Clinical skills: cardiovascular exam Flashcards by Jemma Sch

What are the components of the cardiovascular exam?

Initial approach
General inspection
Vital signs
Upper limb (hands, wrists, elbows/arms)
Face
Neck
Chest
Lungs
Liver
Lower limb
Conclude exam

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INITIAL APPROACH:
What do you need to do?

7 normal steps
Ask if they’re in any pain or discomfort before beginning the exam, and ask throughout

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GENERAL INSPECTION:
What to look for?

Body build
Comfort
Congenital abnormality
Dyspnoea
Distress/pain
Debility
Hydration

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What are the 3 congential abnormalities and their features?
Why is it relevant to CVD?

Turner’s syndrome: webbed neck, short
Marfan syndrome: tall, skinny, long limbs/fingers, kyphosis
Down syndrome: almond shaped eyes
As they confer increased risk to CVD

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VITAL SIGNS
- What are they?
- Do you have to perform them in the APEX?

Respiratory rate
Pulse: radial pulse rate and rhythm
Blood pressure
Temperature

No - can say you’d ordinarily do them but skipping today

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UPPER LIMB: HANDS
- What are you looking for?
- What are you feeling for?

LOOK
General:
- Clubbing
- Peripheral cyanosis

Lesions (pictured!)
- Janeway lesions
- Osler nodes
- Splinter haemorrhage
- Tar staining
- Xanthomata

FEEL
- Cold
- Sweat
- Capillary refill

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What is endocarditis?
What is its usual cause?
How does it contribute to Janeway lesions, Osler nodes, splinter hemorrhage?

Inflammation of the inner lining of the heart’s chambers and valves.
Due to infection.
Infective emboli go from heart and are deposited in capillaries

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Are Janeway lesions and Osler nodes rare?

Yes

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Difference between Janeway lesiosn and Osler nodes? How to remember?

Janeway lesions: palpable but not painful.
Osler nodes: palpable and painful (O for ouch/oh that hurts)

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UPPER LIMBS: WRISTS
What to do?
Is it okay to skip?

Radio-radio delay
Radio-femoral delay

Yes - if you acknowledge

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UPPER LIMBS: ELBOWS AND ARMS
What to do?

Xanthomata
Brachial pulse

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Xanthomata
- What is the singular name?
- What are they?
- What are they caused by?

Xanthoma
Yellow skin lesions
Fat within macrophages is deposited in the skin. Usually due to primary lipid disorders.

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Xanthomata
- What is the singular name?
- What are they?
- What are they caused by?

Xanthoma
Yellow skin lesions
Fat within macrophages is deposited in the skin. Usually due to primary lipid disorders.

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FACE
What 3 parts of the face do you look at?

Cheeks
Eyes
Mouth

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FACE
Overall, what do you look for?

Cheeks: mitral facies
Eyes:
- Jaundice (whites)
- Pallour (conjunctiva)
- Corneal arcus/arcus senilis
- Xanthelasma

Mouth
- Lips: central cyanosis, petechiae
- Tongue: central cyanosis
- High arched palate
- Teeth and gums

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FACE
What does conjunctival pallour indicate?
Xanthelasma are ________ but around the eyelids
What are petechiae and their causes?
Where should you look on the tongue for central cyanosis?
High arched palate is a sign of

Anemia
Xanthomata
Red dots, due to capillaries bursting. Due to impaired blood clotting/vascular integrity
Underneath
Marfan syndrome

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FACE
Mitral facies
-What is the cause?
- What is the effect?

Severe mitral valve stenosis –> cutaneous vasodilation –> abnormal flushing of the cheeks

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FACE
Corneal arcus
- What causes it?
- Is it normal in older people? What is it called?
- Is it normal in younger people? What is its cause?

Deposits of lipids around the corneal margin, forming an arc (thus the name)
Yes, arcus senilis
No, lipid metabolism disorders

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NECK
- What must you do before the tests?

Make table 45 degrees

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NECK
What are the tests

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Internal jugular vein:
- Jugular venous pressure
- Abdominojugular reflex

Carotid artery
- Palpation (2 fingers)
- Thrills (palm of hand)
- Bruits (auscultate)

NECK
Jugular venous pressure
- What does it approximate?
- How to locate the internal jugular vein?

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central venous pressure

Turn head 45 degrees to the left
Should see double flickering - if not, light and abdominojugular reflex can help

NECK
Jugular venous pressure
- How to measure

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Measure vertically from the sternal angle to the top of the jugular vein.

With ruler going up, stick going across.

NECK
Jugular venous pressure
- What is normal?
- What does above and below this mean?

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3-4cm is normal
Above: elevated central venous pressure
Less: dehydration, low blood volume

NECK
Abdominojugular reflex
- How to conduct?
- Normal and abnormal results?

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Place hand firmly in middle part of upper abdomen, then look at internal jugular vein.
Normal: temporary jugular vein distension
Abnormal: persistent distension

NECK - When should you palpate both carotids at once? - Carotid bruits: when do they occur? NOrmal and abnormal findings?

- Never - During turbulent flow. So don't hear normally, only during narrowing

CHEST What are the 4 parts of the chest exam?

Inspect Palpate Auscultate Specialised manouevres

CHEST Inspect: what do you inspect for?

Skin: - Scars - Rashes CVS: - Apex beat - Abnormal pulsation - Breathing pattern Other deformities - Skeletal deformities (barrel chest, funnel chest, pigeon chest) - Sacral oedema - Pacemaker

CHEST Inspect: do you know what barrel chest, pigeon chest, funnel chest deformities look like?

Yes

CHEST Palpate: what 3 things do you palpate for?

Apex beat Heaves Thrills

CHEST Palpate: - How do you palpate the apex? - Is it palpable in all people? - Who is it harder to palpate in?

With fingertips Not all - 50% Women, larger people

CHEST Palpate: heaves -How do you do heaves? - Where do you palpate?

Palpate the left of the sternum with the heel (H for heaves and heel) of your hand

CHEST Palpate: thirlls - How do you palpate thrills? - Where do you palpate thrills?

with palm of hand Over aortic, pulmonary, tricuspid, mitral areas

CHEST Palplate: where is the - Base - Apex - Aortic area - Pulmonary area - Tricuspid area - Mitral area

CHEST Auscultate - Which areas do you ausculate and with bell, diaphragm, or both? - What additional step must you complete?

- Aortic: diaphragm only - Pulmonary: diaphragm only - Tricuspid: diaphragm only - Mitral: diaphragm and bell Comment on heart sounds S1 (lub) and S2 (dub), and additional sounds

CHEST Special manoeuvres What are the 5 you must perform? With bell, diaphragm, or both?

Left lateral decubitus: lie on left side. Auscultate with bell over the mitral valve. aOrtic: get patient to breathe Out, hold breath, auscultate with diaphragm over aortic area Pulmonary: get patient to breathe in, hold breath, auscultate with diaphragm over the pulmonary area Tricuspid: get patient to breathe in, hold breath, auscultate with diaphragm over the tricuspid area Leaning fOrward: get patient to lean fOrward, breathe Out, hold breath, auscultate with diaphragm over 3rd left intercostal space.

CHEST What are some symptoms of right heart failure

Lower limb pitting odema Sacral odema GI tract congestion (abdominal pain, anorexia, weight loss) Hepatomegaly

CHEST What are some symptoms of left heart failure

Decreased CO --> cyanosis, decreased exercise tolerance Fluid in lungs: - Orthopnoea, paroxysmal nocturnal dyspnoea - Cough with frothy sputum - Cyanosis, hypoxia

LUNGS Percussion (generally): what structures lead to dull sounds? Resonant sounds?

Solid/liquid structures Gas structures

LUNGS Auscultation of lungs - What leads to normal breath sounds? Crackles? No breath sounds?

Normal lungs, pulmonary oedema, loss of lung tissue (eg. pleural effusion which pushes lungs up)

LUNGS Complete the table

LUNGS - What positiondoes the patient need to be at? - What two steps need to be done (in how many places?)

Sitting up Percuss (4 spots) Auscultate (4 spots)

LIVER - What position/angle should the patient be at? - What two steps do you need to do? - What is the goal of these steps?

Flat/0 degrees Palpate Percuss Determining liver size - hepatomegaly may indicate right heart failure

LIVER How to palpate the liver?

Get patient to breathe in and out During out breaths, move, fingers up. Should be able to feel the curvature of the liver just under the right ribcage.

LIVER How to percuss the liver? What percussion sound should it be?

Go straight up then diagonally up Dull

LOWER LIMB What should you look for?

Achilles tendon xanthomata Colour change/cyanosis Clubbing of toenails Hair loss Janeway lesions Osler nodes Pitting oedema Ulcers Varicose veins

LOWER LIMB What should you feel for?

Pitting odema Temperature Capillary refill Pulses - femoral, popliteal, posterior tibial, dorsalis femoris

BEFORE FINISHING THE EXAM - What two things could you consider examining?

Urinanalysis for assessment of white blood cells if endocarditis is suspected Examine the fundi for vascular changes if appropriate

FINISHING THE EXAM What 3 steps?

* Report findings to supervising clinician * Ask if they have any questions * Thank patient for their time

Clinical skills: cardiovascular exam Flashcards

(48 cards)