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12.11.22 Cardiovascular exam + management

General inspection
  • Anasarca = Generalised oedema
  • Cardiac cachexia
  • All equipment
    • Scales
    • Oxygen

Hands + arms

  • Look for tremor!
    • Might indicate hyperthyroidism
    • Especially in combination with AF
  • Splinter haemorrhages are really very difficult to see
    • Carefully inspect each nail
  • Tendon xanthoma is a much more sensitive sign than xantholasma
  • ALWAYS comment on the presence or absence of tar stains
    • Key risk factor

Pulse
  • You can't feel the radial pulse during diastole
    • But you should be able to feel the brachial
  • For collapsing pulse, palpate both pulses
    • See if just one or both disappear during diastole
  • In AF, some beats won't be palpable at the radial artery
    • Aortic valve won't even open for some
    • Auscultate over the apex to get the correct rate

Neck
  • Palpate carotids
    • This is the place to feel the CHARACTER of the pulse (collapsing, slow-rising etc)
  • Turn head to the left for JVP, but not too much
    • You don't want to engage the SCM, which lies above the internal jugular
  • Follow a line joining the earlobe to the space between the two SCM heads

Face
  • Don't forget anaemia
  • Look at the eyebrows for signs of hypothyroidism
  • Look inside the mouth with a TORCH

Chest
  • Look for, comment on and THINK ABOUT scars
    • e.g. With a sternotomy:
      • Check the arms and legs for graft scars to suggest CABG
      • If there are none, think valve replacement, and listen for a metallic click
  • Heaves represent RV impulse
    • LV is hidden underneath
  • Thrills are palpable murmurs
    • So feel everywhere you'd auscultate
  • Feel right round to the mid-axillary line for apex

Heart sounds
  • Comment on the presence of normal sounds (S1 + S2)
  • Then mention any added sounds
    • S3 is very common in heart failure (rapid ventricular filling)
  • Finally, comment on murmurs
    • Make sure you've timed them against the carotid pulse!

The rest
  • Auscultate the lung bases, with the patient sitting upright
  • Check for sacral and ankle oedema
    • Press in for TEN SECONDS, over a BONY PROMINENCE
    • Move upwards to determine extent, if there's ankle oedema

CXR
  • Don't forget the basics
    • Name, date
    • AP/PA
    • Rotation
    • Penetration (vertebral bodies)
  • Look for congested pulmonary veins
    • Vertical or oblique lines in upper zones
  • Kerley B lines are because the lymphatic system tracks along fissures

NYHA Scale
ICardiac disease, but no symptoms and no limitation in ordinary physical activity, e.g. shortness of breath when walking, climbing stairs etc.
IIMild symptoms (mild shortness of breath and/or angina) and slight limitation during ordinary activity.
IIIMarked limitation in activity due to symptoms, even during less-than-ordinary activity, e.g. walking short distances (20–100 m).
Comfortable only at rest.
IVSevere limitations. Experiences symptoms even while at rest. Mostly bedbound patients.

Management
  • Heart failure - A+E
    • GTN
      • Sublingual then infusion
      • Monitor BP
    • Morphine
    • Oxygen
    • Furosemide
  • Drugs with survival benefit in chronic heart failure
    • ACE inhibitor
    • Beta blocker
    • Spironolactone

Notes
  • GTN and morphine are good for off-loading heart
    • Much better than furosemide
  • Breathlessness on exertion does NOT come from pulmonary congestion
    • Probably from a systemic response to hypoperfusion
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