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

A good history


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)


What is chest pain a cardinal manifestation of?

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


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!


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


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


What are some common locations of chest pain?

- Substernal
- Epigastric
- Under left breast


Where are common locations for chest pain to radiate?

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


What are some common associated symptoms?

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


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

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

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

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


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


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


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


Describe aortic stenosis pain

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


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


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


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


Describe pulmonary hypertension pain

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


Describe pneumonia or pleuritis pain

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


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


Describe esophageal reflux pain

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


Describe esophageal spasm pain

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


Describe peptic ulcer pain

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


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


Describe musculoskeletal disease pain

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


Describe herpes zoster "Shingles" virus

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


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


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


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.


Describe orthopnea and platypnea

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

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