Cardiology - Cardiovascular Examination

Question 1

What angle should the bed be in a cardiovascular exam?

Answer 1

45 degrees

Question 2

When you carry out a general inspection of the patient what should you be looking for?

Answer 2

Cyanosis
Shortness of breath
Pallor
Malar flush
Oedema

Question 3

What does cyanosis suggest?

Answer 3

Poor circulation
- Peripheral vasoconstriction secondary to hypovolaemia

Inadequate oxygenation of blood
- Right-to-left cardiac shunting

Question 4

What does SOB suggest?

Answer 4

Congestive heart failure
Pericarditis
Pneumonia
PE

Question 5

What does pallor suggest?

Answer 5

Underlying anaemia
- Haemorrhage
- Chronic disease

Poor perfusion
- Congestive heart failure

Question 6

What does malar flush suggest?

Answer 6

Mitral stenosis

Question 7

What does oedema suggest?

Answer 7

Congestive heart failure

Question 8

What does pallor of the hands suggest?

Answer 8

Congestive heart failure

Question 9

What does cyanosis of the hands suggest?

Answer 9

Hypoxaemia

Question 10

What does xanthomata on the hands suggest?

Answer 10

- Hyperlipidaemia (typically familial)
- Coronary artery disease
- Hypertension

Question 11

What does Arachnodactyly (spider fingers) suggest?

Answer 11

Marfan’s syndrome

Associated with:
- Mitral valve prolapse
- Aortic valve prolapse
- Aortic dissection

Question 12

What is clubbing of the fingers suggestive of?

Answer 12

• Congenital cyanotic heart disease
• Infective endocarditis
• Atrial myxoma

Loss of Schamroth’s window

Question 13

What do splinter haemorrhages suggest?

Answer 13

• Trauma
• Infective endocarditis
• Sepsis
• Vasculitis
• Psoriatic nail disease

Question 14

What do Janeway lesions suggest?

Answer 14

Infective endocarditis

Question 15

What do Osler’s nodes suggest?

Answer 15

Infective endocarditis

Question 16

What do cool hands vs cool and sweat hands suggest?

Answer 16

Cool hands
Congestive cardiac failure
Acute coronary syndrome

Cool and sweaty
Acute coronary syndrome

Question 17

What does a capillary refill time of over two seconds mean?

Answer 17

Poor peripheral perfusion

Hypovolaemia
Congestive heart failure

Question 18

What does radio-radial delay suggest?

Answer 18

Subclavian artery stenosis (compression by cervical rib)
Aortic dissection
Aortic coarctation

Question 19

What causes a collapsing pulse?

Answer 19

• Pregnancy
• Fever
• Aortic regurgitation
• Patent ductus arteriosus
• Anaemia
• Arteriovenous fistula
• Thyrotoxicosis

Question 20

What do these types of pulse mean when palpating brachial pulse?

Slow-rising
Bounding
Thready

Answer 20

Slow-rising
- Aortic stenosis

Bounding
- Aortic regurgitation
- CO2 retention

Thready
- Intravascular hypovolaemia e.g. sepsis

Question 21

What causes narrow pulse pressure?

Answer 21

Aortic stenosis
Congestive heart failure
Cardiac tamponade

Question 22

What causes wide pulse pressure?

Answer 22

Aortic regurgitation
Aortic dissection

Question 23

What does a difference in blood pressure between arms suggest?

Answer 23

Aortic dissection

Question 24

Why do you need to listen to the carotids first before palpating?

Answer 24

Rule out a bruit, as this suggests carotid stenosis making palpation dangerous

Risk of dislodging a carotid plaque

Be aware of aortic stenosis radiating

Question 25

What causes raised JVP?

Answer 25

**Right-sided heart failure** Commonly due to left-sided **Tricuspid regurgitation** Infective endocarditis and rheumatic heart disease **Constrictive pericarditis**

Question 26

What is a positive hepatojugular reflux?

Answer 26

Pressure to liver, JVP rise should last for 1-2 cardiac cycles before falling Sustained rise in JVP is **positive**

Question 27

What do these signs suggest? - Conjunctival pallor - Corneal arcus - Xanthelasma - Kayser-Fleischer rings

Answer 27

**Conjunctival pallor** - Anaemia **Corneal arcus** - In under 50s hypercholesterolaemia **Xanthelasma** - Hypercholesterolaemia **Kayser-Fleischer rings** - Wilson's disease, can cause cardiomyopathy

Question 28

What do these signs suggest? - Central cyanosis - Angular stomatitis - High-arched palate - Dental hygiene

Answer 28

Central cyanosis - Hypoxaemia Angular stomatitis - Iron deficiency High-arched palate - Marfan's (risk for mitral/aortic valve prolapse and aortic dissection) Dental hygiene - Infective endocarditis risk factor

Question 29

What do these different chest scars suggest? - Median sternotomy - Anterolateral thoracotomy - Infraclavicular - Left mid-axillary

Answer 29

**Median sternotomy** - CABG **Anterolateral thoracotomy** - Cardiac valve surgery **Infraclavicular scar** - Pacemaker insertion **Left mid-axillary scar** - Subcutaneous implantable cardioverter-defibrillator

Question 30

What causes thrills and how do you assess them?

Answer 30

Turbulent blood flow (palpable murmur) Assess at each of the heart valves and parasternal heave for right ventricular hypertrophy

Question 31

What accentuation manoeuvres are used for aortic stenosis?

Answer 31

Auscultate carotids while patients holds their breath

Question 32

What accentuation manoeuvres are used for aortic regurgitation?

Answer 32

Sit patient forwards, listen to aortic area during **expiration** for early diastolic murmur

Question 33

What accentuation manoeuvres are used for mitral regurgitation?

Answer 33

Roll patient to left side, listen to mitral area during **expiration** for pansystolic murmur due to mitral regurgitation Auscultate into axilla to identify radiation

Question 34

What accentuation manoeuvres are used for mitral stenosis?

Answer 34

While patient on left side, use **bell** during **expiration** for a mid-diastolic murmur

Question 35

When auscultating the posterior chest wall, what do coarse crackles suggest?

Answer 35

Pulmonary oedema

Question 36

What does absent air entry and stony dullness on percussion suggest?

Answer 36

Pleural effusion, associated with left ventricular failure

Question 37

Why do you need to carefully inspect the patients legs?

Answer 37

Evidence of saphenous vein harvesting

Question 38

What do you need to "do" to complete your assessment?

Answer 38

* Measure BP * Peripheral vascular examination * 12-lead ECG * Urine dip * Blood glucose * Fundoscopy