HISTORY/EXAM Flashcards
List history to take for angina patinet
1) Can you tell me what the pain or discomfort is like – is it sharp, dull heavy or tight
2) When do you get the pain- does it come out of the blue or come on when you do physical things - is it worse if you exercise after eating
3) How long does it last
4) where do you feel it
5) does it make you stop or slow down
6) does it go away quickly when you stop exerising
7) is it coming on with less effort or at rest - unstable
8) have you had angina before and is this the same.
Discuss history features that can differentiate syncope cause
1) favours vasovagal
- onset in teens or 20s
- Occurs in response to emotional distress -e/g sight of blood
- associated with nausea and clamminess
- injury uncommon
- Unconsciousness brief no neurological signs on waking
2) Favours orthosatatic
- onset when getting up quickly
- Brief duration
- injury uncommon
- more common when fasted or dehydrated
- known low BP
- use of antihtn
3) favous situational
- occurs during micturation or defecation
- occurs with prolonged coughing
4) Favours outflow obstruction
- on exertion
5) Favors arrhythmia
- family hx of sudden death (brugada or long QT)
- anti arrhythmic medications (long qt)
- histroy of cardiac disease
- history of rapid palpitations
- no warning ( heart bloke - stoke adams attack)
HX to ask patients with palpitaitons
1) is the sensation one of the heart beating abnormally or something else
2) does the heart seem fast or slow - have you counted how faster - is it faster then at other times i.e exercise
3) Does the heart seem regular or irregular - stopping and starting - if it is irregular is this the feeling of normal heart beats interruprted by missed or strong beats i.e ectopic or completley irregular
4) how long do the episodes last
5) do the episodes start and stop very very suddenly i.e SVT
6) can you terminate the episodes by deep breathing or holding your breath – svt
7) is there a sensation of pounding in the neck – some types of SVT
8) has an episode ever been recorded on ECG
9) have you lost consciousness during an episode - V arrythmias
10) have you had other heart problems in the past V- arrythmias
Describe HX points for peripheral vascular disease
1) Have you had problems with walking because of pain in the legs
2) where do you feel the pain
3) how far can you walk before it occurs
4) does it make you stop
5) does the pain ever occur at rest – severe ischaemia may threaten limb
6) does the pain go away when you stop walking
7) have there been changes in the colour of the skin over your feet or ankles
8) have you had any sores or ulcers on your feet or legs that have not healed
9) have you needed treatment of the arteries of your legs in the past
10) have you had diabetes, high blood pressure or problems with strokes or heart attackes in the past
11) have you ever been a smoker
Describe the cardiovascular exam
1) position patient lying in bed at 45 degrees
2) cachexia –> severe heart failure, signs of syndrome (marfans, downs, turners)
3) Hands –> clubbing
- splinter haemorrhages (IE, vasculitis - RA, PAN, APS, sepsis, haem malignanncy)
- osler node - red raised palpable nodules on the pulps of the fingers or on the thenar or hypothenar eminences.
- Janeway lesions - non tender erythematous maculopapular lesions containing bacteria
- Tendon xanthomata
List causes of clubbing
COMMON
1) CVS
- cyanotic congenital heart disease
- IE
2) Respiratory
- Lung carcinoma (usually not NSCC)
- Chronic pulmonary suppuration (bronchiectasis, lung abscess, empyema)
- Idiopathic pulmonary fibrosis
Uncommon
1) Resp
- CF
- asbestosis
- pleural mesothelioma or pleural fibroma
2) GIT
- cirrhosis ( especially biliary cirrhosis)
- IBD
- Coeliac disease
3) thyrotoxicosis
Describe effect on BP of inspiration
During inspiration the systolic and diastolic blood pressure normally decreases (because intrathoracic pressure becomes more negative blood pools in the pulmonary vessels so left heart filling is reduced)
When this normal reduction in blood pressure with inspiration is exaggerated it is termed pulsus paradoxus.
A fall in arterial pressure on inspiration of more than 10mmHg is abnormal and may occur with constrictive pericarditis, pericardial effusion or severe asthma.
Define postural hypotension and causes for the same
A fall of more than 15/10 mmHg is consided postural hypotension
H- hypovolaemia , hypopituitarism A - Addisons N - neuropathy - autonomic (e.g DM D) Drugs Idioapthic
Describe features on the face important to a CVS exam
1) arcus senilis
2) mitral facies - rosy cheeks with a bluish tinge due to dilation of the malar capillaries. This is associated with pulmonary hyptension and low cardiac output states such as severe MS
3) high arched palate of Marfans
4) dentition
How do you differentiate the JVP from the carotid pulse
1) visible but not palpable pulse
2) more prominenet inward movement then the artery
3) complex wave form usually seen to flicker twice with each cardiac cycle
4) moves with respiration usually decreases with inspiration
When more than 3cm above zero it is indicative of right heart failure
Discuss JVP waves
A-wave is the first +Ve wave and co-insides with the first heart sound (atrial contraction) and precedes the carotid pulsation.
The second impulse is called the V wave and is due to atrial filling in the period when the triscuspid valve remains closed.
Between the A and the v wave there is a trough caused by atrial relaxation termed the x descent
It is interrupted by the c point which is due to transmitted carotid pulsation and coincides with tricuspid valve closure.
Following the V-wave the tricuspid valve opens and rapid ventricular fillign occurs and results in the Z descent
Discuss abnormal finding in the JVP
Causes of an elevated JVP
- RV failure
- Tricuspid stenosis or regurg
- Pericardial effusions or constrictive pericarditis
- Superior vena caval obstruction
- fluid overload
- hyperdynamic circulation
WAVES Causes of dominant a wave - triscuspid stenosis (also causes a slow y descent) -pulmonary stenosis -pulmonary htn
Causes of a cannan a wave
- compelte heart block
- paroxysmal nodal tachycardia with retrograde atrial conduction
- VT with retrograde atrial conduction or AV dissociation
Cause of a dominant v wave
-tricuspid regurg
X-descent
- Absent: AF
- exaggerated - acute cardiac tamponade, constrictive pericarditis
Describe the normal heart sounds
S1 -has two components; mitral and triscupsid closure. Mitral closure occurs slightly before triscuspid but usually only one sound is audible.
S2 - softer and shorter and at a slightly higher pitch than the first marks the end of systole. Caused by closure of the pulmonary and aortic valve closures. Although left and right systole occur at the same time the lower pressure in the pulmonary circulation means that flow continues into the pulmonary artery after the end of right ventricular systole. - as a result closure of the pulmonary valve occurs later than the aortic valve and are usually separated in time so that splitting of the second heart sound is audible.
It can be difficult to determine which heart sound is which and timing it with the radial pulse can be useful.
Describe abnormalities that can arise in heart sounds
S1
- loud S1 occurs when the tricuspid or mitral valve remain open at the end of diastole and shut forecefully with the onset of systole – stenosis.
- other causes of loud S1 are related to reduced diastolic filling time
- Soft first heart sound due to mitral regurg or increased diastolic filling time
S2
- Loud aortic component in patient with systemic hypertension. - Aortic valve stenosis is another cause
- P2 is loud in pulmonary stenosis and pulmonary htn
Splitting
- Splitting of the first heart sound is normally not heard - is present in conduction delays such as RBBB
- Increased normal splitting of the second heart sound occurs when there is any delay in right ventricular emptying as in (RBBB, pulmonary stenosis, VSD, mitral regurg)
- Reversal of splitting can occur due to LBBB, delayed left ventricular emptying (severe aotic stenosis, coaractation of the aorta) or increased ventricualr volume load
Discuss extra heart sounds
3rd
- Low pitched mid diastolic sounds that is best appreciated by listening for a triple rhythm
- Likened to the sound of a horse galloping or similar to the word Kentucky
- Can be physiological in children and young people and is due to very rapid diastolic filling.
- Pathological S3 is due to reduced ventricular compliance so that a filling sound is produced even when diastolic filling is not especially rapid.
4th heart sounds
- late diastolic sound
- Tennessee
- Due to high pressure atrial wave reflected back from a poorly compliant ventricle - does not occur if the patient is in atrial fibrillation
- left ventricular S4 occurs whenever left ventricular compliance is reduced due to AS, MR, systemic hypertension , IHD or advanced age.
