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

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