CVS- IM Flashcards by Maria Hazel Quiban

Causes of cardiovascular symptoms:
myocardial ischemia (___________-
abnormal contraction/relaxation of the myocardium _____________
obstruction to blood flow _______________
abnormal cardiac rate and rhythm _____________
inflammation _________

chest pain of CAD)

(dyspnea of CHF)

(dyspnea of valvular heart disease)

(palpitations)

(chest pain)

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Cardinal Symptoms of Heart Disease

chest pain/discomfort
dyspnea
palpitations
edema
cyanosis
syncope
claudication

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Pressing
•squeezing
•Constricting
•burning
•band across the chest
•“mabigat”
•“nakadagan”
•“sinasakal”

Typical Angina

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exertion (ie. walking fast or up an incline)
emotional excitement
heavy meals
cold exposure
smoking a cigarette

usually retrosternal
diffuse, most patients cannot localize the pain to a particular area
may radiate to neck, jaw, teeth, arms and shoulders

Angina

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_____________
dyspnea (more localized )
discomfort in areas of secondary radiation (e.g. ulnar aspect of left arm, lower jaw, teeth, neck, shoulders, gas and belching, nausea, indigestion, “dizziness”, diaphoresis”)
Usually limited to the area from the mandible to the umbilicus

Anginal equivalent

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Levine’s sign: clenched fist to middle of chest

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uncomfortable awareness of breathing
it can occur in normal individuals
abnormal if:
a**t rest or
at a level of activity not expected to cause this **
in cardiac patients, most commonly associated with pulmonary congestion (heart failure)

may come from diseases of:
heart
lungs
chest wall
respiratory muscles
may be associated with anxiety

dyspnea

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forms of dyspnea in heart disease:
___________________

exertional dyspnea
dyspnea at rest
orthopnea
paroxysmal nocturnal dyspnea (PND)

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________________
dyspnea on lying flat
due to redistribution of fluid from the lower extremities to the lungs

orthopnea

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___________
a variant of orthopnea
patient awakens from sleep after 2-4 hours
dyspneic
with cough, wheezing and sweating
relieved by upright position

PND

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____________
unpleasant awareness of forceful or rapid beating of the heart
pounding, jumping, racing, irregularity of heart beat, pounding in the neck
caused by disorders of cardiac rhythm and rate, augmented stroke volume and hyperkinetic states (increased cardiac output)
accompanied by or caused by anxiety, panic reactions, emotionally stressful situations

Palpitations

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Palpitations History

anxiety/panic attacks

syncope on standing

postural hypotension

tobacco, coffee, tea, alcohol intake

medications

epinephrine, aminophylline, MAO

I illegal drugs

cocaine, shabu

middle aged women, associated flushes and sweats menopausal syndrome

thyrotoxicosis, anemia

family history of arrhythmia, syncope, sudden cardiac death

Palpitations

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Localization is important!

Edema

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starts around the face and eyes
____________________________

usually non-cardiac
~ renal, angioneurotic, hypoproteinemia, myxedema

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EDEMA

limited to the face and neck______________

superior vena cava syndrome

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EDEMA

unilateral extremity
_______________________________

deep venous thrombosis, cellulitis, lymphedema

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peripheral, bilateral

cardiac failure
chronic venous insufficiency
hypoalbuminemia - nephrotic syndrome, liver disease, protein losing enteropathy

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_______________
usually a feature of heart failure (ask for symptoms of CHF)
due to weakened contractility of the heart
bilateral and ascending
ambulatory patients
found on the ankles, legs, thighs and lower abdomen
bedridden patients (found over the sacrum)
usually pitting, except if long standing

Cardiac edema

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__________________
bluish discoloration of the skin and mucus membranes
may be unnoticed by patient (sometimes reported by relative)
if present since infancy/childhood
- think congenital heart disease

Cyanosis

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______________
due to decreased arterial saturation
right-to-left shunting in congenital heart disease
 impaired pulmonary function

Central Cyanosis

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_____________
due to vasoconstriction
exposure to cold
shunting due to low blood
pressure

Peripheral Cyanosis

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_______________
transient loss of consciousness usually from reduced brain perfusion
disorders of vascular tone or volume
cardiovascular disorders
cerebrovascular disorders

Syncope

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____________________
rapid onset
no aura
not associated with convulsive movements, urinary incontinence or post-ictal confusion
consciousness regained promptly

Cardiac syncope:

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Syncope Important to ask for :

family history of syncope some forms of are genetic and may be fatal (ie. Brugada syndrome) intake of medications previous episodes

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_- Intermittent pain in the legs, usually the calf, occurring during activity forcing the patient to rest Located usually at the calf but may vary depending on level of obstruction Episodic muscular ischemia induced by exercise due to obstruction of large or medium-sized arteries by atherosclerosis

Claudication

Other Symptoms \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_- pink frothy sputum of pulmonary edema associated with heart failure symptoms \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_- non-specific decreased cardiac output

Cough Fatigue

Other Symptoms \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_- **common in early heart failure** anorexia abdominal fullness right upper quadrant abdominal discomfort weight loss cardiac cachexia

nocturia

Some patients may be asymptomatic! incidental finding of elevated blood pressure, heart murmur, abnormal ecg, elevated cholesterol, elevated glucose first event can by catastrophic such as massive myocardial infarction

Personal & Social History cigarette smoking active vs. sedentary lifestyle diet drug use, alcohol intake occupation psychosocial impact of disease

IMPORTANT: Lifestyle has a big impact on cardiovascular diseases!

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Ask about use of oral contraceptives Ask about conditions during pregnancy: Pregnancy-induced Hypertension (PIH) Pre-eclampsia / Eclampsia Peripartal Cardiomyopathy Gestational Diabetes mellitus Ask about manner of delivery, large birth weight babies Ask about menopause, medications taken

OB-Gyne History

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Heart disease (be specific!) coronary artery disease, valvular heart disease, congestive heart failure, etc. ** Concomittant disease** diabetes dyslipidemia hyper/hypothyroidism PTB asthma/COPD \* include hospitalizations, medications (note disparities in drug taken from that prescribed)

Past Medical History

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Familial clustering/transmission CAD (esp. early CAD) Dyslipidemia Hypertension Diabetes mellitus Sudden Cardiac Death (SCD)

Family Medical History

THE CARDIOVASCULAR EXAM SEQUENCE:

* General Survey * Vital Signs * Carotid Artery and JVP * Anterior Chest * Peripheral Vessels * Extremities

\_\_\_\_\_\_\_\_\_\_\_\_\_ Best examined with **SCM relaxed**, patient’s **head slightly facing examine** r Check for **bruits** **bilaterally first**. If no bruits noted, **palpate both carotids with thumb or index fingers, ONE AT A TIME**. Note rate, rhythm, quality.

Arterial Pulses Carotid Artery

Arterial Pulses Normal * \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

* Rapid upstroke, gradual downstroke

Abnormal Pulsus parvus – \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

diminished LV stroke volume, increased vascular resistance

Arterial Pulse Abnormality Bisferiens pulse – \_\_\_\_\_\_\_\_\_\_\_\_\_\_

2 systolic peaks, seen in AR and HOCM

Pulsus alternans –\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_-

alternating amplitudes despite regular rhythm, seen in severe LV impairment

\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Estimating JVP important and frequently used skill

Jugular Venous Pressure (JVP)

What are the main objectives in JVP

Main objectives: inspection of waveforms estimate the central venous pressure (CVP)

Jugular Venous Pressure (JVP) NORMAL JVP: \_\_\_\_\_\_\_\_\_\_\_\_\_ Significance: estimates the **central venous pressure (CVP)** estimates the **hydration status of patient and pressure in right atrium**

3-4 cm H20 at 30 deg

What is the signifcance of JVP?

Significance: estimates the **central venous pressure (CVP** ) estimates the **hydration status of patient and pressure in right atrium**

a wave = right atrial contraction c wave = bulging of TV into RA x descent = atrial relaxation v wave = increasing volume in RA during atrial filling y descent = opening of the TV and rapid flow into LV

Jugular Venous Pressure Technique Elevate the head of the **bed to 30 degrees** (may adjust as necessary). Turn patient’s **head slightly away** from the side you are inspecting Use **tangential lighting** to i**dentify the jugular venous** pulsations. Identify the **highest point of pulsation** in the right internal jugular vein . Measure JVP at the level of the **sternal angle.**

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Done in patients suspected of having **RV failure** but **have normal CVP at rest** **Palm** of examiner’s hand is placed **over abdomen**, **firm pressure for 10 seconds** Positive test: **sustained increase in JVP of \>3 cm for 15 sec after 10 sec firm** , RUQ pressure followed by rapid drop in pressure of 4 cm on release of compression

Jugular Venous Pressure (JVP) Abdominojugular or Hepatojugular Reflux Test sustained increase in JVP of \>3 cm for 15 sec after 10 sec firm

THE CARDIAC EXAM

Inspection Palpation Auscultation

Patient Position Supine, head elevated 30 deg Left lateral decubitus Supine, head elevated 30 deg Sitting, leaning forward, exhalation

Inspection

Pectus Excavatum (Funnel Chest)

Pectus Carinatum (Pigeon Breast)

Inspection Xanthelasmas

Inspection Xanthomas

bulbous uniform swelling of the soft tissue of the terminal phalanx of a digit with subsequent loss of the normal angle between the nail and the nail bed . hypoxia may activate local vasodilators, consequently increasing blood flow to the

Inspection Clubbing

Inspection Edema Grading: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Gr 1 – up to ankles Gr 2 – up to knees Gr 3 - above the knees

Palpation

Heaves Thrills PMI

Where do you palpate?

\_\_\_\_\_\_\_\_\_\_\_ Forceful, sustained systolic lift due to increased cardiac mass or force Felt best by the **palm of examiner’s hand** Depends on location : LPSB: RV heave Apex: LV heave

Heaves/Lifts Thrills

Palpable, **low frequency vibrations** felt over the precordium (like a **purring cat)** Felt best by palmar **bases of fingers** Denotes **turbulent flow of blood coursing through abnormal valves or heart chambers** Associated with **Gr 4-6 murmurs**

Thrills

Palpation\_\_\_\_\_\_\_\_\_\_\_ Brief, early pulsation of the LV as it moves anteriorly during contraction and touches the chest wall Normally located at **5th left intercostal space midclavicular line** or **7-9 cm from the midsternal line** Usually known as the\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ - PMI = most prominent pulsation  AB = most lateral pulsation Visible pulsations anywhere other than the normally located ventricular apex beat are ABNORMAL.

: Apical Impulse **point of maximal impulse (PMI) or apex beat **

Palpation: Apical Impulse Technique : Palpate for impulses using your fingerpads. Note: Location Diameter: usually **\<2.5 cm and occupies only 1 interspace** Amplitude: brisk, tapping Duration If apical impulse cannot be identified, ask patient to roll to l**eft lateral decubitus position**