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Phase 2b Medicine > Cardiovascular Examination > Flashcards

Cardiovascular Examination Flashcards

1
Q

What should be done in the introduction of the cardiovascular examination?

A
  • Wash hands
  • Identify patient
  • Explain examination
  • Gather consent
  • Position the patient at 45 degrees on examination couch
  • Expose chest & offer chaperone
  • Confirm well-being
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2
Q

What should be noted on general inspection of the bedside in a cardiovascular exam?

A
  • Mobility aids

- GTN spray & other medications

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3
Q

What should be noted on the general appearance of the patient in a cardio exam?

A
  • Cyanosis
  • Shortness of breath
  • Pallor
  • Malar flush
  • Oedema
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4
Q

What does cyanosis indicate?

A

Bluish discolouration of the skin due to poor circulation or inadequate oxygenation of the blood

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5
Q

What does shortness of breath indicate in a cardio exam?

A

Underlying cardiovascular or respiratory disease

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6
Q

What does pallor indicate in a cardio exam?

A

A pale colour of the skin that may suggest anaemia/poor perfusion

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7
Q

What does malar flush indicate in a cardio exam?

A

May indicate mitral stenosis

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8
Q

How does malar flush present?

A

Plum-red discolouration of the cheeks

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9
Q

What signs may be picked up from the hands in a cardio exam?

A
  • Tar staining
  • Vasodilation/constriction & temperature
  • Sweating
  • Pallor of palm creases
  • Peripheral cyanosis
  • Clubbing
  • Splinter haemorrhages
  • Janeaway lesions
  • Oslers nodes
  • Xanthomata
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10
Q

What may sweating of the hands indicate in a cardiovascular exam?

A
  • Increased sympathetic drive

- Indicates acute coronary syndrome

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11
Q

What does peripheral cyanosis indicate on a cardio exam?

A

Hypoxia

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12
Q

What does clubbing indicate on a cardio exam?

A

Cyanotic heart defect, endocarditis or chronic hypoxia

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13
Q

What are splinter haemorrhages and what do they indicate?

A
  • Red/brown streaks on nail bed

- Indicate bacterial endocarditis

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14
Q

What are Janeaway lesions and what do they indicate?

A
  • Painless red spots which blanch on pressure on the hands

- Indicate bacterial endocarditis

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15
Q

What are Osler’s nodes and what do they indicate?

A
  • Painless red spots which blanch on pressure on the fingers
  • Indicate bacterial endocarditis
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16
Q

What is xanthomata and what does it indicate?

A

Raised yellow lesions on the hands - indicate hyperlipidaemia

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17
Q

What are Roth spots and what do they indicate?

A
  • Red haemorrhages seen on fundoscopy

- Indicative of bacterial endocarditis

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18
Q

What is normal capillary refill time on cardio exam?

A

Less than 2 seconds

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19
Q

What should be assessed when feeling the radial pulse?

A
  • Rate, rhythm, volume and character
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20
Q

What is arachnodactyly and why might it be seen on cardio exams?

A
  • Abnormally long and slender toes/fingers

- Feature of Marfan’s = associated with mitral/aortic valve prolapse & aortic dissection

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21
Q

How is finger clubbing assessed?

A
  • Ask the patient to place their index nails back to back
  • Should be a small diamond shaped window present in healthy individuals
  • This is lost in clubbing
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22
Q

What may cool hands indicate in a cardiovascular exam?

A

Poor peripheral perfusion e.g. congestive cardiac failure, ACS

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23
Q

What may cool and clammy hands indicate in a cardio exam?

A

ACS

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24
Q

What may a long capillary refill time indicate?

A

Poor peripheral perfusion e.g. hypovolaemia & congestive heart failure

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25
Q

What is a normal healthy pulse rate?

A

Between 60-100bpm

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26
Q

What are some causes of bradycardia?

A
  • Healthy athletic individuals
  • AV block
  • Medications
  • Sick sinus syndrome
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27
Q

What are some causes of tachycardia?

A
  • Anxiety
  • Supraventricular tachycardia
  • Hypovolaemia
  • Hyperthyroidism
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28
Q

What is the most common cause of irregular rhythm?

A

Atrial fibrillation

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29
Q

What is radio-radial delay?

A

A loss of synchronicity between the radial pulse on each arm, resulting in the pulses occurring at different times

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30
Q

How do you assess for radio-radial delay?

A
  • Palpate both radial pulses simultaneously
  • In healthy individuals, the pulses should occur at the same time
  • If the radial pulses are out of sync, this would be described as radio-radial delay
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31
Q

Name 3 causes of radio-radial delay

A
  • Subclavian artery stenosis
  • Aortic dissection
  • Aortic coarctation
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32
Q

How else can a collapsing pulse be referred to?

A

Water hammer pulse

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33
Q

What is a collapsing pulse?

A

A forceful pulse that rapidly increases and subsequently collapses

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34
Q

How do you assess for a collapsing pulse?

A
  • Ask the patient about pain in the right shoulder
  • Palpate the radial pulse of the right arm and the brachial pulse of the left arm
  • Ask about pain in the shoulder
  • Briskly raise the patient’s arm above their head
  • Feel for a loss of radial pulse, with it returning soon after.
  • When it is lost radially, it should be felt brachially
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35
Q

What is the main cause of a collapsing pulse?

A

Aortic regurgitation

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36
Q

Name some minor causes of a collapsing pulse

A
  • Fever/pregnancy
  • Patent ductus arteriosus
  • High output states e.g. anaemia, arteriovenous fistula, thyrotoxicosis
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37
Q

What pulses should be felt in a cardiovascular examination?

A
  • Radial
  • Brachial
  • Carotid
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38
Q

How do you palpate the brachial pulse?

A
  • Support the patient’s right forearm with your left hand
  • Position the patient so that their upper arm is abducted, their elbow is partially flexed and their forearm is externally rotated
  • Palpate in line with the ‘pinky finger’
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39
Q

What are the 4 types of pulse character?

A
  • Normal
  • Slow-rising
  • Bounding
  • Thready
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40
Q

What may a slow-rising pulse character indicate?

A

Associated with aortic stenosis

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41
Q

What may a bounding pulse character indicate?

A

Aortic regurgitation OR CO2 retention

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42
Q

What may a thready pulse character indicate?

A

Intravascular hypovolaemia in conditions such as sepsis

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43
Q

What are the 5 types of blood pressure abnormalities?

A
  • Hypertension
  • Hypotension
  • Narrow pulse pressure
  • Wide pulse pressure
  • Difference between arms
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44
Q

What is a narrow pulse pressure?

A

Less than 25 mmHg of difference between the systolic and diastolic blood pressure

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45
Q

What 3 conditions may cause a narrow pulse pressure?

A
  • Aortic stenosis
  • Congestive heart failure
  • Cardiac tamponade
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46
Q

What is a wide pulse pressure?

A

More than 100 mmHg of difference between systolic and diastolic blood pressure

47
Q

What 2 conditions may cause a wide pulse pressure?

A
  • Aortic regurgitation

- Aortic stenosis

48
Q

What may a difference in BP between arms indicate, and when is it significant?

A
  • More than 20 mmHg is significant

- May indicate aortic dissection

49
Q

What are the two things that need to be done to a carotid pulse?

A
  • Auscultate

- Palpation

50
Q

Why is the carotid artery auscultated before palpation?

A

To exclude the presence of a bruit

51
Q

What may a bruit of the carotid artery indicate and why is this important?

A
  • Carotid stenosis

- Palpation of the vessel may dislodge a carotid plaque and cause an ischaemic stroke

52
Q

How do you auscultate the carotid artery?

A
  • Place the diaphragm of the stethoscope between the larynx and the anterior border of the sternocleidomastoid muscle
  • Ask the patient to take a deep breath and hold it whilst you listen
53
Q

What is it important to be aware of when auscultating the carotid artery?

A

A ‘bruit’ may be a radiating cardiac murmur

54
Q

How do you palpate the carotid pulse?

A
  • Place the fingers between the larynx and the anterior border of the sternocleidomastoid muscle to locate the carotid pulse
  • Assess the character (e.g. slow-rising, thready) and volume of the pulse
55
Q

What is the jugular venous pressure used for?

A

To give an indirect measure of central venous pressure

56
Q

How do you measure the JVP?

A
  • Position the patient at a 45 angle on the bed
  • Ask the patient to turn their head slightly to the left
  • Look for the IJV (inferior jugular vein) between the medial point of the clavicle and the ear lobe
  • Measure the JVP by assessing the vertical distance between the sternal edge and the top of the pulsation of the IJV
57
Q

What is a healthy length of the IJV when measuring JVP?

A
  • When healthy, it should be no greater than 3cm
58
Q

What does a raised JVP indicate?

A

Venous hypertension

59
Q

Name 3 causes of a raised JVP

A
  • Right-sided heart failure (caused by left sided)
  • Tricuspid regurgitation (caused by infective endocarditis & rheumatic heart disease)
  • Constrictive pericarditis
60
Q

What is the hepatojugular reflux test?

A
  • Involves the application of pressure to the liver to help see for a sustained rise in JVP
61
Q

At which point should you perform a hepatojugular reflux test?

A

Should be at least a 3cm distance from the upper margin of the baseline JVP to the angle of the mandible

62
Q

How do you perform the hepatojugular reflux test?

A
  • Position the patient at 45 degrees
  • Apply direct pressure to the liver
  • Closely observe the IJV for a rise
  • If healthy: rise shouldn’t last longer than 1-2 cardiac cycle
  • If raise is sustained and equal to or greater than 4cm = positive result
63
Q

What may a positive hepatojugular reflux test indicate?

A

That the right ventricle is unable to accommodate an increased venous return

64
Q

Name 4 conditions which may give a positive hepatojugular reflux test

A
  • Constrictive pericarditis
  • Right ventricular failure
  • Left ventricular failure
  • Restrictive cardiomyopathy
65
Q

What may conjunctival pallor indicate on a cardio exam?

A

Underlying anaemia

66
Q

What is corneal arcus?

A

A hazy white, grey or blue opaque ring located in the peripheral cornea

67
Q

What may a corneal arcus indicate in a cardio exam?

A

May suggest hypercholesterolaemia

68
Q

What is xanthelasma?

A

Yellow, raised cholesterol-rich deposits around the eyes

69
Q

What may xanthelsasma indicate?

A

Hypercholesterolaemia

70
Q

What are Kayser-Fleischer rings?

A

Dark rings that encircle the iris

71
Q

What is the relevance of Kayser-Fleischer rings in a cardio exam?

A
  • Associated with Wilson’s disease

- May be excess deposition in the heart, which may cause cardiomyopathy

72
Q

What is angular stomatitis?

A

An inflammatory condition at the corners of the mouth

73
Q

What is the relevance of angular stomatitis in a cardio exam?

A

May indicate iron deficiency

74
Q

What is the relevance of poor dental hygiene in a cardio exam?

A

Risk factor for infective endocarditis

75
Q

What are the 3 things to palpate for in a cardio exam?

A
  • Apex beat
  • Heaves
  • Thrills
76
Q

How do you palpate for the apex beat?

A
  • Palpate the apex beat with the fingers placed horizontally across the chest
  • When healthy = 5th intercostal space in the midclavicular line
77
Q

What may cause displacement of the apex beat?

A

Due to ventricular hypertrophy

78
Q

What is a parasternal heave?

A

A precordial impulse that can be palpated

79
Q

How do you feel for a parasternal heave?

A
  • Place the heel of your hand parallel to the left sternal edge (vertical fingers)
  • If present, the heel of the hand will be lifted with each systole
80
Q

What does a parasternal heave indicate?

A

Right ventricular hypertrophy

81
Q

What is a thrill in a cardio exam?

A

A palpable vibration caused by turbulent blood through a heart valve

82
Q

How do you feel for a thrill in a cardio exam?

A
  • Place your hand horizontally across the chest wall, with the flats of your fingers and palm over the valve to be assessed
  • Do this for every valve
  • This is to assess for palpable murmurs
83
Q

Where is the mitral valve located in the chest?

A

5th intercostal space in the midclavicular line

84
Q

Where is the tricuspid valve located in the chest?

A

4th or 5th intercostal space at the lower left sternal edge

85
Q

Where is the pulmonary valve located in the chest?

A

2nd intercostal space at the left sternal edge

86
Q

Where is the aortic valve located in the chest?

A

2nd intercostal space at the right sternal edge

87
Q

In which order should you auscultate the heart valves?

A
  • Aortic, pulmonary, tricuspid, mitral

- Listen with the diaphragm, then the bell

88
Q

How do you check for mitral regurgitation on auscultation?

A
  • Auscultate the left axilla

- Listen with the diaphragm of the stethoscope

89
Q

How do you check for mitral stenosis on auscultation?

A
  • Have the patient rolled 45 degrees to the left
  • Place the stethoscope over the mitral area and listen with the bell
  • Listen while the patient is holding their breath
90
Q

How do you check for aortic regurgitation on auscultation?

A
  • Sit patient forwards
  • Auscultate at the 4/5th intercostal space to the left of the sternum on held expiration
  • Listen while the patient is holding their breath
91
Q

When auscultating the carotid arteries, what are you listening for?

A

A bruit or a transmitted systolic murmur

92
Q

What you should be assessed for when auscultating the back of the chest?

A
  • Sacral oedema

- Any crackles in the base of the lung

93
Q

What auscultation should be performed is coarctation is suspected?

A

Auscultate to the left of the spine in the 3rd/4th intercostal space

94
Q

What should be checked peripherally in a cardiovascular exam?

A
  • Ankles - pitting oedema
  • Hepatomegaly & pulsations
  • Shifting dullness if ascites suspected
  • Posterior chest wall for lungs
95
Q

If ankle oedema is found in a cardiovascular exam, what else should be examined?

A

The abdomen, to check for ascites

96
Q

What is significant about checking for hepatomegaly and pulsations in a cardiovascular exam?

A
  • If there is a pulsation = may indicate tricuspid regurgitation
97
Q

What would coarse posterior chest crackles indicate on a cardiovascular examination?

A

Pulmonary oedema

98
Q

What would a absent air entry and stony dullness on percussion of the posterior chest wall indicate on a cardiovascular exam?

A

Potential pleural effusion

99
Q

Name 6 potential tests/exams/investigations which would be useful after a cardiovascular examination?

A
  • Blood test (inc. capillary blood glucose)
  • Blood pressure (lying and standing - in different arms)
  • Twelve-lead ECG
  • Fundoscopy
  • Femoral pulses (to check for femoral-radio delay)
  • Peripheral vascular examination
100
Q

What does the 1st heart sound represent?

A

The closure of the mitral and tricuspid valves

101
Q

What does a loud 1st heart sound represent?

A

Mitral stenosis

102
Q

What does a soft 1st heart sound represent?

A

Mitral incompetence

103
Q

What does the 2nd heart sound represent?

A

Aortic and pulmonary valve closure

104
Q

What may a soft 2nd heart sound indicate?

A
  • Aortic stenosis

- Pulmonary stenosis

105
Q

What may a harsh 2nd heart sound indicate?

A
  • Pulmonary hypertension
106
Q

What may a 3rd heart sound indicate?

A
  • Rapid ventricular filling (mitral regurg, VSD)

- Poor LV function (post-MI)

107
Q

When is a 3rd heart sound heard?

A

Just after a 2nd heart sound

108
Q

When is a 4th heart sound heard?

A

Just before a 1st heart sound

109
Q

What may a 4th heart sound indicate?

A

Aortic stenosis

110
Q

What may cause an ejection-systolic murmur?

A
  • Aortic stenosis

- Pulmonary stenosis

111
Q

What may cause a pan-systolic murmur?

A

Mitral or tricuspid regurgitation

112
Q

What may cause an early diastolic murmur?

A
  • Characterised by absence of silence

- Aortic/pulmonary regurgitation

113
Q

What may cause a mid-diastolic murmur?

A
  • Mitral stenosis
  • Rheumatic fever
  • Aortic regurgitation

Phase 2b Medicine (17 decks)

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