Cardio PES

incomplete

Diaphoresis

profuse sweating

(unrelated to temperature or activity)

may indicate MI or shock

Cyanosis signs

either peripheral or central:

• Central cyanosis:

  • bluish lips, tongue (especially the underside), and oral mucous membranes (use a light)

  • causes:

    • cyanotic congenital heart disease with right-to-left shunt

    • respiratory disease e.g. COPD and pulmonary embolism

    • high altitude + resultant decreased inspired oxygen concentration

    • polycythaemia (increased hematocrit and/or hemoglobin concentration)

    • haemoglobin abnormalities

• Peripheral cyanosis

  • bluish discoloration of the hands, nail beds and feet

  • causes:

    • All causes of central cyanosis cause peripheral cyanosis

    • exposure to the cold

    • reduced cardiac output

    • arterial or venous obstruction

can reflect poor oxygenation, reduced perfusion, or anaemia

Pallor

pale conjunctiva, nail beds, and palmar creases

can reflect poor oxygenation, reduced perfusion, or anaemia

male risk factor

Earlier Coronary Artery Disease (CAD) risk

obesity risk factor

Coronary Artery Disease (CAD) risk

ethnic background risk factor

South Asian, Indigenous Australians, Pacific Islanders have higher Coronary Artery Disease (CAD) risk

GTN spray

Common nitrate used in angina
Suggests known ischaemic heart disease

down syndrome cardiac relation

• 50% of patients will have a cardiac defect

• most often an atrioventricular septal defect

marfan syndrome cardiac relation

Check for:

• High arched palate

• tall stature

• long limbs

• long fingers

Associated with:

• aortic dilatation with risk of dissection

• mitral valve prolapse

• aortic regurgitation

Turner syndrome cardiac relation

50% of patients will have a major cardiac defect e.g.

• coarctation of the aorta

• bicuspid aortic valve

Turner Syndrome signs

• short stature

• webbing of the neck

• stocky build

• shield-like chest

• lack of breast development and cubitus valgus in female patients

hydration status

• fluid overload:

  • can be a sign of cardiac failure

  • e.g. bilateral ankle swelling due to peripheral oedema

  • could also be renal failure or excessive IV drug use

• dehydration:

  • sunken eyeballs

  • a ‘moribund’ appearance (i.e., look very unwell)

  • altered consciousness

heart rate

normal resting: 60-100 beats per minute

bradycardia: <60

tachycardia: >100

• radio-radial delay

  • inequality in timing or volume of the pulse

  • can occur with:

    • coarctation of the aorta

    • aortic dissection

    • subclavian artery stenosis

• radio-femoral delay

  • suggestive of coarctation of the aorta

heart rhythm categories

• regular

• regularly irregular

• irregularly irregular

respiratory rate

12-20 breaths per minute

blood pressure ranges

Diastolic: 60-90mmHg

Systolic: 90-140mmHg

oxygen saturation

• normal: 95-100% (room air)

• Hypoxaemia: <92%

temperature range

36.1 - 37.9^oC

fever could signify

infection (e.g. endocarditis, pericarditis, pneumonia)

peripheral perfusion of hands

well perfused: warm and pink, normal CRT

shut down: cold and pale, reduced CRT

capillary refill time (CRT)

1. apply pressure to the nail bed, pressing over the top of the fingernail until it turns white

2. Release the pressure and count the number of seconds it takes for the colour to return to the nail bed

3. Colour should return in less than 2 seconds

clubbing

• loss of normal hyponychial angle:

  • the angle between the nail bed and the cuticle increases and rounds out

  • nails curve downwards

• Schamroth’s sign:

  • Ask the patient to place the dorsal surfaces of the terminal phalanges of index back-to-back.

  • Normal: A small diamond-shaped window of light is visible between the nails.

  • Positive Schamroth’s Sign: No window — the space is obliterated due to the nails being more convex and the tissues swollen, indicating clubbing.

• linked with cyanotic congenital heart disease

splinter hemorrhage

• most commonly trauma related

• can be a peripheral sign of infective endocarditis due to:

  • Microemboli (tiny clots or infected material from heart valves) traveling through circulation

    or

  • Vasculitis (immune complex deposition) causing damage to capillaries

tobacco staining

• sign of smoker

• risk factor for ischaemic heart disease and peripheral vascular disease

xanthomata

• lipid deposits under the skin suggests hyperlipidaemia → risk factor for ischaemic heart disease and peripheral vascular disease

• typically seen over extensor tendons such as on the back of the hand (wrist) or the elbows

ischaemic heart disease

• Also called Coronary Artery Disease (CAD)

• reduced blood flow to the heart muscle (myocardium) occurs due to narrowing or blockage of coronary arteries

• usually from atherosclerosis

• Pathophysiology:

  • Atherosclerosis → Plaque buildup in coronary arteries

  • ↓ Blood supply to myocardium → Myocardial ischaemia

  • Can be stable or acute

  Clinical Presentations:

  • Stable Angina: Chest pain on exertion, relieved by rest

  • Unstable Angina: Chest pain at rest or minimal exertion

  • Myocardial Infarction (MI): Prolonged ischaemia → Heart muscle damage

  • Silent ischaemia (especially in diabetics)

peripheral vascular disease

• Also called Peripheral Arterial Disease (PAD)

• arteries supplying the limbs, especially the legs, become narrowed or blocked

• due to atherosclerosis

• results in poor circulation

• Pathophysiology:

  • Atherosclerosis in peripheral arteries

  • ↓ Blood flow to limbs, especially during exercise

    → Ischaemic muscle pain

• Clinical Presentations:

  • Intermittent claudication:

    • Cramping leg pain during walking

    • relieved by rest

  • Critical limb ischaemia:

    • Pain at rest

    • non-healing ulcers

    • gangrene

  • Diminished pulses:

    • cool or pale skin

    • poor wound healing

angina

• chest pain or discomfort caused by reduced blood flow to the heart muscle

• symptom of CAD

• Stable angina:

  • most common type

  • occurs predictably: usually during exertion or emotional stress

  • relieved by rest or medication. 

• Unstable angina:

  • more serious type

  • follows an irregular pattern

  • not relieved by rest or medication

  • can be a sign of a more severe heart problem and may precede a heart attack. 

• Variant angina (Prinzmetal's angina):

  • occurs at rest due to a spasm in the coronary arteries (myocardial vessel vasospasm), which can reduce blood flow to the heart

Symptoms of Angina: 

• Chest pain or discomfort that may feel like squeezing, tightness, or pressure.

• Pain or discomfort that may radiate to the neck, jaw, arms, shoulders, or back.

• Feeling of indigestion, heartburn, or nausea.

• Shortness of breath, fatigue, or dizziness

Osler’s nodes

• tender palpable nodules

• rare, peripheral signs of infective endocarditis

• noted on the finger pulps or thenar/hypothenar eminences

• thought to be due to:

  • Septic Microemboli (tiny clots or infected material from heart valves) traveling through circulation

    or

  • Vasculitis (immune complex deposition) causing damage to capillaries

Janeway lesions

• non-tender, late peripheral sign of infective endocarditis

• found on the palms or finger pulps and are thought to be septic emboli

• rarely seen in western cultures due to advances in medical treatment

infective endocarditis pathogenesis

1. Endothelial Damage

   • Damaged endothelium exposes collagen and tissue factor, promoting platelet-fibrin thrombus formation

2. Bacteremia

   • Microorganisms (bacteria or fungi) enter the bloodstream via:

     • Dental procedures

     • Poor gingival health

     • IV drug use

     • Surgery

     • Infected devices (e.g., catheters, prosthetic valves)

3. Vegetation Formation

   • Bacteria adhere to the thrombus → form infected vegetations composed of fibrin, platelets, and microorganisms

   • These vegetations are protected from immune cells, allowing bacteria to multiply

4. Destructive and Embolic Effects

   • Vegetations can destroy valve tissue

     → regurgitation or heart failure

   • Septic Microemboli (tiny clots or infected material from heart valves) can break off

     → travel to skin, brain, kidneys, etc.

     → infarctions or abscesses

   • Immune complexes can deposit in tissues

     → vasculitis, glomerulonephritis

     

infective endocarditis clinical features

• Splinter hemorrhages

  • Linear nailbed bleeding (septic microemboli or immune complexes (vasculitis))

• Osler nodes

  • Tender, palpable nodules on finger pulps or thenar/hypothenar eminences (septic microemboli or immune complexes (vasculitis))

• Janeway lesions

  • Non-tender lesions on palms or finger pulps (septic microemboli)

blood pressure

• normally there is a small, non-palpable drop in systolic blood pressure on inspiration

  • If this drop is palpable, it is called pulsus paradoxus

  • >10mmHg drop in systolic pressure during inspiration may indicate pericardial tamponade or severe asthma 

• The pulse pressure is defined as the systolic pressure minus the diastolic pressure

  • A wide pulse pressure is a sign of aortic regurgitation (80-100mmHg)

  • A narrow pulse pressure is a sign of aortic stenosis (less than 25% of the systolic pressure)

  • An average pulse pressure is approximately 40mmHg

scleral jaundice

• yellowing of the sclera (the white of the eye)

• e.g. in cardiovascular disease can signify cardiac failure associated with hepatic congestion

signs of anemia

• conjunctival pallor

• tachycardia

• systolic murmur

xanthelasma

• seen near the upper inner eyelid

• yellow-orange cholesterol deposits under the skin

• sign of hyperlipidaemia in young patients (normal for old)

corneal arcus

• grey/white ring around the iris

• sign of hyperlipidaemia in young patients (normal for old)

malar flush

• Sign of mitral stenosis

  • causes decreased cardiac output and pulmonary hypertension

    → dilatation of the blood vessels in the cheeks giving them a dusky red or purple colour

Gingival health and dentition

• check for signs of gum disease or infection

• Poor gingival health = entry route for bacteria causing infection endocarditis

Angular stomatitis

• inflammation at the edges of the mouth

• may be present in iron and/or vitamin B deficiencies

mucosal petechiae

• small red-purple haemorrhages on the oral mucosa, often seen on the palate

• sign of infective endocarditis

collapsing pulse

• Rapid upstroke, higher volume, fast downstroke (i.e. rises and falls quickly)

• Occurs with:

  • physiological states:

    • fever

    • exercise

    • pregnancy

  • hyperdynamic circulation:

    • anaemia

    • thyrotoxicosis

    • large arteriovenous fistula

• commonly associated with aortic regurgitation

bifid pulse

• can feel two separate peaks (a double impulse) during systole

• Occurs with:

  • co-existing aortic stenosis and aortic regurgitation

  • hypertrophic obstructive cardiomyopathy (HOCM)

(pulsus bisferiens)

plateau pulse

• Slow-rising or anacrotic (small volume, slow-rising)

• Occurs in aortic stenosis

pulsus alternans

• Alternating strong and weak beats

• Can be caused by left ventricular failure

carotid pulse volume categories

• strong

• weak and 'thready'

• normal

carotid pulse character categories

Collapsing pulse 

Bifid pulse (pulsus bisferiens)

Plateau pulse

Pulsus alternans

JVP

• jugular venous pressure

• reflects right atrial pressure

• visible in around 50% of people

• elevated JVP can indicate:

  • right heart failure

  • fluid overload

• say: “I’m looking at the base of the neck between the two heads of the sternocleidomastoid”"

how to measure JVP

• patient is positioned at a 45° angle with their head supported on a pillow

• Ask the patient to turn their head away from you slightly

• Look at the base of the neck for a double pulsation

• say: “I’m looking at the base of the neck between the two heads of the sternocleidomastoid”

then:

• Identify the highest point of the pulsation up the internal jugular vein and draw an imaginary horizontal line across to vertically above the sternal angle (Angle of Louis)

• Measure or estimate the vertical distance between this point and the sternal angle

• A normal JVP height is 3cm or less

then:

• abdominojugular reflux test:

• ask whether the patient has any abdominal pain

• compress over the centre of the abdomen firmly, using the flat of your hand

• hold for 10 seconds while watching the JVP

• abdominal pressure increases venous return to the right atrium

  • it is normal for the JVP to rise transiently

  • should return to normal within a few seconds as the compliance of the right heart and vessels adapts to the increased volume 

• A positive (bad) test is when the JVP remains elevated at > 4 cm for the full 10 seconds that you maintain pressure

types of visible pulsatations

1. Apex of the heart (coin)

   • in a thin person

   • in cardiac conditions that cause a forceful apex beat

2. A right ventricular impulse may be seen in the 3rd, 4th or 5th intercostal spaces at the left sternal edge

   • in right ventricular hypertrophy

3. Over the pulmonary artery at the left 2nd intercostal space

   • if severe pulmonary hypertension is present

apex beat palpation

• 5th left intercostal space (demonstrate counting out the rib spaces)

• the tips of all the fingers of the right hand flat on the chest (palpable in 50% patients)

• roll the patient into the left lateral position

• Identify:

  • whether or not it is palpable

  • normal position, or is it displaced left or right

    • e.g. left displacement in volume overload in mitral regurgitation

  • character:

    • A forceful or pressure-loaded 'heaving' apex beat

      • in left ventricular hypertrophy

      • Causes:

        • hypertension

        • aortic stenosis

    • A volume-loaded 'thrusting' apex beat (displaced laterally and inferiorly)

      • in left ventricular dilatation

      • Causes:

        • mitral regurgitation

        • dilated cardiomyopathy

tricuspid palpation

• Sit the patient forward

• use the heel of the hand flat to palpate over the left sternal edge 

• Identify:

  • heaves (or ‘parasternal impulse’)

    • in right ventricular hypertrophy

      • pulmonary hypertension

        • chronic lung disease: chronic hypoxia leading to constriction of the pulmonary vasculature

      • left heart failure causing congestive cardiac failure

    • if the patient is thin

• place your fingers flat on the chest (A)

• identify:

  • thrills (palpable murmur that feels like a rapid vibration under your fingers)

    • suggests severe valve disease

    • useful for murmur grading

mitral palpation

• after palpating for the apex beat, with patient rolled to their left side

• feel with the flat of your hand (with fingers extended) (B)

• identify:

  • thrills (palpable murmur that feels like a rapid vibration under your fingers)

    • suggests severe valve disease

    • useful for murmur grading

aortic and pulmonary palpation

• with the patient sitting forward

• feel with the flat of your hand (with fingers extended) over the aortic and pulmonary areas (base of the heart) (C)

• identify:

  • thrills (palpable murmur that feels like a rapid vibration under your fingers)

    • suggests severe valve disease

    • useful for murmur grading

splitting

• clearly heard gap in the second heart sound (S2, closure of aortic and pulmonary valves)

• significant delay between aortic valve closure and pulmonary valve closure

  • normal: on deep inspiration

  • pathological: right bundle branch block (abnormal conduction)

third heart sound (S3)

• unexpected heart sound heard shortly after S2 (during early diastole)

• heard:

  • with the bell (low pitched)

  • over the apex (patient left lateral position/side) or the left sternal edge

• can occur:

  • in healthy individuals (especially younger patients)

    or

  • where there is high cardiac output

    or

  • left ventricular failure and dilatation

fourth heart sound (S4)

• unexpected heart sound heard shortly before S1 (late diastole)

• heard:

  • with the bell (low pitched)

  • over the apex (patient left lateral position/side) or the left sternal edge

• can occur in high pressure states such as:

  • aortic stenosis

  • hypertension

murmurs

• additional heart sounds due to turbulent blood flow (stenosis or regurgitation (??))

• if identified, describe:

  1. Timing (during systole or diastole)

  2. Location (over which area it is loudest)

  3. Radiation (whether it can be heard anywhere else)

  4. Effect of inspiration/expiration (right-sided are louder on inspiration, left-sided on expiration)

  5. Effect of the Valsalva manoeuvre (murmurs of HOCM and mitral valve prolapse get louder on Valsalva, the rest get quieter)

  6. Whether a thrill is present (represents more turbulence/louder murmur)

pericardial friction rub (probably not assessed)

• inconsistent crunching sound which may occur in systole or diastole and may come and go

• sometimes seen in pericarditis and is due to inflamed pericardial surfaces moving over each other

Auscultation steps

• With the patient supine at 45°

  • Listen with the bell over the mitral area [for mitral stenosis, S3 or S4]

  • Palpate the carotid pulse simultaneously to identify S1 and S2

• Ask the patient to roll to the left

  • mitral area [for mitral stenosis, S3 or S4]

• Ask the patient to return to supine at 45°

  • Change to the diaphragm

  • mitral area [for mitral regurgitation]

  • in the axilla [for the radiation of mitral regurgitation]

  • tricuspid area [for any tricuspid murmurs]

  • Left sternal edge to the pulmonary area [for any aortic murmurs]

  • Pulmonary area [for any pulmonary murmurs]

  • Aortic area [for any aortic murmurs]

  • Change to the bell

  • Listen over both carotids [for radiation of aortic stenosis and for carotid bruit]

• Ask the patient to hold their breath

  • Listen over both carotids [radiation of aortic stenosis (bilateral) or carotid bruit (unilateral or bilateral)]

• Dynamic manoeuvres - Leaning Forward & Inspiration/Expiration

• Dynamic manoeuvres - Valsalva manoeuvre

leaning forward inspiration and expiration

Ask the patient to lean forwards and breathe all the way in and hold then all the way out and hold

[To help differentiate between right sided murmurs (louder on inspiration) and left sided murmurs (louder on expiration)]

Tip: Right Inspiration, Left Expiration (RILE)

• Listen over the aortic area with the diaphragm [for any aortic murmurs]

• Listen over the left sternal edge (Erb's Point) with the diaphragm [for radiation of aortic regurgitation]

Valsalva maneuver

Ask the patient to take a deep breath in, then pinch their nose and try to pop their ears like on a plane [to accentuate the murmur of HOCM, mitral valve prolapse]

• Listen over the left sternal edge (Erb's Point) with the diaphragm [for mid-systolic murmur of HOCM which gets louder on Valsalva]

• Listen over the mitral area with the diaphragm [for late-systolic murmur of mitral valve prolapse which gets louder on Valsalva]

carotid bruit

• swooshing sound over carotid artery

• may indicate plaque buildup in the carotid artery

HOCM

• hypertrophic obstructive cardiomyopathy

• heart muscle thickens, particularly in the septum, causing a blockage of blood flow

posterior back examination

• Inspect for any scars and any obvious deformities of the chest wall or spine

• Palpate for sacral oedema:

  • press over the sacrum gently for 5-10 seconds

    • allows any fluid to be pushed out of the way

  • After releasing the pressure, look and feel for a pit in the area (pitting oedema)

    • fluid will accumulate at the sacrum in patients who spend a lot of time in bed

  • Pitting oedema: sign of cardiac failure or fluid overload