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Imperial College London Surgical Society Junior Anatomy Series CPA SUMMARY GUIDE Cardiovascular Exam Abdullah Abdelbaky Defne Artun (CPA Lead) Anya Nanchahal (Phase 1a Lead) Andrea Perez Navarro (Phase 1b Lead) Imperial College London Surgical Society Junior Anatomy Series Starting the Examination Starting an Examination One of the easiest ways to remember the steps of introducing yourself at the start of the station is using WIPERQQ. This is a quick acronym to remember all the steps when you’re asked to introduce yourself to the patient in a quick and concise manner to not waste your limited time. It stands for: Wash your hands Introduction: introduce yourself and what you will be doing and confirm NAME and DATE OF BIRTH (DOB). Permission: easiest to gain permission when you introduce what you are going to do and asking them if they are happy with that Exposure: make sure they are exposed from the waste up for this examination. There is no need to remove underwear or make sure to uphold the patient's dignity by keeping them covered except when it is necessary to expose them for the examination. Reposition: make sure they are lying on the bed at a 45 angle depending on if the bed needs to be readjusted. Question: “Are you comfortable?” Question: “Are you in pain” Abdullah Abdelbaky Defne Artun (CPA Lead) Imperial College London Surgical Society Junior Anatomy Series Intermediate Cardiovascular Exam For the different sections of the examination PIPPA is a good acronym to follow all the parts of the examination. For this examination: 0 Position and Exposure: must be laying on the bed at a 45 angle and exposed from the waist up. Inspection: only require a general inspection however unlikely that you will be asked to carry this out in the CPA exam Palpation: for this examination you could be required to palpate a few pulses: radial, ulnar, brachial, common carotid pulse. When you palpate the radial pulse you will be asked to measure the pulse rate. To carry this out measure the pulse for 15 to 30 seconds and multiply accordingly using a watch. You may also be asked to palpate the apex beat and for heaves and thrills. Percussion: there is no percussion required for this station. Auscultation: you will need to auscultate at 4 sites to listen to the valves. Abdullah Abdelbaky Defne Artun (CPA Lead) Imperial College London Surgical Society Junior Anatomy Series Palpating Pulses At the wrist you will need to be able to palpate the radial and ulnar pulse and be able to measure a pulse rate. This is normally done on the right arm as you are approaching the patient from the right. You cannot comment on the character and volume on these peripheral pulses. You can only comment on these with the common carotid pulse. In addition you need to palpate the brachial artery. You can do this at 2 sites in the cubital fossa or the medial side of the tendon of the biceps brachii. To carry this out effectively you should keep the arm fully extended. For the carotid pulse try to keep the patients head straight without the neck looking to either side or else you may not be able to feel the carotid as the sternocleidomastoid will cover it. Abdullah Abdelbaky Defne Artun (CPA Lead) Imperial College London Surgical Society Junior Anatomy Series Palpating for the Apex Beat and Heaves & Thrills To palpate for the Apex beat you should first locate the second rib and you can do this by feeling for the first rib you can feel as you cannot palpate the first anatomical rib or you can locate the sternal angle and then locate the 2 rib afterwards as they are on the same level. Afterwards you should count down to the 5 intercostal space on the left and move laterally to the mid-clavicular line. Once you have done so you should start to feel for the apex beat laterally and move more medially incase the apex beat is displaced. You may not be able to palpate the apex beat depending on the patient to help you feel it you can get the patient to jog on the spot for 1 minute to increase their heart rate. However, I do not recommend you do this in your CPA exam as you do not want to waste 1 out of your 5 minutes that you have, to do the exam before questions. To feel for heaves place your hand vertically adjacent to the sternum on the left and right side. If heaves are present you should feel the heel of your hand lift off the chest. The main causes of heaves are hypertrophy of the left or right ventricle depending on where you feel the heaves due to there being more muscle to push against the anterior chest wall. Thrills are felt in the same areas as the points of auscultation across all 4 valves as they are just palpable murmurs. To feel for them instead place your hand horizontally with your fingers more than the rest of your hand as they are more sensitive to the vibrations. Abdullah Abdelbaky Defne Artun (CPA Lead) Imperial College London Surgical Society Junior Anatomy Series Auscultation in a Cardiovascular Exam Auscultate at all 4 valve regions using the diaphragm for all the valves expect for the mitral where you should use the bell. Normally you would only hear S1 and S2 heart sounds which signify the closure of the mitral and tricuspid valves and the closure of the aortic and pulmonary valves. The sound may also radiate to other areas of the body where you can hear them and these will be signs of specific murmurs. There are also accentuating maneuvers that will make the murmurs louder and easier to hear. However, it is unnecessary to carry them out in your exam unless specifically told to do so. Abdullah Abdelbaky Defne Artun (CPA Lead) Imperial College London Surgical Society Junior Anatomy Series Surface Anatomy The sternal angle is the manubriosternal joint between the manubrium and the sternal body and is at the same level of the 2 nd nd costal cartilage so is easy to use to find the 2 rib and count to find the relevant areas for auscultation and the apex beat. nd In additionally the 2 intercostal space is where the aortic arch starts and ends so is a key anatomical landmark. Furthermore the 4 borders of the heart are: rd nd Upper Border: 3 CC – 1cm from sternal border to the 2 ICS Right Border: 6 CC 1 cm from sternal border to the 3 ICS 1 cm from sternal border th th Lower Border: 5 ICS to apex beat at MC line to 6 CC 1 cm from sternal border nd th Left Border: 2 ICS to the 5 ICS to apex beat at MC line Defne Artun (CPA Lead) Abdullah Abdelbaky Imperial College London Surgical Society Junior Anatomy Series Valvular Dysfunction and Murmurs Murmurs occur due to abnormal blood flow across a valve. This can have many reasons for the valvular dysfunction such as: calcification causing stenosis, congenital conditions causing defects in the valve, structural remodelling around the valve causing regurgitation due to heart failure and infection such as rheumatic fever causing mitral stenosis. These can then cause issues on the heart causing remodelling or cause symptoms for the patient such as syncope and lethargy. The main valves that become diseased in the heart are the aortic and mitral valve and they are also the most important so they usually present more severely than tricuspid or pulmonary valve issues. Aortic stenosis is more common than aortic regurgitation but are both still important to understand and distinguish from each other. You can also use accentuating manoeuvres to improve the clarity of the sound you hear. The main point to remember is that you are trying to get the valve closer to your diaphragm or bell when listening. In addition all valves on the left side of the heart, aortic and mitral valves are loudest during expiration and all valves on the right side of the heart, pulmonary and tricuspid valves, are loudest during inspiration. For mitral murmurs mitral stenosis is also more common than mitral regurgitation. To be able to confirm your differential diagnosis of a valvular dysfunction the gold standard is to get an echocardiogram so you can image the valves and see how they function and how they interact with the chambers of the heart to better understand the movement of the valves during a cardiac cycle. On the next page I have summarised some of the key points about the aortic and mitral murmurs you could hear. Abdullah Abdelbaky Defne Artun (CPA Lead) Imperial College London Surgical Society Junior Anatomy Series Aortic Regurgitation Aortic Stenosis Ejection Systolic Murmur Early diastolic No radiating sounds Radiates to carotid arteries Loudest on Expiration Loudest on Expiration Accentuating Maneuver: Accentuating Maneuver: get the patient to lean get the patient to lean forward and get them to forward and get them to breath out breath out Mitral Stenosis Mitral Regurgitation Low rumbling mid- Pan-systolic murmur diastolic with opening snap murmur Radiates to the left Radiates to left axilla axilla Loudest on Expiration Loudest on Expiration Accentuating Maneuver: Accentuating Maneuver: get the patient to lean get the patient to lean on their left and get on the left and get them them to breath out to breath out Defne Artun (CPA Lead) Abdullah Abdelbaky Imperial College London Surgical Society Junior Anatomy Series Interpreting a 12 lead ECG To effectively interpret a 12 lead ECG you must break it down into steps and look at each lead systematically whilst thinking of all of these steps to reach the over arching pathology that is being shown on the ECG or ascertain if it normal. Calculating a heart rate from an ECG To calculate a heart rate there are two main methods to deploy. If the PQRST complexes are regular then you can divide 300 by the number of large boxes between each R wave. This will give you a good estimate as long as each small box accounts for 0.04s or 40ms and it is a 25mm/s ECG. The other method for a slow or irregular rate is to multiply the number of R waves seen on the rhythm strip at the bottom by 6 as the rhythm strip is measured across 10 seconds and by multiplying by 6 you get number of R waves in 60 seconds. There is a third way which is to calculate the amount of time it takes for 1 cardiac cycle to occur and then 60 divided by it but this method is more time consuming. Rhythm To assess rhythm look at the space between each PQRST complex and see if the are generally the same happening in the same intervals. If it becomes irregular regularly then this is called regularly irregular. Cardiac Axis There are many methods to estimate the QRS axis and calculate specifically but the easiest and fastest method is by using lead I and aVF. This is achieved by looking at the overall charge of the QRS complexes in leads I and aVF. If lead I is positive then the axis will be between -90 to +90 and if aVF is positive then it will be between 0 to 180 and the only quadrant covered by both areas is 0 to 90 leading to this being a normal axis. The same ideas can be used conversely to find left axis and right axis deviation. Defne Artun (CPA Lead) Abdullah Abdelbaky Imperial College London Surgical Society Junior Anatomy Series Interpreting a 12 lead ECG PR Intervals A normal PR interval is between 0.12 to 0.2 seconds and anything longer is more likely looking at a type of heart block and is a type of bradycardia. First degree heart block is normally an incidental finding, is asymptomatic and leads to prolonged PR intervals but each P wave is still followed by a QRS complex. This is caused by an abnormally slow conduction through AVN. Second degree heart block is split up into two types Mobitz I (also known as Wenckebach) and is a gradually prolonged PR interval until a P wave is not followed by a QRS complex and this is regular so is terms regularly irregular. Mobitz II is when regularly P waves are not followed by QRS complexes in a pattern where there is a ratio between P waves and QRS complexes of 1:2 or 1:3. This can cause a wide variety of symptoms such as chest pain, SOB and postural hypotension and can quickly deteriorate to third degree heart block. Third degree heart block is when there is no relationship between P waves and QRS complexes and they occur at their own rate because the cardiac myocytes are myogenic. Normally the atrial rate is faster than the ventricular rate so you find more P waves than QRS complexes but sometimes the P waves are hidden by the QRS complexes because there is more depolarisation in the ventricles hiding the depolarisation of the P waves. Abdullah Abdelbaky Defne Artun (CPA Lead) Imperial College London Surgical Society Junior Anatomy Series Interpreting a 12 lead ECG ST Segment Finally ST segment is very important in showing signs of an NSTEMI or STEMI or unstable angina and helping us differentiate between them. If there is ST elevation this signifies a STEMI. If there is ST depression this points to an NSTEMI. If both are present then it is a STEMI with reciprocal changes due to ischaemia of the myocytes in other areas of the heart due to the added workload placed on them. In addition because each of the 12 leads show a different view or area of the heart we can use this to determine which area of the heart is being most affected and which area of the heart will need a more rapid response. These sections are: The reason these changes happen is due to the coronary arteries that perfuse the cardiac tissue have been occluded. This could happen due to atherosclerosis of the coronary arteries where a plaque has formed which can cause partial occlusion or has ruptured causing blood clot formation and complete occlusion of the blood vessel. In an NSTEMI or unstable angina there is partial occlusion, in a STEMI there is complete occlusion. Abdullah Abdelbaky Defne Artun (CPA Lead) Imperial College London Surgical Society Junior Anatomy Series WE HOPE YOU ARE ENJOYING OUR SERIES! Feedback Please fill out the following feedback form. Let us know if there is anything we can improve on: ✓ Are we missing anything? ✓ Want to see more of something? ✓ What are we doing well? ✓ Finding anything confusing? Abdullah Abdelbaky aa5319@ic.ac.uk Defne Artun (CPA Lead) da1019@ic.ac.uk Anya Nanchahal(Phase 1a Lead) sn1119@ic.ac.uk Andrea Perez Navarro (Phase 1b Lead) ap6418@ic.ac.uk
