Cardiovascular Examination PDF

Cardiovascular Examination. Dr Rebecca Walmsley Slide content from Dr Robert Humphreys [email protected] 1 Learning Outcomes.  To demonstrate an understanding of the fundamentals of the Cardiovascular Examination.  To identify physical signs of cardiovascular disease.  To relate clinical...

Cardiovascular Examination. Dr Rebecca Walmsley Slide content from Dr Robert Humphreys [email protected] 1 Learning Outcomes.  To demonstrate an understanding of the fundamentals of the Cardiovascular Examination.  To identify physical signs of cardiovascular disease.  To relate clinical signs to underlying pathology.  To recognise the importance of using history & examination findings to help reach a diagnosis. 2 The Traditional Medical Model. • History • Examination • Investigation • Diagnosis • Treatment • Follow-up 3 https://st-andrews.cloud.panopto.eu/Panopto/Pages/Viewer.aspx?id=59b911a6-cf87-4f47-9471-a97e00b1e37a 4 5 Cardiovascular Examination. • Use what you have learned from the history to direct and focus your clinical examination. • The Cardiovascular System does not exist in isolation from the other systems. • Apply your scientific knowledge. 6 7 Cardiovascular Examination. • Introduction and explanation. • Inspection. • Palpation. • (Percussion). • Auscultation. • Other areas. • Conclusion. 8 INTRODUCTION • Ensure adequate hygiene of hands and stethoscope. • Introduce yourself. • Confirm patient’s name and date of birth. • Ask if patient is in any discomfort. • Explain the procedure. • Seek permission to examine. • Position patient at 45 degrees with chest adequately exposed. 9 GENERAL and CLOSE INSPECTION. • Stand at end of bed. • Look around the patient. • Look at patient. • Does patient look unwell? • Any suggestion breathlessness, discomfort, pain? 10 GENERAL and CLOSE INSPECTION. • Examine hands to assess circulation for warmth, capillary refill, evidence of peripheral cyanosis, tar staining, clubbing, splinter haemorrhages, Janeway lesions, Osler’s nodes, and koilonychia. • Examine face, eyes and mouth for signs of e.g. malar flush, pallor, clinical anaemia, xanthelasmata, corneal arcus, and central cyanosis. • Assess capillary refill time; normal <2s 11 Peripheral Cyanosis 12 Central Cyanosis. • Cyanosis (> 5g/dl deoxyhaemoglobin) https://www.blackandbrownskin.co.uk/mindthegap 13 Malar Flush. • A high colour over the cheekbones, with a bluish tinge caused by reduced oxygen concentration in the blood. • Malar flush is considered to be a sign of mitral valve disease, which often follows rheumatic fever. • However, malar flush is not always present in mitral stenosis, and many people with this colouring do not have heart disease. 14 Butterfly Rash. • This is the characteristic skin lesion of systemic lupus erythematosus (SLE). • Erythema occurs in a butterfly distribution on the cheeks of the face and across the bridge of the nose. • Frequently precipitated by sun exposure. • May precede SLE by weeks or months. • Another differential that is common is Acne Rosacea. https://dermnetnz.org/ 15 Anaemia. 16 Koilonychia. • Koilonychia is an abnormality of the nails that is also called spoon-shaped (concave) nails. • It is primarily recognized as a manifestation of chronic iron deficiency, which may result from a variety of causes, such as malnutrition; gastrointestinal blood loss; worms; gastrointestinal malignancy; and coeliac disease. 17 Tar staining. 18 Clubbing describes changes in the area under and around the fingernails and toenails that occur with some disorders. • The nail beds soften. The nails may seem to "float" instead of being firmly attached (fluctuation of the nail bed). • The last part of the finger may appear large or bulging. It may also be warm and red. • The nail curves downward so it looks like the round part of an upside-down spoon. • Clubbing can develop quickly, often within weeks. It also can go away quickly when its cause is treated. 19 Causes of Clubbing. • Clubbing often occurs in heart and lung diseases that reduce the amount of oxygen in the blood. • Lung cancer is the most common cause of clubbing. • Congenital Cyanotic Heart Disease. • Chronic lung infections that occur in people with bronchiectasis, cystic fibrosis, or lung abscess. • Interstitial lung disease. • Coeliac disease. • Cirrhosis of the liver and other liver diseases. • Overactive thyroid gland. • Other types of cancer, including liver, gastrointestinal, Hodgkin lymphoma. • Infective Endocarditis. 20 Infective Endocarditis. • Fever, possibly low-grade and intermittent, is present in 90% of patients with Infective Endocarditis (IE). • Heart murmurs are heard in approximately 85% of patients. • One or more classic signs of IE are found in as many as 50% of patients. They include the following: • Petechiae: Common, but nonspecific, finding. • Subungual (splinter) hemorrhages: Dark-red, linear lesions in the nail beds. • Osler nodes: Tender subcutaneous nodules usually found on the distal pads of the digits. • Janeway lesions: Nontender maculae on the palms and soles. • Roth spots: Retinal hemorrhages with small, clear centers. http://emedicine.medscape.com/article/216650-overview 21 Petechiae. Splinter Haemorrhages. 23 Osler's nodes 24 Janeway lesions. 25 Roth’s Spots. • A Roth spot, seen most commonly in acute bacterial endocarditis is a red spot (caused by hemorrhage) with a characteristic pale white center. • This white center usually represents fibrin-platelet plugs. • Roth spots can also be seen in leukaemia, diabetes, intracranial hemorrhage, hypertensive retinopathy, cerebral malaria and in HIV retinopathy. https://pedclerk.bsd.uchicago.edu/page/infective-endocarditis 26 Xanthelasma and Corneal Arcus. Xanthelasma palpebrarum XP is characterized by sharply demarcated yellowish flat plaques on upper and lower eyelids. It is commonly seen in women with a peak incidence at 30–50 years. It is also considered as the cutaneous marker of underlying atherosclerosis along with the disturbed lipid metabolism. XP and corneal arcus are associated with increased levels of serum cholesterol and lowdensity lipoprotein (LDL) cholesterol. 27 PULSES. • Palpate both radial pulses. • Assess and comment on rate and rhythm on right radial pulse. • Assess for collapsing pulse. • Palpate right carotid pulse and assess and for volume and character. • Measure and record BP now, if convenient, or at end of examination. 28 ASSESSMENT OF RADIAL PULSE. • • • • • • • • • Rate (most adults between 60 and 100 at rest) Rhythm Collapsing pulse The radial pulse is felt between the radial styloid and the tendon of flexor carpi radialis. Feel with two or three fingers (not the thumb). Check both radial pluses simultaneously to make sure that they are equal, and then concentrate on the right radial pulse. Count the radial rate per minute. (Count for 15 seconds and multiply by four). Assess the rhythm: Is it regular? If it is not, is it occasionally irregular, as when an ectopic heart beat occurs, or is it totally irregular as in atrial fibrillation? https://www.bhf.org.uk/informationsupport/tests/ checking-your-pulse 29 ASSESSMENT OF CAROTID PULSE. • Feel for the carotid pulse, which is found at the anterior border of sternomastoid muscle, using the cricothyroid membrane as a landmark and rotate fingers over. • Use your index and middle fingers, not your thumb. • Assess volume and character. • Never feel both carotids simultaneously. 30 Abnormal pulses. Rate / Rhythm. • Fast and regular. e.g. exercise, anxiety, pain, fever, medication, hyperthyroidism. • Regularly irregular. e.g. ectopic beat. • Irregularly irregular. e.g. atrial fibrillation (fast if uncontrolled). • Slow and regular. e.g. athletic training, hypothyroidism, medication. • Slow and irregular e.g. Sick sinus syndrome, second degree heart block, complete heart block. 31 Abnormal pulses- volume/character. • Low volume e.g. hypovolaemia, left ventricular failure. • Increased volume e.g. anaemia, fever, thyrotoxicosis. • Character Slow rising pulse – aortic stenosis. • Collapsing pulse – aortic regurgitation. 32 Pulses rate & rhythm. A Regular. B Tachycardia. C Bradycardia. D Bounding. E Weak (thready). F Irregularly irregular. G Regularly irregular. http://brooksidepress.org/vitalsigns/lessons/lesson-3-pulse/3-3-what-factors-are-noted-when-taking-a-patients-pulse/ 33 JUGULAR VENOUS PULSE ASSESSMENT. • It is ideal to examine the internal jugular vein with the patient resting comfortably at an angle of 450. • The jugular vein closely reflects the pressure changes within the right atrium. • In health, at 450 incline the upper limit of the venous column lies just behind the right sternoclavicular joint, which is at the same horizontal level as the sternal angle. • When right atrial pressure is increased as in right-sided heart failure, the venous column is seen above the right sterno-clavicular joint and the vertical height of this column is measured to express the increase in venous pressure. 34 https://www.youtube.com/watch?v=MZKSkVSbH8k 35 36 The Praecordium. • Look! • Shape? • respiratory rate? • Scars? • Visible apex beat? • Pacemaker? • Apex beat. • Find it first. • Then check its position (“normal” = 5th intercostal space midclavicular line). https://geekymedics.com/cardiovascular-examination-2/ 37 The Praecordium. • Heaves. • Left sternal edge – right ventricular enlargement. • Thrills. • Palpable murmur 38 Auscultation. • Palpate carotid pulse initially. • Distinguish 1st and 2nd heart sounds. • Listen for: Heart sounds, added sounds, murmurs (turbulent blood flow). • Use bell and diaphragm and listen in all 4 key areas. • Manoeuvres to accentuate murmurs and remember carotids. 39 www.medcomic.com 40 41 https://www.med.ucla.edu/wilkes/inex.htm 42 Manoeuvres to accentuate murmurs. Bell at apex in expiration in left lateral position. Accentuation of diastolic murmur of mitral stenosis. At left axilla with diaphragm. Radiation of systolic murmur of mitral regurgitation. At lower left sternal edge with patient sat forwards. With diaphragm in expiration. Accentuation of diastolic murmur of aortic regurgitation. Over carotids. With diaphragm in held inspiration. Accentuation of murmur of aortic stenosis radiation / carotid bruits. 43 https://geekymedics.com/cardiovascular-examination-2/ https://www.healio.com/cardiology/learn-the-heart/cardiology-review/topic-reviews/heart-murmurs 44 Examination of other areas. • Auscultate lung bases. • Look for sacral oedema. • Offer abdominal examination – inspect, palpate, percuss for hepatomegaly, listen for renal and femoral bruits, feel for radio-femoral delay and palpate for pulsatile, expansile mass suggesting abdominal aortic aneurysm. • Peripheral vascular examination. 45 Examination of other areas. • Check for ankle oedema. • Check BP. • Fundoscopy. • Urinalysis. • Observation chart (including temperature and oxygen saturation). 46 Conclusion. • Thank patient. • Wash hands. • Summarise and present findings. 47 Learning Outcomes.  To demonstrate an understanding of the fundamentals of the Cardiovascular Examination.  To identify physical signs of cardiovascular disease.  To relate clinical signs to underlying pathology.  To recognise the importance of using history & examination findings to help reach a diagnosis. 48