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1

What is a fundamental part of cardiovascular physical diagnosis that cannot be replaced by testing?

A good history

2

What are the cardinal symptoms of cardiovascular disease?

- Chest pain or discomfort
- Dyspnea, orthopnea, paroxysmal nocturnal dyspnea, wheezing
- Palpitations, dizziness, syncope
- Cough, hemophysis
- Fatigue, weakness
- Pain in extremities with exertion (claudication)

3

What is chest pain a cardinal manifestation of?

Myocardial ISCHEMIA
- This means there is an imbalance of myocardial oxygen demand and supply

4

Describe chest pain in relation to an MI

- Occurs WITHOUT an immediate or obvious precipitating clinical cause
- Builds in intensity for several minutes
- Sensation can range from annoying discomfort to severe pain

Need to be suspicious of any discomfort, especially if it radiates to the neck, shoulder or arms!

5

What questions do you need to ask about chest pain when your patient is experiencing it?

- Onset
- Duration
- Frequency
- Quality
- Precipitating or relieving factors
- Location
- Radiation
- Severity (1-10)
- Associated symptoms

6

What sort of precipitating or relieving factors would be relevant?

- Activity (does it go away when you rest?)
- Food ingestion (not heart)
- Deep breathing (not heart)
- Coughing (not heart)
- Cold temperatures

7

What are some common locations of chest pain?

- Substernal
- Epigastric
- Under left breast

8

Where are common locations for chest pain to radiate?

- Neck
- Jaw
- Down either upper extremity
- Around to the back

9

What are some common associated symptoms?

- Lightheadedness
- Nausea
- Diaphoresis
- Loss of consciousness
- Dyspnea

10

List all of the differential diagnoses for chest pain (cardiovascular, non-cardiovascular and miscellaneous)

Cardiovascular
- Angina
- Unstable angina
- Acute myocardial infarction
- Aortic stenosis
- Pericarditis
- Aortic dissection

Non-cardiovascular
- Pulmonary embolism
- Pulmonary hypertension
- Pneumonia or pleuritis
- Spontaneous pneumothorax
- Esophageal reflux
- Esophageal spasm
- Peptic ulcer
- Gallbladder disease

Miscellaneous
- Musculoskeletal disease
- Herpes zoster - "Shingles"
- Emotional and psychiatric conditions

11

Describe angina pain

- Lasts for 2-10 min
- Feels like pressure, tightness, squeezing or burning
- Located in retrosternal area with radiation to neck, jaw, shoulders or arms
- Precipitated by exertion, cold, stress, S4 gallop or MR during pain

12

Describe unstable angina pain

- Lasts 10-20 min
- Similar feeling as angina, but more severe
- Same location as angina
- Precipitated by the same thing as angina, but it occurs with low exertion and at rest

13

Describe acute myocardial infarction pain

- Duration variable, but more than 30 minutes
- Quality similar to angina, but more severe
- Location similar to angina
- Unrelieved by nitroglycerin
- Can be associated with heart failure or arrhythmia

14

Describe aortic stenosis pain

- Recurrent pain similar to angina
- Quality similar to angina
- Location similar to angina
- Systolic murmur will be present

15

Describe pericarditis pain

- Lasts hours to days
- Sharp pain
- Located in the retrosternal or toward the apex
- May radiate to left shoulder
- Relieved by sitting up and leaning forward
- Associated with a pericardial friction rub

16

Describe an aortic dissection pain

- Abrupt onset with unrelenting pain
- Tearing or ripping sensation (knife-like)
- Located in anterior chest, often radiating to back between shoulder blades
- Associated with hypertension, connective tissue disorder (Marfan's), murmur of aortic insufficiency, pericardial tamponade or loss of peripheral pulses

17

Describe pulmonary embolism pain

- Abrupt onset and lasting several minutes to a few hours
- Pleuritic quality - sharp chest wall pain
- Located laterally on the side of the embolism
- Associated with dyspnea, tachypnea, tachycardia and hypotension

18

Describe pulmonary hypertension pain

- Variable duration
- Feels like pressure
- Substernally located
- Associated with dyspnea, signs of increased venous pressure (edema, jugular venous distention)

19

Describe pneumonia or pleuritis pain

- Variable duration
- Pleuritic quality
- Unilateral and localized
- Associated with dyspnea, cough, fever, rales, occasional rub

20

Describe spontaneous pneumothorax pain

- Sudden onset, lasts for several hours
- Pleuritic quality
- Located lateral to the side of the pneumothorax
- Associated with dypnea, decreased breath sounds on side of pneumothorax

21

Describe esophageal reflux pain

- Lasts 10-60 min
- Burning quality
- Located in substernal and epigastric region
- Worsened by postprandial decumbency
- Relieved by antacids

22

Describe esophageal spasm pain

- Lasts 2-30 min
- Feels like preassure, tightness or burning
- Located in the retrosternal region
- Can closely mimic angina

23

Describe peptic ulcer pain

- Prolonged duration
- Feels like burning
- Located in epigastric, substernal area
- Relieved with fods or antacids

24

Describe gall bladder disease pain

- Prolonged duration
- Feels like burning or pressure
- Located in epigastric region, right upper quadrant and substernal region
- May follow a meal

25

Describe musculoskeletal disease pain

- Variable duration
- Aching quality
- Variable location
- Aggravated by movement
- May be reproduced by localized pressure on examination

26

Describe herpes zoster "Shingles" virus

- Variable duration
- Sharp or burning quality
- Dermatomal distribution
- Vesicular rash in the area

27

Describe emotional and psychiatric pain

- Variable duration
- Variable quality
- Variable location, but may be retrosternal
- Situational factors may precipitate symptoms
- Anxiety or depression often detectable with careful history

28

Describe chronic dyspnea

- Due to an increase in pulmonary venous pressure as a result of left ventricular failure or valvular disease
- Occurs during exertion, while supine and at rest
- Associated with cough, sputum, fevers, chills, chest pain, edema

29

What is paroxysmal nocternal dyspnea?

- This refers to attacks of severe shortness of breath and coughing that generally occur at night.
- It usually awakens the person from sleep, and may be quite frightening.
- Though simple orthopnea may be relieved by sitting upright at the side of the bed with legs dependent (legs dangling), in a patient with paroxysmal nocturnal dyspnea, coughing and wheezing often persist even in this position.

30

Describe orthopnea and platypnea

Orthopnea
- Orthopnea is SOB while laying flat
- You can ask the patient how many pillows they sleep with

Platypnea
- Platypnea is SOB when standing up
- This happens with liver disease
- Patient will need to lay flat to alleviate symptoms