General inspection - Anasarca = Generalised oedema
- Cardiac cachexia
- All equipment
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
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
- 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 | I | Cardiac disease, but no symptoms and no limitation in ordinary physical activity, e.g. shortness of breath when walking, climbing stairs etc. | | II | Mild symptoms (mild shortness of breath and/or angina) and slight limitation during ordinary activity. | | III | Marked limitation in activity due to symptoms, even during less-than-ordinary activity, e.g. walking short distances (20–100 m).
Comfortable only at rest. | | IV | Severe 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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