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OSCEAZY X GEEKY MEDICS THE CARDIOLOGY STATION (EXAMINATION) MEGAN HODGSON KEY POINTS FOR EXAMINA TIONS RIGHT SIDE TALKING IN EXAMS 01 03 05 BE SYSTEMATIC Examine the patient from their Hard to time correctly when Be slick right side talking through exams Follow systematic order of “There is no evidence of” rather examinations than “I am looking for” WIPE & PREAMBLE INSPECTION CONFIDENCE 02 04 06 Wash your Hands During general inspection, LOOK Put on a show! Patient detailself a good 10-20 secondsd the bed for Explain exam & gain consent Have a preamble for all examinations committed to memory! Ask for patient’s age, not DOB Role Final Year Medical Student Setting Emergency Department Patient Thomas Jones, a 52-year-old male presents with acute chest pain STUDENT Student Perform a focused cardiovascular examination on INSTRUCTIONS this patient. Task At 7 minutes, the examiner will stop you and ask you to summarise your findings & present your differentials.A 75-year-old male presents to the GP short of breath and Heart Failure coughing up pink sputum. On examination, his shins form pits with compression with a finger. The JVP is elevated. A 53-year-old male presents to a Well Man check at the GP. Hypertension His blood pressure is 161/100mmHg. On examination, there is tar staining on his fingers. A 60-year-old male presents to A&E with crushing central Stable Angina chest pain after running. 30 minutes later, this pain has gone away. On examination, he is sweaty and there is tar staining on his fingers. Troponins are normal. A 62-year-old female presents to A&E with gradually Cardiac Tamponade worsening shortness of breath. She has cardiac surgery recently for triple-vessel disease. On examination, she has hypotension, a raised JVP and muffled heart sounds on auscultation. START GENERATING DIFFERENTIALS WIPE Hello, my name is …. and I am a medical student. Can I confirm your full name and age please? Are you happy for me to call you …? Today, I’ve been asked to perform an examination of your heart. What that will involve is me having a general look of you, examining your hands, face and neck and having a listen to your chest. For this examination, I will need you to remove your shirt. Does that all sound okay? Do I have your consent? Are you in any pain at the moment? The examination should not be painful but if you feel any discomfort, please let me know General Inspection Signs: Body Habitus / Cyanosis / Shortness of Breath / Pallor / Malar Flush / Oedema Objects: Oxygen delivery devices / ECG leads / Medications / Prescription Chart / Mobility aids / Pillows / Vital Signs / Fluid Balance / Cannula / Catheter PATIENT SIGNS Shortness of Breath Body Habitus Pallor Cardiovascular or Respiratory Disease Large body habitus  increased Anaemia or Poor Perfusion cardiovascular disease risk Blood Loss, Heart Failure Malar Flush Oedema Cyanosis Cutaneous vasodilation due to pulmonary Swelling of limbs or abdomen, fluid pooling Poor circulation or Inadequate oxygenation hypertension & low cardiac output Congestive Heart Failure Cardiovascular or Respiratory Disease Mitral Stenosis OBJECTS Oxygen Delivery Mobility Aids ECG Leads Medications Devices Medication Chart Vital Signs Fluid Balance Pillows Congestive Heart Failure (orthopnoea) General Inspection Hands & Arms Signs: Body Habitus / Cyanosis / Shortness Inspection: Pallor / Cyanosis / Tar Staining/ of Breath / Pallor / Malar Flush / Xanthomata/ Arachnodactyly/ Oedema Finger Clubbing/ Splinter Haemorrhages/ JanewayLesions / Objects: Oxygen delivery devices / ECG Osler’s Nodes leads / Medications / Prescription Chart / Mobility aids / Pillows / Palpation: Temperature Radio-radialDelay Vital Signs / Fluid Balance / CapillaryRefill Time Collapsing Pulse Radial Pulse Cannula / Catheter Arms: Brachial Pulse Offer Blood Pressure Pallor Xanthomata Tar Staining Anaemia or Poor Perfusion Hyperlipidaemia Stains from Smoking Blood Loss, Heart Failure Cardiovascular Disease & Familial Hypercholesterolemia Cardiovascular Disease Cyanosis Arachnodactyly Poor circulation or Inadequate oxygenation Marfan’s Syndrome  Mitral / Aortic Cardiovascular or Respiratory Disease valve prolapse & Aortic Dissection Clubbing Janeway Lesions Osler’s Nodes Soft tissue swelling of the terminal Haemorrhagic lesions due to microemboli Red-purple raised tender lumps caused (Non-Tender, Palms & Soles) phalanx of the digit from chronic by localized immune response hypoxaemia (low blood oxygen) Infective Endocarditis (Tender, Fingers & Toes) Infective Endocarditis Congenital Cyanotic Heart Disease Infective Endocarditis Atrial Myxoma Splinter Haemorrhages Longitudinal haemorrhage from tiny clots damaging small capillaries under the nail Infective Endocarditis, Local trauma, Sepsis, Vasculitis Schamroth’s window Temperature Capillary Refill Time (CRT)  Use dorsal aspect of your hand  5 seconds of pressure  2 seconds to return to normal colour Cool Hands (poor perfusion)  Congestive Heart Failure, ACS CRT >2 seconds (poor perfusion)  Hypovolaemia, Congestive Heart Failure Sweaty / Clammy  ACS Collapsing Pulse  Pulse remains strong on lifting the arm  Ask about pain before raising the arm! Palpate Radial Artery Radio-Radial Delay Normal physiology (e.g. fever, pregnancy) nd rd th Aortic Regurgitation, Patient Ductus Arteriosus  Use tips of 2 , 3 & 4 fingers  Pulses are synced in both arms High output states (e.g. anaemia, AV fistula, thyrotoxicosis)  Assess Rate & Rhythm Aortic Dissection Aortic Coarctation Subclavian artery stenosisPalpate Brachial Artery Offer Blood Pressure  Partially flex, externally rotate & Measurement abduct the upper arm at the elbow  Measure in both arms + standing/sitting  Found medial to biceps brachii tendon Hypertension (≥140/90 mmHg)  Assess Volume & Character Hypotension (<90/60mmHg) Narrow Pulse Pressure (<25mmHg difference between systolic & diastolic values)  Aortic stenosis, congestive heart failure, cardiac tamponade Wide Pulse Pressure (>100mmHg difference between systolic & diastolic values)  aortic regurgitation & aortic dissection Difference between arms (>20mmHg)  Aortic dissection General Inspection Hands & Arms Neck Signs: Body Habitus / Cyanosis / Shortness Inspection: Pallor / Cyanosis / Tar Staining/ Carotid Arteries: Auscultate of Breath / Pallor / Malar Flush / Xanthomata/ Arachnodactyly/ Palpate (1 at a time) Oedema Finger Clubbing/ Splinter Haemorrhages/ JanewayLesions / JVP: Measure at 45 degrees Objects: Oxygen delivery devices / ECG Osler’s Nodes Patient looks to left leads / Medications / Prescription Chart / Mobility aids / Pillows / Palpation: Temperature Radio-radialDelay Vital Signs / Fluid Balance / CapillaryRefill Time Collapsing Pulse Radial Pulse Cannula / Catheter Arms: Brachial Pulse Offer Blood Pressure CAROTIDS Auscultate Carotid Artery Palpate Carotid Artery  Ask patient to take a deep breath  Ensure patient is safely laying on and then hold it whilst you listen the bed --> risk of syncope (reflex  One side at a time bradycardia on palpation)  Use bell of stethoscope  Assess Character & Volume Carotid Bruit (Carotid Stenosis) If carotid bruit present  DO NOT PALPATE CAROTID ARTERY Location: between larynx & anterior border of the Risk of dislodging carotid plaque  sternocleidomastoid muscle over carotid pulse ischaemic stroke JVP Jugular Venous Pressure (JVP) Hepatojugular Reflex  Indirect measure of Central Venous pressure using internal  Apply direct pressure to the liver jugular vein  Observe for rise in Internal jugular vein  Position the patient at 45°  Healthy: Rise no longer than 1-2 cardiac cycles  Turn the head to the left  Pathology: Sustained rise ≥4cm  Location: between the 2 heads (clavicular & sternal) of sternocleidomastoid muscle  Measure: Vertical distance between sternal angle & top of pulsation points of internal jugular vein (<3cm = normal) Venous Hypertension Right ventricle cannot cope with increased venous return Right-sided heart failure Tricuspid regurgitation Right-sided heart failure Constrictive pericarditis Left-sided heart failure Restrictive cardiomyopathy Constrictive pericarditis General Inspection Hands & Arms Neck Auscultate Signs: Body Habitus / Cyanosis / Shortness Inspection: Pallor / Cyanosis / Tar Staining/ Carotid Arteries: Palpate (1 at a time) of Breath / Pallor / Malar Flush / Finger Clubbing/ Splintery/ Oedema Haemorrhages/ JanewayLesions / JVP: Measure at 45 degrees Osler’s Nodes Patient looks to left Objects: Oxygen delivery devices / ECG leads / Medications / Prescription Palpation: Temperature Radio-radialDelay Chart / Mobility aids / Pillows / CapillaryRefill Time Collapsing Pulse Vital Signs / Fluid Balance / Radial Pulse Cannula / Catheter Arms: Brachial Pulse Offer Blood Pressure Face Eyes: ConjunctivalPallor / Corneal Arcus / Xanthelasma/ Kayser-FleischerRings Mouth: Central Cyanosis/ Angular Stomatitis / High Arched Palpate / Dental Hygiene EYES Steps:  Ask the patient to pull their lower eyelid down  Ask them to open their mouth  Ask them to stick the tongue to the room of their mouth Conjunctival Pallor Corneal Arcus Anaemia Lipid deposits creating a hazy white, grey or blue opaque ring located in peripheral cornea Benign in >60 years old, Hypercholesterolemia Xanthelasma Kayser-Fleischer Rings Raised, yellow deposits cholesterol- Dark rings of copper in iris rich around the eyes Wilson’s disease  Cardiomyopathy Hypercholesterolemia MOUTH Poor Dental Hygiene Angular Stomatitis Cracked, irritated skin at the Infective endocarditis corners of your mouth (Strephtococcus viridans) Iron-deficiency (causes immunocompromise -> Central Cyanosis High-arched Palate opportunistic infections) Poor circulation or Marfan’s Syndrome  Inadequate oxygenation Mitral / Aortic valve prolapse (hypoxaemia) & Aortic Dissection Cardiovascular or Respiratory Disease General Inspection Hands & Arms Neck Signs: Body Habitus / Cyanosis / Shortness Inspection: Pallor / Cyanosis / Tar Staining/ Carotid Arteries: Auscultate of Breath / Pallor / Malar Flush / Xanthomata/ Arachnodactyly/ Palpate (1 at a time) Finger Clubbing/ Splinter Oedema Haemorrhages/ JanewayLesions / JVP: Measure at 45 degrees Osler’s Nodes Patient looks to left Objects: Oxygen delivery devices / ECG leads / Medications / Prescription Palpation: Temperature Radio-radialDelay Chart / Mobility aids / Pillows / CapillaryRefill Time Collapsing Pulse Vital Signs / Fluid Balance / Radial Pulse Cannula / Catheter Arms: Brachial Pulse Offer Blood Pressure Face Eyes: ConjunctivalPallor / Corneal Arcus / Xanthelasma/ Kayser-FleischerRings Mouth: Central Cyanosis/ Angular Stomatitis / Chest High Arched Palpate / Dental Hygiene Inspection: ThoracicScars / Pectus Excavatum / Pectus Carinatum/ Pulsations Accentuation Aortic Stenosis: auscultate carotid arteries with Palpation: Apex Beat Manoeuvres: diaphragm whilst patient holds their breath Heaves (heal of your hand) Aortic Regurgitation: sit patient forward, Thrills (flats of the fingers) auscultate over aortic area with diaphragm during expiration Auscultation: All 4 valves (mitral, tricuspid, listen over mitral area with diaphragm duringside, pulmonary& aortic) expiration, move into axilla With diaphragm& bell Mitral Stenosis: roll patient onto left side, listen over mitral area with bell during expiration, move into axilla Pectus Excavatum Pectus Carinatum Apex Beat Pulsations The chest has a caved-in The chest has a protrusion of A forceful apex pulsing visible under the skin, or sunken appearance the sternum and ribs due to an enlarged ventricular chamber Marfan Syndrome Marfan Syndrome Ventricular Hypertrophy  Severe Hypertension, Aortic Stenosis, Hypertrophic Cardiomyopathy, Heart Failure CARDIOTHORACIC SCARS MIDLINE STERNOTOMY SCAR BILATERAL THORACOTOMY POSTEROLATERAL Indications: Open heart surgery (e.g. SCAR / CLAMSHELL INCISION THORACOTOMY SCAR Indications: Lobectomy, CABG, valve replacement) Indications: Lung Transplant Pneumonectomy, Bullectomy, Mitral valvuloplasty (less invasive than LEFT SUBCLAVICULAR SCAR anterior thoracotomy) Indications: Pacemaker insertion, Implantable cardiac defibrillator, Implantable loop recorded ANTEROLATERAL THORACOTOMY SCAR Indications: Lobectomy, Pneumonectomy, Bullectomy, Single lung transplant MINI THORACOTOMY Indications: Minimally invasive valve replacement / repairApex Beat:  Use Flats of Fingers  Horizontal th  Location: 5 Intercostal space midclavicular line Displacement  Ventricular Hypertrophy Parasternal Heaves:  Pulsations from heart palpable on anterior chest wall (called precordial impulse), lifting your hand during systole  Use Heel of Hand  Vertical  Location: Left & Right Sternal Edges Raising of Heel of Hand  Right Ventricular Hypertrophy Thrills:  Palpable murmur – a vibration caused by turbulent blood flow through a heart valve  Use Flats of Fingers  Horizontal  Location: 4 valve locations (see previous) Palpable vibration  valvular pathology ACCENTUATION MANOUVRES Aortic Stenosis: Mitral Stenosis:  Auscultate carotid arteries  Roll patient onto left side, with diaphragm whilst patient listen over mitral area with holds their breath bell during expiration, move into axilla Aortic Regurgitation: Mitral Regurgitation:  Sit patient forward, auscultate  Roll patient onto left side, over aortic area with listen over mitral area with diaphragm during expiration diaphragm during expiration, move into axilla RILE Right Inspiration,Left ExpirationTYPES OF MURMURS TYPES OF MURMURS S1 heart sound (‘lub’): closure of S2 heart sound (‘dub’): closure of aortic atrioventricular valves (mitral & & pulmonary valves at end of tricuspid) at start of ventricular ventricular systole Normal Heart Aortic Sounds Aortic Stenosis Regurgitation Mitral Aortic Valve Regurgitation Mitral Stenosis ReplacementGRADING MURMURS PRESENTING MURMURS Heart Sounds 1+2 Present Location heard loudest 01 05 Atrial, Mitral, Pulmonary or Tricuspid 02 Additional Sounds 06 Radiation e.g. S3 or S4 Carotid arteries or Axilla Timing Changes with Accentuation Manouvres 03 07 Systolic or Diastolic Increased with leaning forward or laying on left side 04 Volume 08 Diagnosis of Murmur Grade 1-6 e.g. Aortic Stenosis, Mitral Regurgitation, etc. General Inspection Hands & Arms Neck Signs: Body Habitus / Cyanosis / Shortness Inspection: Pallor / Cyanosis / Tar Staining/ Carotid Arteries: Auscultate of Breath / Pallor / Malar Flush / Xanthomata/ Arachnodactyly/ Palpate (1 at a time) Oedema Finger Clubbing/ Splinter Haemorrhages/ JanewayLesions / JVP: Measure at 45 degrees Objects: Oxygen delivery devices / ECG Osler’s Nodes Patient looks to left leads / Medications / Prescription Palpation: Temperature Radio-radialDelay Chart / Mobility aids / Pillows / CapillaryRefill Time Collapsing Pulse Vital Signs / Fluid Balance / Radial Pulse Cannula / Catheter Arms: Brachial Pulse Offer Blood Pressure Face Eyes: ConjunctivalPallor / Corneal Arcus / Xanthelasma/ Kayser-FleischerRings Back & Legs Chest Mouth: Central Cyanosis/ Angular Stomatitis / High Arched Palpate / Dental Hygiene Back: Inspect Posterior Chest Wall Inspection: ThoracicScars / Pectus Excavatum Auscultate Posterior Lung Fields / Pectus Carinatum/ Pulsations Palpate for Sacral Oedema Accentuation Aortic Stenosis: auscultate carotid arteries with Palpation: Apex Beat diaphragm whilst patient holds their breath Legs: Palpate ankles for Pitting Oedema Heaves (heal of your hand) Manoeuvres: Aortic Regurgitation: sit patient forward, Inspect legs for SaphenousVein Thrills (flats of the fingers) auscultate over aortic area with diaphragm Harvesting Sites during expiration Auscultation: All 4 valves (mitral, tricuspid, Mitral Regurgitation: roll patient onto left side, pulmonary& aortic) listen over mitral area with diaphragm during With diaphragm& bell Mitral Stenosis: roll patient onto left side, listen over mitral area with bell during expiration, Thank patient & restore clothing move into axillaInspection of Posterior Wall: Auscultation of Posterior Wall: Palpate for Sacral Oedema: Course Crackles: Pulmonary oedema Pitting Oedema  Congestive (left ventricular failure) heart failure Absent Air Entry: Pleural effusion (left ventricular failure)Inspection for Saphenous Vein Harvesting Sites: Palpate for Pitting Oedema: CABG Pitting Oedema  Right Ventricular Failure EXPLAIN TO PATIENT THANK THE PATIENT WASH HANDS & THAT EXAM IS FINISHED DISPOSE OF PPE “Today, I performed a cardiovascular examination on ___, a __ year old (fe)male with ____ On general inspection, the patient was sitting upright on the bed and seemed comfortable at rest. There was no medical equipment around the bed of relevance. On inspection of the hands, arms, face & neck, there was no peripheral stigmata of cardiovascular disease. The pulse was 80, regular and had a strong volume. There was no evidence of radio-radial delay. Their JVP was not elevated. On closer inspection of his chest, there were no scars to suggest previous surgeries and there were no chest wall deformities. There were no palpable thrills or heaves, and the apex beat was not displaced. On auscultation, heart sounds 1 + 2 were present with no added sounds or murmurs. In summary, this was a normal cardiovascular examination.”CASES EXAMINA TION FINDINGS MITRAL STENOSIS Malar Flush Mid/late-diastolic rumble with opening snap Location: 5 ICS, midclavicular line Best heard with bell Conservative Medical Surgical • Patient education / leaflets• Lifelong • Open Valve • Patient support groups / anticoagulation for replacement charities (e.g. British Heart mechanical valves • Transcatheter valve Foundation) • MDT approach (e.g. warfarin) replacement • Full functional assessment • Balloon valvuloplasty • Reduce strenuous exercise • Optimise cardiovascular risk factors (e.g. smoking cessation, reduce alcohol intake, diet, optimise HTN, diabetes and cholesterol) EXAMINA TION FINDINGS Shortness of Breath Pitting Oedema CHRONIC HEART FAILURE Raised JVP CRT: 4s Pillows Prolonged CRT Conservative Medical Surgical st • Patient education / leaflets 1 line: • Cardiac Resynchronisation • Furosemide • Patient support groups / • ACE-I Therapy OR Implantable charities (e.g. British Heart • Beta Blocker Cardioverter Defibrillator Foundation) nd • Prolonged QRS • MDT approach 2 line: • High risk sudden cardiac • Pneumococcal vaccine & • Aldosterone antagonist (e.g. death annual flu vaccine spironolactone)  check U&Es • NYHA I-III • SGLT-2 inhibitors • Lifestyle: Smoking cessation, rd • LBBB reduce alcohol intake, fluid & 3 line: salt restriction • Digoxin (if AF present) • Manage comorbidities (e.g. • Ivabradine HTN, Diabetes) • Hydralazine + nitrate (in Afro- Caribbean patient) • NYHA classification • Sacubitril-valsartan EXAMINA TION FINDINGS Clubbing Janeway lesions 4 ICS INFECTIVE ENDOCARDITIS Lower left sternal edge Tricuspid Regurgitation Osler’s Nodes Splinter haemorrhages Poor Dental Hygiene Conservative Medical Surgical • A-E approach Initial Therapy (before blood • Emergency Valvuloplasty culture results): • Referral to Cardiology and • Amoxicillin (± low-dose • Haemodynamic contact Infectious getamicin) instability diseases/Microbiology • Aortic root abscess (PR Staphylococcus (after blood prolongation) • Patient education / leaflets culture results): • Severe heart failure (e.g. ensure good dental • Flucloxacillin • Caused by an • (penicillin allergic: rifampicin + health, risk of injecting low-dose gentamicin) uncontrolled infection drugs, etc.) • MDT approach Streptococcus (after blood culture • Recreational drug cessation results): programme referral • Benzylpenicillin • (penicillin allergy: vancomycin + low-dose gentamicin) EXAMINA TION FINDINGS MARFAN’S SYNDROME / AORTIC DISSECTION High-arched Palate Arachnodactyly Difference between arms: 24mmHg Radio-Radial Delay Conservative Medical Surgical • A-E approach • Put out an emergency call • Oxygen Type A: (2222) • IV fluids • Referral to Cardiology / • Analgesia (opiates) • Surgical aortic root Cardiothoracic Surgery / • Beta Blockers (IV labetalol) replacement (open or Vascular • Aim: 100-120mmHg systolic endovascular repair) & heart rate <60bpm • Patient education / leaflets • Charities (e.g. Aortic Type A  Surgical Prep: Dissection Awareness UK) • NBM • Lifestyle changes: Smoking • Insert Cannula cessation, Diet & Exercise • Catheter • Avoid contact sports & • Crossmatch strenuous physical activities • Ongoing HTN therapyA 65-year-old male presents to A&E with a high fever, general Infective Endocarditis malaise and a headache. He reports a change in bowel habit for 9 months. On examination, his fingers are clubbed and there is a pansystolic murmur in the 5 intercostal space midclavicular line. A 72-year-old male presents to his GP with chronic shortness of Aortic Stenosis breath and chest pain on exertion, relieved by rest. On examination, he has a crescendo-decrescendo murmur at the 2 nd intercostal space, right sternal edge. A 45-year-old female presents to A&E with sharp acute chest pain, Acute Pericarditis worse on lying down. On examination, there is “scratching” sound at the left lower sternal edge. A 58-year-old male presents to A&E with sudden shortness of Mitral Regurgitation breath and inability to sleep lying flat. He had an ACS event affecting the inferior section of the heart recently. On examination, he has a pansystolic murmur that radiates to the axilla. Conservative Medical Surgical • A-E approach • NSAIDs (high dose Naproxen) • Pericardiocentesis (if cardiac • Referral to Cardiology • Omeprazole (PPI cover) tamponade suspected) • Colchicine • Pericardiectomy (persistent, • Patient education / leaflets symptomatic, recurrent • Exercise restriction (until pericarditis) symptoms resolve) • Treat underlying cause (e.g. TB, uraemia, autoimmune disorders, trauma, malignancy, medications)PLEASE FILL OUT THE FEEDBACK FORM PLEASE TUNE IN TO OUR REMAINING SESSIONS THIS WEEK