Cardiovascular exam Flashcards
What are you looking for in general inspection in a cardio exam?
Bed area: oxygen devices, ECG leads, GTN spray, pillows
Patient: colour (cyanosis? pallor? malar flush?), breathing, oedema, discomfort
What are you looking for in the hands in a cardio exam?
Colour: pallor/cyanosis
Temperature: cold (poor perfusion), sweaty/clammy (ACS)
Capillary refill: >2 seconds = poor perfusion
Tar staining: smoking
Clubbing: congenital heart disease, infective endocarditis
Signs of endocarditis: Janeway lesions, splinter haemorrhages, Osler’s nodes
How do you asses pulses for a cardio exam?
- Asses heart rate and rhythm using one radial pulse
- Compare the radial pulses for delay (aortic coarctation) or difference in strength (aortic dissection)
- Asses volume and character of the brachial pulse (slow-rising = aortic stenosis, bounding = aortic regurgitation/CO2 retention)
- Collapsing/water hammer pulse (aortic regurgitation)
- Auscultate carotid arteries for bruit then palpate for character and volume
How do you asses JVP?
- The patient should be lay at 45 degrees with their head turned to the left
- Look between the medial end of the clavicle and the ear lobe, under the medial aspect of the sternocleidomastoid
- The JVP has a double wave pulsation and is not palpable (which helps distinguish it from the carotid artery)
- Measure the JVP by assessing the vertical distance between the top of the sternal angle and the top point of the JVP
- should be less than 3cm, raised = cor pulmonale/pulmonary hypertension
What are you looking for in the face in a cardio exam?
Eyes:
- conjunctival pallor (anaemia)
- corneal arcus (hyperlipidaemia)
- xanthelasma (hyperlipidaemia)
- Kayser-Fleischer rings (Wilson’s disease)
Mouth:
- central cyanosis (hypoxaemia)
- angular stomatitis (anaemia)
- high arched palate (Marfan syndrome)
- dental hygiene (risk of infective endocarditis)
Face:
- malar flush (mitral stenosis)
What are you looking for in inspection of the chest in a cardio exam?
Scars (e.g. sternotomy)
Pectus excavatum/carinatum
Visible pulsations
How do you palpate the chest in a cardiac exam?
Apex beat:
- typically in he 5th intercostal space in the midclavicular line
- displacement can be due to left ventricle hypertrophy
Heaves:
- place the heel of your hand on the left sternal edge
- a heave will cause the hand to lift with each systole (associated with right ventricle hypertrophy)
Thrills:
- place your fingers and palm across each heart valve
- a thrill is a palpable murmur
How do you auscultate the heart valves?
- Aortic valve: 2nd intercostal space at the right sternal edge
- Pulmonary valve: 2nd intercostal space at the left sternal edge
- Tricuspid valve: 4th or 5th intercostal space at the lower left sternal edge
- Mitral valve: 5th intercostal space in the midclavicular line
When is each type of heart murmur heard?
Aortic stenosis = systole
Mitral regurgitation = systole
Aortic regurgitation = diastole
Mitral stenosis = diastole
How do you accentuate each heart murmur?
- Aortic stenosis = patient holds breath, ejection systolic murmur radiates to the carotids
- Aortic regurgitation = patient sits forward, early diastolic murmur is heard on expiration
- Mitral stenosis = patient lies on left side,
diastolic murmur is heard in mitral area - Mitral regurgitation = patient lies on left side, pansystolic murmur is heard in mitral area and radiates to axilla
What do you need to asses away from the chest in a cardio exam?
- Auscultate the lung bases (oedema/effusion associated with left ventricular failure)
- Sacral and peripheral oedema (associated with right heart failure)
- Palpate for hepatomegaly (sign of congestive heart failure) and pulsation (tricuspid regurgitation)
- Assess for shifting dullness if ascites is suspected
- Check femoral pulses (only state in OSCE)
- Check blood pressure (only state in OSCE)
- Ophthalmoscopy (only state in OSCE)
- 12-lead ECG (only state in OSCE)
