Cardiovascular examination (inc. general principles) Flashcards
(26 cards)
What should be included in the introduction to the consultation?
- Greet your patient
- Introduce yourself and your role
- Explain what you are going to do and why, and gain consent to proceed with the examination
- Clean your hands
- Ongoing communication to patient involves clear instructions and attention to your patient’s comfort.
- Demonstrate a Professional manner throughout
- Examination method is structured and performed fluently and in a logical order.
What should you note in your general observation of the patient?
- colour
- conscious level
- any pain or breathing difficulty
- build
What should your note in your general observation of the observation?
oxygen or other bedside equipment
- GTN spray/medication
What key signs of cardiovascular disease might be observed in the hands and nails?
- clubbing
- nicotine staining
- splinter haemorrhages
- tendon xanthoma
- Janeway lesions
- Osler’s nodes, pale palmar creases
- palpate to ascertain capillary refill time which should be
What might clubbing indicate?
- Lung disease (see respiratory exam)
- GI disease (see GI exam)
- Cardio disease:
- Any disease featuring chronic hypoxia (e.g. COPD)
- Congenital cyanotic heart disease (most common cardiac cause)
- Subacute bacterial endocarditis
- Atrial myxoma (benign tumor)
- Tetralogy of Fallot
What might splinter haemmorhages indicate?
- subacute infective endocarditis,
ALSO - scleroderma, - trichinosis - systemic lupus erythematosus (SLE) rheumatoid arthritis - psoriatic nails - antiphospholipid syndrome - haematological malignancy - trauma
What are Janeway’s lesions are what might they indicate?
Non-tender, small erythematous or haemorrhagic macular or nodular lesions on the palms or soles only a few millimeters in diameter that are indicative of infective endocarditis.
What are Osler’s nodes and what might they indicate?
Painful, red, raised lesions found on the hands and feet. They are associated with a number of conditions, including infective endocarditis, and are caused by immune complex deposition.
ALSO
- SLE
- Marantic endocarditis
- Disseminated gonococcal infection
- Distal to infected arterial catheter
What might pale palmar creases indicate?
Anaemia
What is tendon xanthoma and what does it indicate?
Deposition cholesterol-rich substance in tendons. Seen in hyperlipidaemia.
How should the patient’s pulse be measured and reported?
- palpate for 30 secs ( 60 secs if pulse irregular)
- report rate, rhythm & character
- Check for radio-radial delay and radio-femoral delay
- Ensure your patient does not suffer with arm or shoulder pain before
Describe the various radial pulse abnormalities and their causes.
Irregularly irregular
- atrial fibrillation (or multiple ectopics)
Regularly irregular
- 2nd degree heart block
Water hammer pulse (= Collapsing)
Strong radial pulse that taps hand on lifting of arm
indicates wide pulse pressure of aortic regurgitation
Bounding pulse
- CO2 retention
- Liver failure
- Sepsis
Small volume thready pulse
- shock
Radio-radial delay
- suggests coarctation or dissection
Arterio-venous fistulae - buzzing - for dialysis
What else should you do following pulse assessment?
Offer to take a standing BP to assess for postural hypertension.
What should be of note in the patient’s face if present?
Malar flush - mitral stenosis
Eyes, lips & tongue
- look in the eyes for xanthelasma, a corneal arcus and for pallor of conjunctivae.
- Look at the lips for peripheral cyanosis and under the tongue for central cyanosis.
- Ascertain general dental hygiene.
What might a high-arched palate be suggestive of?
Marfan’s syndrome
What is xanthalasma and what might it indicate?
- Sharply demarcated yellowish deposit of fat underneath the skin, usually on or around the eyelids.
- May indicate hyperlipidaemia
What is a corneal arcus and what might it indicate?
White, grey, or blue opaque ring in the corneal margin (peripheral corneal opacity), or white ring in front of the periphery of the iris. It is present at birth, but then fades; however, it is quite commonly present in the elderly. It can also appear earlier in life as a result of hypercholesterolemia.
What should you listen for in the carotid pulse and what might it indicate?
Bruits - turbulant blood flow, may indicate carotid artery disease
How do you take a jugular venous pressure and what is its relevance?
- Sit patient at 45° and turn head slightly away from you.
- Look for JVP in internal jugular vein medial to the clavicular head of sternocleidomastoid; the vein passes behind the angle of the jaw in direction of earlobe.
- Measure JVP in cm above the sternal notch - a vertical not diagonal distance - if larger than 3cm the JVP is raised.
Raise JVP might indicate:
- right heart failure
- fluid overload
- bradycardia
- many other things!!!
What is the hepato-jugular reflux?
Hepatojugular reflux is the distension of the neck veins precipitated by the maneuver of firm pressure over the liver.
It is seen in:
- tricuspid regurgitation
- heart failure due to other non-valvular causes
- constrictive pericarditis
- cardia tamponade
- inferior vena cava obstruction.
What should you look out for when observing the patient’s chest/praecordium?
- Scars (thoracotomy, sternotomy)
- Deformity
- Pulsation
- Pacemaker boxes
What should be observed when performing palpation?
Thrills
- Palpable heart murmers
Heaves
- Precordial chest movements
- parasternal heave of RVH
Apex beat may be (5th intercostal space)
- tapping (quick and light) - mitral stenosis
- thrusting (diffuse and long) - mitral regurgitation
- heaving (sharp and firm) - LVH & aortic stenosis
Aside from auscultating the heart valves, what else should you auscultate?
Listen at lung bases for fine inspiratory creps of pulmonary oedema (LVF)
What might sacral oedema in the bedbound patient indicate?
Heart failure
