Cardiac Exam

Question 1

First thing to do in cardiovascular exam

Answer 1

• general inspection from 5 feet away:
  a) distressed?
  b) body habitus ( size an shape of the person - refer to the person’s bmi i.e. they have a very high bmi rather than they are morbidly obese)
  c) well vs. unwell appearance (combo of skin colour,, level of distress, breathing pattern, level of consciousness, body habitus, facial expression ect)
• well nourished
• well perfused

Question 2

After general inspection hat comes next

Answer 2

Vitals

• BP
• HR
• RR
• O2 sat
• pulsus paradoxus

Question 3

Pulsus paradoxus

Answer 3

A decrease in systolic pressure during inspiration and/or an increase in systolic pressure during expiration
-when difference in systolic pressures is greater than 10 mmHg it is considered abnormal

Question 4

When does pulsus paradoxus occur

Answer 4

Occurs with:

a) cardiac tamponade
b) severe volume depletion
c) severe asthma

Question 5

Things to check for on the hands/wrists/fingers

Answer 5

1) Clubbing
2) Cyanosis (peripheral)
3) Capillary refill
4) Radial and brachial pulses
5) Splinter haemrrhage
6) Janeway lesions
7) Osler’s nodes
8) Raynaud’s phenomenon

Question 6

Clubbing

Answer 6

• a bulbous swelling of the soft tissue at the nail base
• loss of normal angle between the nail an the proximal nail fold (angle inreases to 180 +)
• nail bed feels spongy or floating

Question 7

Mechanism of clubbing

Answer 7

-still not completely known

Question 8

Conditions that cause clubbing

Answer 8

X

Question 9

Signs of bacterial endocarditis

Answer 9

• splinter haemorrhages
• janeway’s lesions
• osler’s nodes

Question 10

Splinter haemorrhage

Answer 10

X

Question 11

Janeway’s lesions

Answer 11

X

Question 12

Osler’s nodes

Answer 12

X

Question 13

Reynaus phenommenon

Answer 13

Vasoconstriction in the fingers

Question 14

Capillary refill

Answer 14

The tine reqiured for finger nail to return to the pink colour after it has been squeeze

• normal is < 2 seconds (brisk)
• abnormally long times usually indicate poor circulation (a number of causes)

Question 15

Things to note on examination of the radial pulse

Answer 15

1) Amplitude of the pulse = the size or strength of the pulse
2) Upstroke- how quickly the pulse reaches it maximum
3) Rate = frequency of pulse
4) Rhythm = description of regularity of pulse

Question 16

Technique for palpation of an artery

Answer 16

• gently (too much pressure will occlude the artery an the pulse will be absent)
• use to figers

Question 17

Things to inspect on legs

Answer 17

1) Pedal oedema
2) Pulses (femoral, popliteal, dorsalis pedis, posterior tibialis)
3) temperature
4) Signs of chronic poor circulation (loss of hair, discoloration, ulcers)
5) Achilles tendon xanthomata

Question 18

Achilles tendon xanthoma

Answer 18

• disfiguring cholesterol deposits
• appreciable by palpation and visualization of the achilles tendon
• sign seen in familial hypercholesterolemia

Question 19

Things to exam in eyes

Answer 19

Eyes:

• corneal arcus
• xanthalosma
• fundoscopic exam
• colour of conjunctiva (pale or pink)

Question 20

Corneal arcus

Answer 20

• a gray color arc or circle that is superimposed on the outer edge of the iris (colored part of the eye)
• can be a sign of high cholesterol (also common in elderly = arcus senilus where is not representative of cholesterol level)

Question 21

Xantholasma

Answer 21

• fatty deposits in the skin that surround the eye

- sign of high cholesterol

Question 22

Importance of fundoscopic exam

Answer 22

Is the only place in the body where we can directly see arteries and veins

Question 23

Things to exam in mouth

Answer 23

1) Petechia (petechiae)
2) Dentition
3) Central cyanosis

Question 24

Signs/ Cause of petechiae of oral mucosa

Answer 24

• red/purple spot
• cause by minor haemorrage (broken capillary vessel)
• occurs with bacterial endocarditis

Question 25

Dental pathology - importance

Answer 25

May alert the examiner to the risk for endocarditis

Question 26

Central cyanosis

Answer 26

-cyanosis of the oral mucosa (not the lips which can appear cyanotic in a patient who is cold)

Question 27

Things to examine in the neck

Answer 27

1) Accessory muscle use 2) Carotid auscultation 3) Carotid palpation 4) JVP inspection 5) Thyroid gland

Question 28

Order of examination of the carotid + why

Answer 28

Carotid auscultaation should precede palpation because if there is a bruit then atherosclerotic stenosis might be present and if so then a plaque could be dislodged by palpation

Question 29

Things to comment on during inspection of carotid pulse

Answer 29

1. Amplitude 2. Upstroke 3. Rate 4. Rhythm

Question 30

Pulsus parvus and tardive-define + causes

Answer 30

Small weak pulse -upstroke may feel slowed an the peak prolonge Causes 1) decreased stroke volume (i.e. heart failure, hypovolemia, severe aortic stenosis) 2) Increased peripheral resistance (exposure to cold, severe heart failure)

Question 31

Waterhammer pulse

Answer 31

- a large, bounding pulse -the rise and fall are rapid, the peak is brief Causes: 1) Increased stroke volume decreased peripheral resistance or both (anemia, hyperthyroidism, aortic regurg, arteriovenous fistulas , PDA) 2) Increased stroke volume because of slow heart rate (bradycardia) and cmlpete heart block 3) Decreased compliance of aortic walls (aging, artherosclerosis)

Question 32

Inspection of JVP- things to note (vs. carotid)

Answer 32

1. Biphasic vs. monophasic 2. Changes with position vs. does not 3. Increase with AJR vs. does not 4. Changes with respiration vs. does not 5. Non-palpable vs. palpable 6. Obliterable vs. not

Question 33

JVP changes with position

Answer 33

Drops as the patient becomes more upright

Question 34

JVP changes with increase in AJR

Answer 34

Height increases with increase in pressure

Question 35

JVP changes with respiration

Answer 35

Height of pulsations fall with inspiration

Question 36

Signs of respiratory distress

Answer 36

- use of accessory muscles | ex: sternocleidomastoid

Question 37

Inspection of the back

Answer 37

1. Percuss the lungs 2. Auscultate the lungs 3. Sacral oedema

Question 38

Things to note when auscultating/percussing lungs

Answer 38

- equal air entry bilaterally | - no adventitious sounds heard (crackles, wheezes)

Question 39

What do crackles indicate

Answer 39

Pulmonary oedema | Pulmonary fibrosis

Question 40

What do wheezes indicate

Answer 40

Early interstial oedema | Asthma/COPD

Question 41

When does sacral oedema frequently develop

Answer 41

In persons who have been lying down for a long time

Question 42

Examination of the chest -general

Answer 42

1. Inspect 2. Palpate 3. Percuss/ausculate lungs 4. Ausculate heart

Question 43

things to inspect on the chest

Answer 43

1. Cardiac pulsations 2. Scars and pacemakers 3. Pectus excavatum, pectus carinatum

Question 44

Cardiac pulsations to observe

Answer 44

1. Apex beat 2. Visible lifts 3. Pulmonary artery pulsations (visible in severe hypertension) 4. Valve positions

Question 45

Pectus excavatums

Answer 45

Hollowed chest

Question 46

Pectus carinatum

Answer 46

Protrusion of sternum and ribs (due to overgrowth of cartilage causing sternum to protrude forward)

Question 47

Things to palpate on chest

Answer 47

1) Apex 2) Right ventricular heave 3) Pulmonary artery 4) 4 valve areas for thrills

Question 48

Apex

Answer 48

``` -most lateral position Note -size (how many interspaces) -mono vs. bi vs. triphsic - duration (sustained or not) ```