flush
* A high colour over the cheekbones, with a bluish tinge
* Caused by reduced oxygen concentration in the blood
* Sign of mitral valve disease, which often follows rheumatic fever
2) Pallor clinical anaemia
* Anaemia can lead to a rapid or irregular heartbeat (arrhythmia).
* When you’re anaemic your heart pumps more blood to make up for the lack of oxygen in the blood.
* This can lead to an enlarged heart or heart failure
* Pale conjunctiva (very little evidence of red colour on the anterior rim) is a sign of anaemia
3) Xanthelasmas
* Xanthelasma palpebrarum XP is characterized by sharply demarcated yellowish flat plaques on upper and lower eyelids.
* It is commonly seen in women with a peak incidence at 30–50 years.
* It is also considered as the cutaneous marker of underlying atherosclerosis along with the disturbed lipid metabolism
4) Corneal arcus
* Grey or white arc visible above and below the outer part of the cornea
* XP and corneal arcus are associated with increased levels of serum cholesterol and low-density lipoprotein (LDL) cholesterol
5) Central cyanosis
* Bluish discoloration of the body and mucous membranes
* Due to inadequate oxygen secondary to diseases of the heart and lungs or by abnormal haemoglobin types
* More than 5g/dl of deoxyhaemoglobin
6) Butterfly rash
* Characteristic skin lesion of systemic lupus erythematosus (SLE)
* Atherosclerosis is the most common manifestation of CVS in people with lupus
* Precipitated by sun exposure
* May predispose SLE by weeks or months
* Another differential that is common is Acne Rosacea
* In a study, blood tests revealed that the people with rosacea had higher levels of cholesterol and C-reactive protein (a marker for heart disease)
When does clubbing occur?
What is the most common cause of clubbing?
What are 8 other causes?
- Clubbing often occurs in heart and lung diseases that reduce the amount of oxygen in the blood.
- Lung cancer is the most common cause of clubbing.
- Other causes of clubbing:
1) Congenital Cyanotic Heart Disease
* Cyanotic heart disease refers to a group of many different heart defects that are present at birth (congenital).
* They result in a low blood oxygen level.
* Cyanosis refers to a bluish colour of the skin and mucous membranes.
2) Chronic lung infections that occur in people with bronchiectasis (widening of lungs, leading to build-up of excess mucous) , cystic fibrosis, or lung abscess.
3) Interstitial lung disease – diseases that cause scarring of the lungs
4) Coeliac disease – immune system attacks its own tissues when gluten is consumed
5) Cirrhosis of the liver and other liver diseases.
6) Overactive thyroid gland.
7) Other types of cancer, including liver, gastrointestinal, Hodgkin lymphoma (cancer of lymphatic system)
8) Infective Endocarditis.
What 7 symptoms are present in those with infective endocarditis (IE)?
- Symptoms are present in those with infective endocarditis (IE):
- 90% of patients with IE – Fever, possible low-grade and intermittent
- 85% of patients with IE – Heart murmurs (sounds such as whooshing or swishing made by rapid, choppy (turbulent) blood flow through the heart because of valves not working properly)
- In as many as 50% of patients (one or more classic signs):
1) Petechiae
* Common, but non-specific findings (cause not immediately known when found)
* Non-blanching rash (rashes that do not disappear with pressure)
* Round spots that appear on the skin as a result of blanching
2) Subungual (splinter) haemorrhages
* Dark-red linear lesions in the nail beds
3) Osler’s nodes
* Tender subcutaneous nodules usually found on the distal pads of the digits.
4) Janeway lesions
* Rare, irregular, nontender haemorrhagic macules (flat, distinct, discoloured skin)
* Located on the hands and feet
* Painless
5) Roth spots
* A Roth spot is a red spot (caused by haemorrhage) with a characteristic pale white centre.
* Seen most commonly in acute bacterial endocarditis
* This white centre usually represents fibrin-platelet plugs.
* Roth spots can also be seen in leukaemia, diabetes, intracranial haemorrhage, hypertensive retinopathy, cerebral malaria and in HIV retinopathy.
What is the duke criteria for diagnosis of endocarditis?
What 3 pulses do we assess during the palpation phase of the CVS examination?
How do we assess these pulses?
What do we offer after the assessment of pulses?
- Assessments during the pulses phase of the CVS examination:
1) Radial pulses
* The radial pulse is felt between the radial styloid and the tendon of flexor carpi radialis.
* Feel with two or three fingers (not the thumb).
- Steps of assessing radial pulse:
1) Check both radial pluses simultaneously to make sure that they are equal, and then concentrate on the right radial pulse.
2) Count the radial rate per minute. (Count for 15 seconds and multiply by four).
* Radial rate in most adults is between 60 and 100 at rest
3) Assess the rhythm
* Is it regular?
* If it is not, is it occasionally irregular, as when an ectopic heart beat occurs, or is it totally irregular as in atrial fibrillation
4) Asses for Collapsing pulse (aka water-hammer pulse)
* Palpate the right radial pulse
* Confirm that the patient has no pain in their shoulder, and then elevate their arm above their head whilst maintaining the position of your hand.
* Feeling for a forceful knocking sensation that is typical of aortic regurgitation
2) Carotid pulse
* Steps of assessing carotid pulse:
1) Feel for the carotid pulse
* Found at the anterior border of sternomastoid muscle
* Use the cricothyroid membrane as a landmark and rotate finger over.
* Use your index and middle fingers, not your thumb, as thumb has a pulse
2) Assess volume and character.
3) Never feel both carotids simultaneously.
3) Jugular venous pulse assessment
* It is ideal to examine the internal jugular vein with the patient resting comfortably at an angle of 45 degrees
* The jugular vein closely reflects the pressure changes within the right atrium.
* In health, at 45 degrees incline the upper limit of the venous column lies just behind the right sternoclavicular joint, which is at the same horizontal level as the sternal angle.
* When right atrial pressure is increased as in right-sided heart failure, the venous column is seen above the right sterno-clavicular joint
* The vertical height of this column is measured to express the increase in venous pressure.
* If there is a high pressure in the IJV, we will see a flickering in the neck that we wouldn’t normally expect
* The carotid pulse will be pulsatile, but if we press the IJV it will stop flickering
- After the assessment of these pulses, we measure and record BP now, if convenient, or at the end of the examination
- We often don’t have time for this, so just tell the OSCE examiner you would measure BP at this time
What are 5 abnormal pulses in terms of rate/rhythm?
When would we expect to see these pulses?
- 5 abnormal pulses in terms of rate/rhythm:
1) Fast and regular.
* Exercise, anxiety, pain, fever, medication, hyperthyroidism.
2) Regularly irregular.
* Ectopic beat (change in heartbeat that is otherwise normal, leading to extra or skipped beats)
3) Irregularly irregular.
* Atrial fibrillation (fast if uncontrolled).
4) Slow and regular.
* Athletic training, hypothyroidism, medication.
5) Slow and irregular
* Sick sinus syndrome, second degree heart block, complete heart block.
* Sick sinus syndrome – rhythm disorder that affects SA node
* Second-degree heart block - the electrical signals between your atria and ventricles can intermittently fail to conduct.
* Total heart block - the electrical signals between your atria and ventricles can intermittently completely fail to conduct.
What are 4 abnormal pulses in terms of volume/character?
When would we expect to see these pulses?
- 4 abnormal pulses in terms of volume/character:
1) Low volume
* Hypovolaemia (body loses fluids), left ventricular failure.
2) Increased volume
* Anaemia, fever, thyrotoxicosis.
3) Character Slow rising pulse
* Aortic stenosis. (aka aortic valve stenosis) - aortic valve is narrow and doesn’t open fully
4) Collapsing pulse
* aortic regurgitation – blood pumped into aorta leaks back into left ventricle
Inspection and palpation of precordium.
What is the precordium?
What are we assessing during this phase?
- Inspection and palpation of the precordium
- The precordium is the portion of the body over the heart and lower chesty
- During inspection of the precordium, we are looking for:
1) Shape
2) Respiratory rate
3) Scars
4) Visible apex beat
5) Pacemaker - Ensure consent is asked for in this following step
- We then find the apex beat and find its position after (normal = 5th intercostal space mid-clavicular line)
- We then check for heaves, which are indications that the muscle of the ventricle is greater (right ventricular hypertrophy) and the heart is working harder than we would expect
- To assess heaves, we place our hand on the left sternal angle to left sternal edge with our arm perpendicular to our hand
- We look to see if the elbow actively lifts up and down
- We then check for thrills, which are palpable murmurs around the valves (sounds such as whooshing or swishing made by turbulent blood flow through the heart due to valves not working properly)
- Murmurs can be sounds of regurgitation (blood moving backwards through valves) or stenosis (narrowing)
- We check the areas of the valves for thrills (aortic, pulmonary, tricuspid, mitral)
- Thrills will feel like a stream of water passing under the hand
What 5 steps do we take during the auscultation (listening to heart sounds) phase of the CVS examination?
Where are the best sites for hearing abnormalities?
What are examples of systolic and diastolic murmurs?
- During the auscultation phase of the CVS examination:
1) Palpate the carotid pulse initially
2) Distinguish 1st and 2nd heart sounds
3) Listen for heart sounds, added sounds, and murmurs
4) Use bell and diaphragm to listen in all 4 key areas
5) Manoeuvres to accentuate murmurs (make murmurs more noticeable)
What are the grades of intensity of a murmur?
What are 4 manoeuvres to accentuate murmurs?
- Manoeuvres to accentuate murmurs:
1) Bell at apex in expiration in left lateral position - Accentuation of diastolic murmur of mitral stenosis.
2) At left axilla with diaphragm - Radiation of systolic murmur of mitral regurgitation.
3) At lower left sternal edge with patient sat forwards, With diaphragm in expiration - Accentuation of diastolic murmur of aortic regurgitation.
4) Over carotids. With diaphragm in held inspiration - Accentuation of murmur of aortic stenosis radiation / carotid bruits (an audible vascular sound associated with turbulent blood flow)
What 9 things do we check for in examinations of other areas?
- Normally during this stage, we will tell the OSCE examiner about other tests we want to run
- Examination of other areas:
1) Auscultate lung bases.
2) Look for sacral oedema.
3) Check for ankle oedema.
4) Offer abdominal examination – inspect, palpate, percuss for hepatomegaly (enlarged liver), listen for renal and femoral bruits, feel for radio-femoral delay and palpate for pulsatile, expansile mass suggesting abdominal aortic aneurysm.
5) Peripheral vascular examination. .
6) Check BP.
7) Fundoscopy - test to see fundus and surrounding structures of the eyes using ophthalmoscope – may reveal signs of diabetic or hypertensive nephropathy (deterioration of kidney function)
8) Urinalysis – blood in urine for Infective endocarditis
9) Observation chart (including temperature and oxygen saturation)
What 3 things do we do during the conclusion of the CVS examination?
- Conclusion of CVS examination:
- Thank patient
- Wash hands
- Summarise and present findings
