Cardiovascular Examination: Findings
You
would be expected to recognise and know the common causes for the
majority of the below for finals. We can help you with the latter, but
the former is up to you!
General
Raised JVP
Important causes:
-
Right heart failure
-
Constrictive pericarditis
-
Pulmonary hypertension
-
SVC obstruction: non-pulsatile
-
Complete heart block: cannon A waves (occur when atria and ventricles constrict simultaneously)
Atrial Fibrillation
Important causes:
-
Conditions resulting in raised atrial pressure: hypertension, heart failure
-
Atrial hypertrophy: mitral stenosis, mitral regurgitation
-
Inflammation/infiltration: cardiomyopathy, alcohol
-
Ischaemia: ischaemic heart disease
-
Metabolic: thyroxicosi
Anticoagulation
is performed if: patient has a prosthetic heat valve, rheumatic mitral
stenosis, prior CVA/TIA, patient is over 75 years old, hypertension,
coronary artery disease, poor left ventricular function.
Clubbing
This list is actually sometimes useful, although must be learnt more because examiners like to ask questions concerning it:
-
Cardiovascular
-
Cyanotic congenital heart disease, infective endocarditis, atrial myxoma
-
Respiratory
-
Carcinoma, mesothelioma, fibrosis, pus (bronchiectasis, empyema, abscess)
-
Abdominal
-
Cirrhosis, inflammatory bowel disase, coeliac
-
Enocrinological
-
Thyroid acropachy
Murmurs
The first heart sound is the tricuspid and mitral valves closing. The
second heart sound is the pulmonary and aortic valves closing. In
finals you would really only be shown a patient with mitral stenosis or
aortic regurgitation but it is important to know the basic features of
other murmurs for written papers.
-
Systolic
-
Ejection
: Intensity rises then falls, greatest
mid-systolic. Aortic stenosis, atrial septal defect, pulmonary stenosis.
-
Pansystolic
: Constant intensity. Mitral regurgition, tricuspid
regurgitation, ventricular septal defect.
-
Late
: hypertrophic obstructive cardiomyopathy.
-
Diastolic
-
Mid
: Mitral/tricuspid stenosis.
-
Early
: Aortic regurg (rarely pulmonary regurgitation): Blowing
(high-pitched) & begin with 2nd sound.
-
Continuous
-
Patent ductus arteriosus: due to connection between
aorta/pulmonary artery meaning pressure in aorta always higher than in
pulmonary artery (PDA).
Coarctation of the aorta.
-
Pericardial friction rub
-
Scratching/crunching due to movement of inflamed pericardium. Most obvious in systole but may
be heard in diastole.
Extra heart sounds
Combined with tachycardia, 3rd and 4th heart sounds are termed a "gallop rhythm".
-
3rd sound
-
Heard immediately after 2nd. Due to early passive filling of
ventricle. In > 40y consider heart failure or volume overload.
-
4th sound
-
Heard immediately before 1st. Caused by atrial contraction. In younger
patients abnormal & due to ventricular stiffness assoc with
hypertension, AS, acute MI.
Apex beat
Impalpable
: muscle/fat, pleural effusion, pneumothorax,
emphysema, pericardial effusion
Thrusting
: volume overload (eg AR/MR, shunts)
Tapping
(palpable 1st beat): mitral (rarely tric) stenosis,
pressure loaded: Aortic stenosis, hypertension
Pulse
-
Irregularly irregular
-
Atrial fibrillation
-
Sinus tachycardia
-
Pain, anxiety
-
Small volume and slow rising
-
Aortic stenosis
-
Large volume and collapsing
-
Aortic regurgitation
-
Pulsus paradoxus
-
Exaggeration of the fall in systolic blood pressure and
pulse pressure during inspiration. Causes: obstructive airways disease, constrictive
pericarditis, tamponade, left ventricular disease (cardiomyopathy).
It is not a feature of left ventricular failure.
-
Pulsus alternans
-
Alternate loud/soft HS in LV failure
-
Radio-femoral delay
-
Coarctation
-
Pulsus bisferiens
-
2 distinct impulses with each pulse beat in
severe combined aortic valve stenosis and regurgitation, hypertrophic obstructive cardiomyopathy
Diseases
Heart failure
Right
: Ankle oedema, ascites, tiredness, hepatomegaly, raised JVP, peripheral
redness
Left
: Shortness of breath, frothy red sputum, orthopnoea, PND
Endocarditis
-
Roth spots (“target lesions” in
eyes)
-
Janeway lesions (
painless
on hypothenar/thenar)
-
Osler's nodes
(blistering
painful
nodules on hands)
-
splinter haemorrhages,
splenomegaly
-
microscopic haematuria.
SVC obstruction
Puffy face, capillary distension in region of SVC (i.e. above nipples)
causing discoloration. ↑JVP, non-pulsatile. 50% have small cell
lung cancer.
Corneal arcus
Grey opaque line surrounding the margin of the
cornea, separated from it by an area of clear cornea. Due to raised lipids.
Mitral facies
Butterfly distribution on face associated with lesions to the mitral valve especially with rheumatic fever.
