CVPR 04-02-14 08-09am Cardiac History and Physical Exam - Horwitz Flashcards Preview

CVPR Unit 1 > CVPR 04-02-14 08-09am Cardiac History and Physical Exam - Horwitz > Flashcards

Flashcards in CVPR 04-02-14 08-09am Cardiac History and Physical Exam - Horwitz Deck (62):
1

"Stable angina"

Recurrent chest pain of at least 2mo in duration, related in a predictable fashion to a given level of exercise or emotional stress, and fairly constant in its degree of intensity, duration, location and quality… Does not require emergency assessment of coronary artery patency

2

"Atypical angina"

May be unrelated to exertion or have unusual quality or location… Implies high risk of an impending acute coronary syndrome & warrants immediate aggressive action, including consideration of emergency cardiac catheterization.

3

“Acute coronary syndrome” defn.

Comprises a spectrum of recent onset presentations ranging from “unstable angina” w/ischemia w/out irreversible damage to “myocardial infarction” involving myocardial necrosis.

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Acute coronary syndromes – associations

Associated w/unstable atherosclerotic plaques where platelets aggregate, causing coronary obstruction…..Many begin at rest, but occurrence with stresses(exercise, shoveling snow, sex) does occur

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Acute coronary syndromes – mechanism

Mechanism is obscure, but appears that acute coronary vascular inflammation or endothelial injury can be a response to physical or emotional stress on occasion…..The tendency for pain to involve more severe or more widely radiating pain than occurred during preceding anginal events probably reflects greater tissue release of the chemical mediators that stimulate nociceptors.

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Acute coronary syndromes – symptoms

Pain more severe or more widely radiating than occurred during preceding angina events….. Dyspnea, diaphoresis, nausea, vomiting, profound weakness, or gaseous distention (while gaseous distention or nausea are common in gastroesophageal disease, diaphoresis or dyspnea are more likely to be cardiac in origin)….. Palpitations, lightheadedness, dizziness or syncope due to arrhythmias are common ….. Inferior infarcts may present w/ hiccups due to diaphragmatic irritation.

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Distribution of pain in acute ischemic cardiac event

Usually, neck to sternum to left arm… Also, can less commonly radiate to jaw, epigastrum , right arm, back

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Chest discomfort in acute ischemic cardiac event

“Like an elephant sitting on my chest”…”Burning sensation.”… “Choking feeling”… “Toothache”… “Bra too tight”

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Common causes of chest pain other than acute coronary syndromes:

MSK pain (discomfort localized to muscle/costochondral joint & precipitated by palpation)….. Pericarditis (exacerbated by cough/deep breath & by position change)….. Pneumonia (associated w/localized rales, productive cough & fever)….. Gastroesophageal reflux disease (worse at night & after spicy foods or alcohol)

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Symptoms to be sought in presumed cardiac pt:

Discomfort or pain in chest?… Faintness or dizziness? ….. Stroke Hx or symptoms (paralysis, suddenly unable to talk)? … Irregular heart beat? … SOB during physical activity?….. Swelling of feet?…..SOB awakening from sleep? (paroxysmal nocturnal dyspnea)… Trouble sleeping while lying flat? (orthopnea; lungs fill w/fluid)… Pain in legs (esp. calves) during physical activity? (atherosclerotic disease)

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Faintness/dizziness/syncope – causes

Low CO (HF)…Overtreating HF (diuretics)… Syncope (actual fainting) b/c of arrhythmias

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Shortness of breath during physical activity – causes

Cardiac (HF, valvular disease w/poor CO) or Pulmonary disease

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Swelling in the feet (edema)

Edema in HF – volume overload, continues throughout the day w/out much change, requires dieresis….. Edema in elderly often due to valvular insufficiency, not HF; usually worsens during the day & disappears at night

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Other useful questions to ask pt w/any form of cardiac disease:

Have you ever been told of: A "heart attack“ or a “heart murmur”?….. An abnormal ECG?….. High BP? ….. High cholesterol/blood lipids?….. Diabetes or high blood sugar? …..A problem w/your thyroid gland?…..Rheumatic fever?

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Family Hx implicated in Cardiac disease

FHx of heart disease, high BP, diabetes/high blood sugar, strokes, or sudden unexpected death?

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Personal habits implicated in Cardiac disease

Smoke or have ever smoked?... Regularly alcohol consumption?...Regular consumption of 3+ cups of coffee/tea?... Weight change in past year?

17

Feel the radial pulse for…

Rate & rhythm

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Palpate the right carotid or brachial artery for…

Amplitude, upstroke, character… carotid w/pt supine & chin elevated…

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Palpate for the apex

Normally in midclavicular line, 5th intercostals space… Can go laterally & down if heart is enlarge… 1+ = barely palpable, quarter sized… 4+ or more if can see it… If can’t feel it, can tilt pt ~15 degrees on left side

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Palpate right ventricle

Feel in epigastric region in adults; Lower left sterna area in kids (congenital)

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Other pulses to palpate

Dorsalis pedis, Posterior tibial

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Look at internal jugular venous pulse for…

Distention, a & v waves…. Look on right side (easier to see)!.... A wave = increased atrial contraction; tells you the sinus rhythm….V wave = simultaneous w/the pulse = tricuspid insufficiency

23

Auscultate both carotids for…

Bruits (evidence of carotid obstructions or of radiation from the murmur of aortic stenosis)

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Auscultate the lungs for…

With pt sitting, from front & rear, for Rales, Wheezes, Absent sounds at bases due to effusions, Pleural rubs

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With patient supine, feel for…

Apex & assess amplitude, character, displacement

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Fell for a right ventricular lit at the…

Lower left sterna border or in the epigastrium

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Feel the pulmonic and aortic areas for…

Palpable lifts

28

Listen to S2 in the…

Pulmonic area (analyze split & amplitude)

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Listen to S1 in the

Tricuspid area

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Listen for S4 in the

Tricuspid area

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Listen for S3 in the…

Mitral area (at the apex)

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Listen for systolic murmurs in the…

aortic & pulmonic areas and then the tricuspid & mitral areas

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Listen at the left sternal border for….

Pulmonic & aortic diastolic regurgitant murmurs….. heard best when pt sits up.

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Listen in tricuspid & mitral areas for…

Tricuspid & mitral regurgitant murmurs and for low pitched murmurs of tricuspid & mitral stenosis or rapid early filling after regurgitant murmurs

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If pericarditis is suspected, listen in/for…

Listen in several precordial sites for a rub.

36

Examine the abdomen, legs & feet for…

Abdomen: Hepatomegaly or ascites….. Legs & feet: Edema & arterial pulses

37

Systolic ejection murmurs – examples& shape

Aortic stenosis, Pulmonic stenosis…. Diamond shape (builds up to halfway between S1 & S2, then diminishes)

38

Aortic stenosis (a systolic ejection murmur) – location to hear --> radiation

2nd right intercostals space ---> neck (but may radiate widely)

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Pulmonic stenosis (a systolic ejection murmur) – location to hear

2nd-3rd left intercostals spaces

40

Holo/Pansystolic murmurs – examples & shape

Mitral regurgitation, Tricuspid regurgitation… Plateau shaped (constant from S1 to S2)

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Mitral regurgitation (a pansystolic murmur) – location to hear --> radiation

Apex ---> axilla

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Tricuspid regurgitation (a pansystolic murmur) – location to hear --> radiation

Left lower sterna border ---> right lower sterna border

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Late systolic murmurs – examples

Mitral valve prolapsed (problem w/papillary muscles that keep valve closed during systole)… start halfway between S1 & S2….

44

Mitral valve prolapsed (late systolic murmur) – location to hear --> radiation

Apex ---> axilla … Hear click + murmur (if no click, probably due to some sort of coronary disease that has damage papillary muscle)

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Early diastolic murmurs – example

Aortic regurgitation, Pulmonic regurgitation (use bell)

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Increasing murmur during inspiration/Decreasing during expiration

Murmur coming from right side of heart

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Aortic regurgitation (an early diastolic murmur) – location to hear --> radiation

Along left side of sternum (hard to tell from pulmonic regurgitation) – use bell

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Pulmonic regurgitation (an early diastolic murmur) – location to hear --> radiation

Upper left side of sternum (hard to tell from aortic regurgitation) – use bell

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Mid-to-late diastolic murmurs – examples

Mitral stenosis

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Mitral stenosis (mid-to-late diastolic murmur) – location to hear --> radiation

Apex … a “rumble”… best heard if turn pt on their left side

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Aortic stenosis

can’t hear; only hear pulmonic closure; normally can hear splitting of S2 on inspiration

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Paradoxical Splitting of S2 on expiration

big afterload (high pressure) on lt ventricular OR left bundle branch block (including from pacemakers in rt ventricle)

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Aortic regurgitation

Firmly press 3-4 intercostal space along lt sterna border; rapid rise & fall of pulse in neck.. lub dub whoosh?... softer sound

54

Aortic stenosis

Harsh sound (galloping)… lub drum… aortic area (in pulmonic area almost sounds like horse walking, w/click = ejection click = comes from a valvular prob)

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Mirtal regurgitation

Sounds like horse heavy breathing (huff) or blowing on microphone… at apex

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Mitral stenosis

Pulmonic area, w/bell lightly (low pitched)…

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S3 - where to hear

bell over apex

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Pulmonic HTN

extentuated pulmonic sound (can hear splitting of S2 at apex; usually only aortic is able to be heard at apex) = lung disease of some sort

59

S4

Augmented blood in late diastole (hear flow during atrial contraction) = common after 55yo; sometimes in children or teen athlete; otherwise, abnormal (ventricle is stiff)

60

Holocystolic murmur (go steady from S1 to S2)

Can be: 1. Mitral regurgitation (at apex) OR 2. Tricuspid regurgitation (epigastrium/lower left sterna border increasing w/inspiration) OR 3. Ventricular septal defect (lt sternal border, 4th? Intercostals space, may be palpable)

61

Ejection murmurs

Aortic outflow obstruction or high flow into pulmonary artery; aortic stenosis – harsh w/crescendo/descrescendo-crescendo, radiates to neck, often associated w/S2 abnormalities (single b/c only pulmonic heard)

62

Aortic/pulmonic insufficiencies

high pitched, deep crescendo, left sternal border

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