Cardiovascular system exam and anatomy

Question 1

What are the margins needed to mark the surface outline of the heart?

Answer 1

3rd CC

6th CC

2nd Inter costal space

5th intercostal space at Mid clavicular line

Question 2

How do you find and palpate the apex beat of the heart

Answer 2

Use 4 finger excluding thumb and line them across 4th, 5th and 6th ICS and move them from right of the patient to left

Question 3

Where can the apex beat be found in adults and children

Answer 3

Adult: 5th ICS along mid clavicular line.

Females- beneath the breast along its lower border a sbreats extend from 2nd to 6th ICS

Children: slightly higher on the 5th rib

Question 4

What does a shift in the apex beat laterally or inferiorly mean?

Answer 4

Normally cardiomegaly OR Occasionally chest wall deformity, mediastinal shift or underlying pleural or lung disease

Question 5

what is a thrill and how can you examine it?

Answer 5

it is a hyperkinetic and more sustained beat.

You can palpate it by placing the flat of hand at the apex and upper precordium

A palpable vibration will be felt under your hands

Question 6

What is a “thrill” a characteristic of? When may it occur?

Answer 6

Volume overload

May occur in heart failure and mitral or aortic regurgitation

N.B aortic regurgitation sound here

Question 7

What may result in a “heave”

Describe how you would palpate for it?

Answer 7

Hypertrophy of left ventricle- this heave may extend out towards axillary

Heaves are palpated by placing you hand vertically on the left of the sternum, a heave will lift the heel of you hand with each beat.

Question 8

Where can the apex beat be palpable in dextrocardia?

Answer 8

Right side of the sternum

Question 9

In what patients may apex beat not be palpable?

Answer 9

Thick chest wall, emphysema, pericardial effusion and shock

Question 10

What are the heart valves you need to auscultate and where can you find them? IN ORDER

Answer 10

Mitral - left 5th ICS at mid clavicular line

Tricuspid- left 5th ICS near sternum

Pulmonary - left 2nd or 3rd ICS near sternum

Aortic - right 2nd ICS near sternum

Question 11

What produces the first large sound (lub) of the heart?

Answer 11

The closing of the tricuspid and mitral valves

Question 12

What produces the 2nd quieter sound (dub) of the heart

Answer 12

The closing of the pulmonary and aortic valve

Question 13

What are the order in which the valves are arranged?

Answer 13

Question 14

During palpation of arterial pulses what can you evaluate?

Answer 14

Pulse rate- right radial pulse

Rhythm- right radial pulse; abnormal during atrial fibrillation or ectopic beats

Character and volume- right carotid

Symmetry- brachial, femoral, radial of both hands

Radio-femoral delay

Question 15

What are the sites of palpating arterial pulses in upper limb

Answer 15

Radial pulse Ulnar pulse Axillary pulse Cubital fossa pulse Brachial artery pulse Subclavian pulse

Question 16

What are the sites of palpating arterial pulses in head and neck

Answer 16

Carotid artery pulse Superficial temporal

Question 17

What is the most common site for venepuncture? How do you discern it?

Answer 17

Median cubittal vein

Encircle patient middle hand and ask them to close and open fist quickly.

Question 18

Outline the procedure for palpating the apex beat

Answer 18

You should use your palm and 4 fingers of your right hand to palpate. You should align your fingers along the left 4th, 5th and 6th intercostal spaces.

You should start palpation from the left lateral chest wall (near the mid-axillary line), and move to the anterior chest wall (towards the mid-clavicular line).

If you find the apex beat difficult to palpate in your colleague, a brisk “jogging on the spot” by your colleague (for 1 minute) may increase the heart rate and strength of the heart beat that enables easier palpation.

In females, the examiner’s hand should be laid beneath the breast along its lower border (a mitral valvotomy scar could be missed if the apex beat is not visualised).

Question 19

What are the Abnormalities of the apex beat and explain what it connotes

Answer 19

Shift laterally and inferiorly- means left ventricular hypertrophy or cardiomegaly

Any shift due to:

• Chest wall deformity
• mediastinal shift
• underlying pleural or lung disease

Shift to the right side of the body- dextrocardia

Not palpabel ins ome pts due to?

Question 20

Summarise the cardio exam we need to know for the CPA

Answer 20

Position and Exposure

• Patient lying down at 45 degrees
• Patient adequately exposed from the waist upwards

Inspection

• General inspection- look for scars, lateral thoractomy, ICDs

Palpation

• Palpation of the radial artery including rate and rhythm
• Palpation of the ulnar artery
• Palpation of the brachial artery
• Palpation of the common carotid artery
• Palpation of the apex beat
• Palpation of heaves
• Palpation of thrills

Percussion

• N/a

Auscultation

• Auscultation of the aortic valve
• Auscultation of the pulmonary valve
• Auscultation of the tricuspid valve
• Auscultation of the mitral valve

Question 21

what causes this heart sound and where do you auscultate for it?

Answer 21

Aortic stenosis-

ausculate at carotid artery

it is a early crescendo decresndo murmur

Question 22

what causes this heart sound and where do you auscultate for it?

Answer 22

Aortic regurgitation

Ausculatate at aortic valve with pt leaniong forward

it is an early diastolic murmur

Question 23

where do you auscultate to ascertain a mitral valve stenosis or mitral valve regurgitation murmur

Answer 23

Mitral valve sound position when pts lie on the left side

Question 24

what does this echocardiogram show and give relevant symptoms or signs

Answer 24

Calcific aortic stenosis

Signs:

• Echogenic and immobile aortic valcve leeaflet
• Turbulent flow and reduced opening of valve
• Ejection systolic murmur radiating to carotid
• Slow risingg pulse felt on carotid and narrow pulse pressure

Question 25

what are all the clinical manifestation of valve disease

Answer 25

Mild- moderate aortic valve- asymptomatic Ejection systolic murmur with chestpain, SOB and dizziness/syncope shows **severe aortic stenosis** Decompensated heart failure * Exertional heart failure with * SOB (bi-basal crepitations) and * pitting oedema * and other signs

Question 26

if you suspect valve disease, what are the relevant Ixs you should order

Answer 26

**Echocardiogram-** gold standard as it allows **evaluation of flow and pressure across valv**e and asseses overall cardiac function CXR and ECG are very useful before getting to echo Cardiac catherisation- diagnostic test for CHD. Cardiac Angiography

Question 27

what is the ankle brachial pulse index and how is it significant in Peripheral artery disease?

Answer 27

ABPI is a ratio of the brachial systolic BP. Can be measured using a sphygmomanometer and a hand held dopple device in peripheral artery disease the ABPI is very low (0.4) in affected leg. The lower the number the more severe the disease Can be normal in unaffected leg

Question 28

if pts has symptoms and exams suggestive of peripheral artery disease, what are the Ixs and in what order? Give advantage and disadvantage of each

Answer 28

**CT angiography** - very accesible in hospital DS angiography- gold standard but had to do as it requires an interventional radiologist USS Doppler- look for blood flow and hence can see stenosis. Very accesible for primary care MRI angio-

Question 29

if someone has intermittent claudication due to peripheral artery disease, what is very important to discern

Answer 29

Claudication distance- can tell severity

Question 30

what are the main symptoms suggestive of aortic dissection? what BP readings can occur

Answer 30

**Sudden severe** chest pain (could be in abdo). it can be sharp or ripping or tearing pain **Radiate to the back** **May faint** There could be very huge discrepancy between right and left brachial BP depending on site of aortic dissection

Question 31

Describe the microanatomy of aortic dissection

Answer 31

A tear in the **tunica intima** of aorta Hence lead to creation of false lumen. Lead to ischaemia

Question 32

if a pt is unstable (fainted) but you have collected collateral Hx with symptoms suggested of aortic dissection, what is the first Ixs afrter stabilising pt

Answer 32

Urgent Coronal CT N.B: can see line in aorta which shows dissection

Question 33

What are the clinical manifestation of the types of aortic dissection in terms of pain

Answer 33

Type A (both type 1 and 2) * Anterior chest pain - 70% * Posterior back pain - 30% Type B (3) * Back pain (64%) then followed by chest (60%) and /orabdominal pain (40%)

Question 34

There are several sites of aortic dissection, what does it mean for the symptoms depending on site

Answer 34

Can present with stroke, neuro symptoms if less blood goes to carotids End organ ischaemia (could be bowel or liver)

Question 35

Contrast the 3 Stanford classification of aortic dissection?

Answer 35

Type A- (1) * Affects aortic arch and body * most common * Can have neuro symptoms Tye A (2) * Affects only arch * Can have neuro symptoms Type B (3) * Common in older people * Arch not affected * Caused by High BP * No need for surgery - treat conservativey with BBs * No neuro symptoms

Question 36

what is the surgical treatment for Aortic dissectio?

Answer 36

In surgical treatment, the area of the aorta with the intimal tear is usually resected and replaced with a Dacron graft.

Question 37

Discern this heart sound

Answer 37

Mitral stenosis Mid-diastolic murmur

Question 38

Discern this heart sound

Answer 38

Mitral regurgitation Pan-sytolic murmur