Extra-Cardiac Flashcards
Inspects for systemic findings relevant to the cardiac system, including malar flush, cyanosis, respiratory distress, diaphoresis, neck vein distension. Comments on findings
Malar Flush⟶ plum red discoloration of cheeks-may suggest mitral stenosis (CO2 retention)
Conjunctival Pallor ⟶ ask patient to gently pull down their lower eyelid/you pull down on the patient’s lower eyelid (always ask for permission before touching the patient) – anemia
Cyanosis ⟶ decreased O2 perfusion- (Central Cyanosis= bluish discoloration of the lips and/or tongue) associated with many conditions e.g. Tetralogy of Fallot (ToF), Transposition of Great Vessels, Truncus Arteriosus (Embryological heart defects), Tricuspid Atresia, Aortic valve Insufficiency
Respiratory Distress⟶ Heart Failure (CHF)
Diaphoresis → Myocardial Infarct (MI), Angina, underlying endocrine pathology (i.e., pheochromocytoma)
Neck Vein Distension → CHF, Constrictive pericarditis, Hypervolemia, Tricuspid stenosis, SVC obstruction (patient should be laying down, do this when doing JVP)
Explain how you would inspect for systemic findings relevant to the cardiac system, including malar flush, cyanosis, respiratory distress, diaphoresis, neck vein distension. Comments on findings
“First, I’ll begin by checking for the systemic manifestations of cardiovascular disease. I’m looking at both cheeks and noting that I do not see any malar flush present which is indicative of mitral stenosis which causes increased CO2 retention. Can you open your mouth and lift your tongue? Ok, now you can close your mouth. I did not see any signs of cyanosis due to decreased O2 perfusion which can be caused by diseases like transposition of great vessels and Tetralogy of Fallot, etc. I do not note any signs of respiratory distress. The patient isn’t using accessory muscles such as the SCM or scalene muscles for breathing and there are also no signs of nasal flaring as could be caused by congestive heart failure. I do not note that the patient is not diaphoretic, or excessively sweating, and there are no signs of neck vein distention indicative of congestive heart failure, pericarditis, or hypervolemia.”
Examine the hands and list signs related to cardiovascular system including splinter hemorrhages, clubbing, peripheral cyanosis, pallor, capillary refill.
Splinter Hemorrhages⟶ blood under nails ((small microvascular blood clots under the nailbeds) seen in bacterial endocarditis): bacterial endocarditis (bacteria in blood stream going to heart)
Clubbing ⟶ In a healthy individual, you should be able to observe a small diamond shaped window (Schamroth’s window). When finger clubbing is present, the window is lost. Finger clubbing has several causes including infective endocarditis and cyanotic congenital heart disease
Peripheral Cyanosis⟶ bluish discoloration on hands: suggest hypoxia Pallor⟶ anemia
Capillary Refill⟶ normal is < 2 seconds-if prolonged may suggest hypovolemia Tar staining ⟶ smoker -risk factor for cardiovascular disease
Explain how you would examine the hands and list signs related to cardiovascular system including splinter hemorrhages, clubbing, peripheral cyanosis, pallor, capillary refill.
“Now I will look at your hands. Can you place your hands like this (indicate for the patient to hold their hands out in front of them palms up and then down)? I’m noting that there are no signs of pallor which would be due to anemia, peripheral cyanosis which could be due to cyanotic congenital heart disease, or tar staining. Now I’m going to gently press down on your fingernail (ensure patient that it will be painless) to check for capillary refill of 2 seconds or less. Flow was returned within 2 seconds which does not indicate a disruption of low as would occur in hypovolemia. Next, can you also make a heart with your fingers for me (demonstrate to patient what you would like them to do)? Ok, I do not see Schamroth’s window which is negative for clubbing which could occur in patients with infective endocarditis or cyanotic congenital heart disease. I’m also noting that there are no signs of splinter hemorrhages which would be due to bacterial endocarditis.”
Auscultates the chest for rales
“Now I need to listen to your lungs for rales under your gown, if that’s okay with you? Can you please breathe in and out as you would normally?” Listen.
“The lungs sounds are normal and vesicular and if rales were heard that would indicate left heart failure due to pulmonary edema.”
Examines the legs for pedal and pitting edema. Comments on findings
Pedal Edema:
“Normally, I would check for 1 minute but for OSCE purposes, I will check for pedal edema for less time.”
Press down on the top part of the foot to see whether the indentation of your finger remains marked in the patient’s skin.
Pitting Edema:
Press down on tibia to see whether the indentation of your finger remains in the patient’s skin after removal of your finger.
Inspects neck, identifies external & internal jugular venous pulsation.
“Next, I will be inspecting my patients neck in order to identify the external and internal jugular venous pulsations (JVP is important to assess index of right heart pressure).”
Make the patient comfortable. Raise the head slightly on a pillow to relax the SCM muscles.
Raise the head of the bed or examining table to about 30°. Turn the patient’s head slightly away from the side you are inspecting.
“I will inspect both sides of the neck using my pen light to identify the external jugular vein on both sides. Can you look away to the left please? I am looking for the internal jugular venous pulsations starting from the suprasternal notch & following it up to the SCM & I’m looking for the point of maximum oscillation.”
Describe A & V waves and lists at least 3 features which distinguish it from the carotid artery.
“The JVP reflects the pressure in the RA. The 1st elevation is the a wave which reflects the rise in RA pressure due to atrial contraction (a wave comes just before the 1st heart sound (S1)). The 2nd elevation is the v wave which reflects the rise in RA pressure due to RA filling (v wave coincides with the second heart sound (S2)). The JVP is not palpable in contrast to the carotid artery whose pulsations are palpable. The JVP also has soft, biphasic, undulating quality with 2 elevations and 2 troughs per heartbeat while the carotid pulsations are vigorous with a single outward component. The JVP pulsations are eliminated with pressure while the carotid pulsations are not eliminated with pressure. The height of the pulsations of the JVP changes with position while the height of the carotid pulsations is unchanged by position. The JVP pulsation height falls with inspiration while the carotid pulsations are not affected by inspiration.”
Measures vertical height with respect to sternal angle and reports in cm. Calculates pressure in cm from right atrium and comments on findings.
Follow the right JVP from the suprasternal notch, up the neck to find the
highest point of pulsation. Place ruler vertically on the sternal angle. Extend note card horizontally from the highest point of pulsation to the ruler. Measure vertical distance in cm above the sternal angle. “Upon measuring the vertical height with the respect to the sternal angle I find it to be (say number less than 3).” To calculate pressure: #cm above sternal angle + 5 = RA pressure with a RA pressure 8 = normal and RA pressure > 8 = increased pressure → right-sided CHF, constrictive pericarditis, tricuspid stenosis, or SVC obstruction. “I calculate the pressure to be about (say number less than 8) which is normal. If the RA pressure were to be greater than 8 cm this would be indicative of RA pressure as would be seen in right-sided CHF, constrictive pericarditis, tricuspid stenosis, or SVC obstruction.”
Demonstrates hepato-jugular reflux and comments on findings. Describes what a positive finding would be
Apply gentle pressure to the right upper quadrant for at least 10 seconds. A Normal response would be JVP increases initially and then returns to normal within 10s.
“Upon applying pressure to the right upper quadrant for 10 seconds to stimulate the hepato-jugular reflex I note that the JVP increases and becomes more distended. However, after withdrawing pressure, the JVP returns to normal within 10 seconds. This indicates the patient has normal functioning of the right ventricle. A positive finding of the JVP not returning to normal would show that JVP remains distended after 10 seconds as would occur in right-sided heart failure.”
