Cardiovascular Exam Competencies 2023 PDF

EPC III Competencies for the Advanced Cardiovascular Exam The Screening Cardiovascular Exam Components/Description https://youtu.be/5RGld6kt1Eo General evaluation: “How are you feeling?” Examine the upper extremity o Hands and nails for color and pat...

EPC III Competencies for the Advanced Cardiovascular Exam The Screening Cardiovascular Exam Components/Description https://youtu.be/5RGld6kt1Eo General evaluation: “How are you feeling?” Examine the upper extremity o Hands and nails for color and pathology. o Evaluate the pulses bilaterally When to apply this exam? o Check capillary refill A patient that has Position the patient supine at 45 degrees of elevation suspected cardiovascular Examine the lower extremity disease. o Examine legs and feet for color and hair distribution o Complaints of chest o Check pulses in feet bilaterally pain, dyspnea, etc. o Check for pitting edema (If patient has been lying supine for an extended period check the sacrum) o Suspected of having Evaluate the Jugular venous pressure visually (JVD?) heart failure, CAD, Ausculate the Carotids Vascular disease of Ausculate the Heart any kind, etc. o Alter positions for ausculation with significant pathology and/or irregular hear sounds Risk factors for heart § Left lateral decubitus disease o Palpate for PMI if suspected displacement o History of Diabetes o Palpate if the ausculation reveals mumur: palpate the chest for a thrill o History of HTN § Have the patient sit up and lean forward o Smoking history Ausculate the Lungs (4 in front, 6 in the back, 1 in right axillae in the sitting position) Perform a Structural exam Position the patient to a supine position (if tolerated) Ausculate the vessels of the abdomen  Technique Description Image Interpretation Description of Findings Inspection General Appearance Evaluate for Distress Does the patient appear ill? Posture, facial expression Diaphoretic Respiratory distress Lying supine Psychiatric (Anxiety, Responsive Irritability) Skin color Cyanosis: Blue color seen through the skin Cyanosis can be documented 1. Check for signs of secondary to deoxygenated hemoglobin in the skin exam or it can be o Cyanosis levels. (also reduced hemoglobin, presence of documented in the methemoglobin, or presence of sulfhemoglobin) § Local (In a certain limb, Local Cyanosis caused by local arterial Cardiovascular section of the or upper limbs and not obstructions, venous stasis and things like Raynaud note. lower limbs) phenomenon. Often skin color is Central Cyanosis Caused by hypoxemia (right to documented in the § Central (In the middle of left shunts or lung disorders), or abnormal body, trunk) hemoglobin pigments. cardiovascular section when § Peripheral (In the distal Peripheral Cyanosis implies normal arterial it pertains to perfusion of the parts of the extremities) oxygenation but increased extraction of the oxygen tissue. peripherally. Caused by vasoconstriction secondary to o Pallor cold exposure, or a reflex response to decreased § Hands cardiac output. § Palms Pallor: lack of pink color to skin. § Conjunctivae Caused by things like anemia, shock, and metabolic derangements like hypoglycemia. Upper Extremities Specific Clubbing The list of causes is very long: The presence of clubbing is 1. Examine for clubbing in fingers Cardiac: commonly documented in the Cyanotic congenital heart disease 2. Angle of nail bed and nail plate Skin/Hair/Nails section or the Infective endocarditis should be less than 160. Pulmonic: Cardiovascular section of the 3. Have the place the nails of both Chronic interstitial lung disease note. index fingers together. Cystic fibrosis 4. The angle between the nail fold Chronic lung infections (ex: lung abscess) S/H/N and nail plate is greater than 180 Lung Cancer No clubbing degrees, loss of diamond shaped Asbestosis window from the dorsal surface of Other: Liver cirrhosis the corresponding finger of each hand represents clubbing. Inflammatory bowel disease Splinter hemorrhages Can be caused by 1. Longitudinal lines on the nail Simple trauma (Not significant) CV plate Often be related to micro emboli from: Splinter hemorrhages under the 2. Splinter hemorrhage – small right index nail. o Endocarditis (most likely) vertical lines 1-3 mm in length, o Thoracic outlet syndrome caused by a red or brown in color, does not cervical rib. involved the nail plate, non blanching Lower Extremities Specific Pitting Edema (primarily in the lower Edema is caused by 1 of 6 mechanisms: extremities, can be in upper 1. Increased venous or hydrostatic pressure 2+ pitting edema up to the extremities and over the sacrum if the 2. Reduced interstitial hydrostatic pressure upper shin. patient is supine) 3. Decreased plasma oncotic pressure 1. Press on a bony surface like the 4. Increased interstital oncotic pressure Grade 1: 0–2 mm lower shin. 5. Increased capillary leakiness Grade 2: 3–4 mm 2. Hold the pressure for at least 2 6. Dysfunctional lymph system Grade 3: 5–6 mm seconds. Some diagnoses that cause pitting edema: Grade 4: 8 mm or deeper. 3. Remove the pressure and evaluate CHF, Liver disease, Nephrotic syndrome, the absence or depth of the Image credit: James Heilman, MD, (2017, Renal failure, Venous insufficiency, temporary cavity in millimeters. February 1). pregnancy, malignancy, hypoalbuminemia (View the depth in thickness of dimes) Auscultation Auscultation of the Carotids Early systolic bruit is associated with CV 1. Auscultate carotid arteries with a 50% decrease in carotid artery No carotid bruits proper technique diameter 2. Position the patient sitting upright There is no sound if the vessel is not Or or supine at 30 degrees of elevation. narrowed or if it is completely 3. Using the bell of the stethoscope, occluded. CV listen for a bruit, check bilaterally. The bruit may be absent if the vessel Left carotid bruit (Littman Cardiology 3 & 4, light contact is the bell, increased pressure serves as the is significantly narrowed. diaphragm) 4. You can ask the patient to hold their breath. If the patient holds Listen over the red line as seen on the their breath, you hold your breath photo. with them. Auscultation of Heart Sounds 1. Identify S1 & S2 CV No edema, or cyanosis. No carotid 1. Auscultate over the following 2. Be aware of the respiratory cycle bruits, PMI non displaced, locations: 3. Evaluate the RRR, no murmurs rubs, or gallops. o Aortic a. Rate Pulses 3+ in the radial, dorsalis pedis, and posterior tibial bilaterally. o Pulmonic b. Rhythm Or o Tricuspid c. Extra beats CV o Mitral d. Murmurs Carotid bruit on the left. Tachycardic regular rhythm. S3 and S4 noted. 3/6 2. Evaluate the rate, rhythm, and crescendo-decrescendo systolic murmur listen for extra beats and loudest at the right upper sternal murmurs at every location. border. 3. ALWAYS on skin!! Auscultation of Abdominal Vessels 1. Listen over each major vessels for just a few seconds for each of the following locations. Right renal artery Aorta Left renal artery Left iliac artery Right Iliac artery Palpation Palpation of the Anterior Chest Wall (If a prominent murmur is auscultated or right heart disease is suspected) Heaves/lifts of precordium, Thrills Heave: A sustained lifting motion that No heaves or lifts 1. Explain to the patient that you pushes the hand up. It signifies right will be feeling for abnormal ventricular hypertrophy. The incidence is vibrations very rare but it often signifies late disease It is generally not necessary 2. Palpate chest wall with finger and poor prognosis. to mention heaves or lifts if Thrill: A palpable vibration coming from the pads held flat against the the patient doesn’t have a murmur. See the scale for grading intensity chest murmur. to identify how a thrill impacts the 3. Feel for sustained impulses evaluation. felt under the fingers  in the 5ᵗʰ intercostalspa Palpation of Apical Impulse or Point of Maximal Impulse (PMI) (If cardiac disease is suspected) 1. Describe to the patient the The apical impulse or PMI is normally A Medial to The PMI is 2cm at the mid purpose and details of the exam. located at the 5th intercostal space 1 to clavicular line. 2. Place the finger pads over the 5th 2 cm medial to the midclavicular line. intercostal space from the PMI is displaced right in pulmonary Or sternum to the lateral chest disease 3. Identify the area of the impulse. PMI is displaced left in left ventricular The PMI is enlarge at 3cm 4. Note the diameter of the hypertrophy/enlargement or a high impulse. and is displaced lateral to the diaphragm or pregnancy. 5. Patients may need to hold breast A displaced apical Impulse is one of the midclavicular line. tissue up and out of the way strongest predictive signs for heart 6. If the impulse is not palpable failure. supine, have the patient move to A PMI with a diameter of >2.5cm the Left Lateral decubitus suggests enlargement. The larger the position. This will move the PMI up to 4cm, the more suggestive. impulse to the midclavicular line Lateral displacement has a strong or just lateral to it. correlation with: o Ventricular dilation o Congestive heart failure o Cardiomyopathy o Mediastinal shifts. Palpation of Peripheral Pulses General Evaluation of the Pulses Rate: 100: Tachycardia 1. Rest the tips of the index and Rhythm: Do the beats occur at uniform middle finger on the correct intervals. anatomic location. The rating of the pulses as part of the 2. Increase to moderate pressure to character: identify a pulse in a vessel. 0 no palpable pulse. 3. If unable to evaluate a pulse, 1+ Diminished compress the tissues against a bony 2+ Normal surface and slowly release until the 3+ increased 4+ indicating a bounding pulse. best pressure is maintained to evaluate the pulse. 4. Evaluate the rate, rhythm, and the character. Carotid 1. Press just inside of the medial border of the SCM with your fingertips and avoid the carotid sinus that lies at the top of the thyroid cartilage. Never press both carotids at the same time as it could lead to syncope. Brachial The brachial artery runs on the medial part of the upper arm from the shoulder to the antecubital fossa. Evaluate the pulse just proximal to the antecubital fossa. Radial The radial artery is just proximal and medial to the styloid process of the radius. Superficial to medium pressure should be sufficient to evaluate this artery. Femoral The femoral artery runs down the medial aspect of the thigh. Visualize the vessel as it splits at the umbilicus and runs down the leg. Popliteal The artery runs down the back of the leg in the center of the knee and deep in the popliteal fossa. Press the fingertips of both hands into the fossa with a significant amount of pressure to evaluate the popliteal artery. Posterior tibial The posterior tibial artery runs about a half centimeter posterior to the medial malleolous. Use the same approach as you would use for the radial artery. Dorsalis pedis The dorsalis pedis artery runs just medial to the Extensor Digitorum Longus tendon to the big toe. Use the same approach/pressure as you would use for the radial artery but you may have alter your vector of pressure to get a hard surface to compress the artery.  Cardiovascular Special Tests Overload Syndromes Measurement of jugular venous A normal jugular venous pressure is less pressure than 8 cm + JVD 1. Adjust the patient to 45 degrees A JVP that is 8cm or higher is called of incline and slightly turn the Jugular Venous Distension (JVD) head to the left The absence of JVD is a better Or 2. Identify the jugular vein on both sides and find the internal jugular instrument to rule out heart failure pulsations than its presence confirms heart 3. Focus on the right internal jugular failure. No JVD vein Some causes of JVD are listed below: 4. Identify the highest point of Right ventricular failure pulsation in the right jugular vein Pericardial compression 5. Extend a hard card or object (constriction/tamponade) – little or horizontally level from this point no pulsations when severe to a ruler placed on the sternal Tricuspid stenosis angle making a right angle Superior vena cava (SVC) obstruction 6. Measure the vertical distance – no pulsations and add 5 cm to this. Circulatory overload 7. This sum is the JVP Renal failure Excessive fluid administration Atrial septal defect with mitral valve https://youtu.be/Zb-rScaQeF0 disease Assessment of Hepatojugular reflux The hepatojugular reflux test evaluates the 1. The patient should be positioned hearts ability to compensate with an increased 30-45 degrees in the supine amount of blood volume. It is likely that a good position. amount of pressure to the liver may shift from a 2. Apply a mildly uncomfortable quarter to a half liter of blood volume into the amount of pressure over the liver vascular circulation. In a healthy cardiovascular and hold that pressure for 10 system you will see an increase in JVP initially seconds. but will the heart will compensate with in 10 3. Evaluate the rise in the JVP seconds to see a lowering of the JVP. during the application of the Positive tests are commonly seen in congestive pressure and identify any heart failure but it could be present in https://youtu.be/acPxmC6oexk changes to the JVP during this constrictive pericarditis or a restrictive time frame. cardiomyopathy.  Perfusion Abnormalities Capillary Refill Capillary perfusion is based on the driving Capillary refill < 2 seconds 1. Check for perfusion/capillary pressure, arteriolar tone, and capillary refill using distal finger or palm of patency & density. Or hand The major factors in delaying capillary refill 2. Press on skin to induce blanching times: Dehydration/low blood volume Capillary refill at 4 seconds 3. Let go of the pressure and Reduced pump pressure (CHF) observe the return of the pink Increased permeability as seen in shock shade to the previously It is most predictive in children and suggests compressed tissue. dehydration. 4. Measure in seconds the time for A good scale to follow: blanched skin to return to the