INDIVIDUAL HEALTH EVALUATION CARDIORESP

Question 1

What should you look for when observing the respiratory system?

Answer 1

Pallor (anaemia)
Central cyanosis
Hypercapnic flush
Engorged neck veins
Accessory muscles of respiration
Pursed lip breathing
Chest shape: COPD, kyphscoliosis, pigeon shaped, pectus axcavatum (depressed sternum), scars and drains
Breathing patterns: normal, laboured, paradoxical, rapid shallow

Question 2

What should you look for when observing the peripheries during a respiratory observation?

Answer 2

Cyanosis (peripheries)
Clubbing
Tremour/flap
Nicotine stains
(Sputum)

Question 3

What should you palpate during a respiraotry observation?

Answer 3

Thoracic expansion
Hi-Lo test (for breathing pattern)
Percussion note
Hydration eg armpits
Tactile fremitus (vibration in the chest wall)
Surgical emphysema
Capillary refill (refill on fingers takes more than 3 seconds indicates poor cardiac output)
Radial pulse

Question 4

Describe the different types of breath sounds:

Answer 4

Normal (Vesicular) : generated by the turbulent airflow in the proximal airways, sound is filtered the lower down the bronchial tree you get, shorter and softer on expiration than inspiration

Abnormal - bronchial: hollow blowing phase, long expiratory phase, pausing, insp and exp equal in length (darth vader breathing)

Diminished breath sounds: air entry is insufficient , or air entry is hindered by an air soli interface eg pneumothroax, or when the patient is poorly positioned

Wheeze: caused when a bronchus is narrowed. Expiratory wheeze eg bronchospasm. Insp obstruction eg tumour. Exp bronchial disease.

Pleural rub: creaky, lethery sounds (sounds like boots on frush snow), caused by roughening or inflammation of the pleural surfaces

Stridor: large airway or tracheal obstruction, loud muscial note and constant pitch (audible without stethoscope)

Crackles: short interrupted sounds by abrupt opening of previously closed airway, intermittent opening as gas squeezes through narrow airway, predom insp. Fine crackles could suggest an intersitial process, whereas coarse crackles suggest excessive fluid eg aspiration or pulmonary oedema.

Rhonchi: continuous low pitch rattling sounds eg pneumonia, COPD etc

Question 5

What is ascultation?

Answer 5

Listening to the internal sounds of the body, using a stethoscope

Question 6

Describe the process of ascultation during a respiratory exam?

Answer 6

Side to side and top to bottom
- APEX of the lungs bilaterally
- Superior lobes anterior and posterior
- Inferior lobes bilaterally anterior and posteriorly
- Middle lobe right anterior only

Question 7

What are the cardinal symptoms related to the chest/respiratory system?

Answer 7

Dyspnea
Breathlessness
Cough
Sputum
Heamoptysis
Wheezing
Chest pain

Question 8

What physiological factors drive dyspnoea?

Answer 8

Increased ventiltaory demand
Respiratory muscle fatigue
Airway obstruction - any obstruction or narrowing of the airways
Decreased lung compliance - conditions that reduce the elasticity or compliance of the lungs making it harder to expand and contract the lungs
Hypoxaemia (low oxygen levels) - triggers the body to breathe more rapidly and deeply to compensate
Hypercapnia (high carbon dioxide levels) - increased breathing effort
Chemoreceptor activation - specialised receptors in the carotid and aortic bodies, called peripheral chemoreceptors are sensitive to changes in blood gas levels. An imbalance can trigger increased respiratory rate and effort to maintain proper gas exchange.

Question 9

What is cardiac related chest pain? (Ischemic cardiac pain)

Answer 9

A reduction in blood flow to the heart
Affects tissue perfusion
Driver for pain
Overhwelming severe pain
Can be linked with exercise, anxiety etc
Sensation of crushing/tightening of the chest
Central
Often radiates but not always (down the left arm, small minority down the right arm)

Easing factors: GTN drug, opens arteries

Question 10

Explain Gastroesophogeal reflux disease - heart burn/Acid reflux pain? (upper gastrointensinal chest pain)

Answer 10

Burning in nature behind breast bone
Associated with lying down
Worse after large/spicy meals
Chronic heart burn can experience dry cough
Disfasia - feels problems swallowing

Easing: sitting up and taking prescribed drugs

Question 11

Explain pleuritic pain?

Answer 11

Inflammation in the pleural space
Chest infection is a common cause (also pulmonary embolism or pneumothorax)
Pain is localised, a lancing pain (sticking something sharp)
Hearts when they breathe in
Cough and sneeze might hurt
Felt more laterally, typically one sided
May radiate to back or shoulders

Question 12

Explain msk causes are chest pain?

Answer 12

Stiffness in joints
Trauma to chest wall eg rib fractures
Strains of muscles which drive pain
Most common: inflammation in the costochondral joint (costochondritis)
Aggravated by specific movements (eased by opposite)
Localised
Not radiating too much
Reproduced by palpation.

Question 13

Examples of questions for chest pain?

Answer 13

Initial: have you ever had any pain or pressure in your chest, neck or arm?

What brings on the pain? What relieves the pain?
Characteristics and duration
Where is the pain and does it radiate?
Pain scale
When did it start? How long does it last?
What do you think is causing it?

Question 14

Examples of questions for shortness of breath?

Answer 14

Initial: do you ever feel short of breath with activity? Short of breath whilst sleeping? Short of breath when lying flat?

What level of activity brings on shortness of breath?
How long to recover?
Have you ever woken up from feeling out of breath? (paroxysmal nocturnal dyspnea)
How many pillows do you need to sleep, or do you sleep in a chair (orthopnea)?

Question 15

Examples of questions for edema?

Answer 15

Initial: have you notices swelling of your feet or ankles? Rings, shoes or clothes tfeeling tight at the end of the day. Unexplained sudden weight gain. New abdominal fullness?

Has this feeling of swelling or restriction gotten worse?
Anything that makes the swelling better (eg feet elevated)
Gaining weight/how much? Over what time period?

Question 16

Examples of questions for palpitations?

Answer 16

Initial: have you ever felt your heart feels as if it is racing or fluttering in your chest? Felt as if your heart skips a beat?
Are you currently experiencing palpitations?
When did it start?
Treatment?

Question 17

Examples of questions for dizziness? (syncope)

Answer 17

Initial: Do you ever feel light headed/dizzy? Have you ever fainted?

What happened?
Warning signs?
Occur with position change?

Question 18

Examples of questions for poor peripheral circulation?

Answer 18

Do your hands or feet ever feel cold or look pale/blue?
Pain in your feet or lower legs when exercising?
What brings on the symptoms?
How much activity needed to cause the pain?
Relieving factors?

Question 19

Examples of questions for calf pain?

Answer 19

Currently have constant pain in lower legs?
Point to the area.

Question 20

Examples of questions for medical history?

Answer 20

Have you ever been diagnosed with any heart or circulation conditions? eg high bp, coronary artery disease, peripheral vascular disease, high cholesterol, heart failure, valve problems.
Have you had any procedures done to improve heart function eg ablation or stent placement?
Have you ever had a heart attack or a stroke?

Question 21

Examples of questions for medication during history taking?

Answer 21

Do you take any heart-related medication, herbs or supplements to treat blood pressure, chest pain, high cholesterol, cardiac rhythm, fluid retention or clot prevention?

Question 22

What questions can be asked for cardiac risk factors?

Answer 22

Have your parents or siblings been diagnosed with any heart conditions? Who has what?
Do you smoke or vape? How much and how long?
Have you ever smoked in the past? How many and what and how long for?
Physical activity levels? How much and what type?
Lifestyle - diet (fruit and veg), saturated fats, eating out, salt, caffeine, alcohol? Units?. Stress, coping and amount 0-10. Sleep, how much and difficulty?

Question 23

What is the inspection stage of an objective CV assessment?

Answer 23

Evaluate vital signs and level of conscioussness.
Inspection - skin colour, cyanosis (pallor is the loss of colour or paleness). Jugular vein distension visible on right side of neck. Inspect chest (precordium) for abnormalities.
Extremities: arms fingers and hands noting colour, warmth, movement, sensation (CWMS). ABilateral inconsistancy may indicate injury. Capillary refill. Toes feet and legs CWMS. Peripheral edema, veins, hair. DVT.

Question 24

What is jugular vein distension?

Answer 24

Increased pressure of the superior vena cava causes the jugular vein to bulge, making it visible on the side side of a persons neck. Should not be present in the upright position.

Question 25

What does CWMS stand for?

Answer 25

Colour, Warmth, Movement and Sensation. What to look for when checking the extremities of the body.

Question 26

What is DVT?

Answer 26

Deep Vein Thrombosis is a blood clot that forms in a vein deep in the body. Emergency notification of a health care provider and immediate follow up due to risk of pulmonary embolism. Unilateral warmth, redness, tenderness, swelling in calf, sudden onset of intense, sharp muscle pain increasing with dorsiflexion indicated DVT.

Question 27

What is edema?

Answer 27

Perifpherel edema is swelling that can be caused by infection, thrombosis, or venous insufficiency due to accumulation of fluid in the tissues.

Question 28

Describe the ausultation stage of an objective CV assessment?

Answer 28

Ausultation sites - APE to Man: Aortic, Pulmonic, Erb’s point, Tricuspid, and Mitral areas.

Aortic - Second intercostal space right of the sternum
Pulmonary - second intercostal space left of the sternum.
Erbs’ point - directly below aortic area (third intercostal space) left of sternum.
Tricuspid - fourth intercostal space left of sternum.
Mitral - fifth intercostal space at the midclavicular line.

When listening over aortic and pulmonic valves the S2 will sound louder than the S1.

The first sound identifies the onset of systole, when the AV valves close and ventricles contract. The second sound identifies the end of systole and the onset of diastole, when the AV valves open and the ventricles fill.

‘lub’ ‘dub’ is the sound.

Palpation - peripheral pulses, capillary refill, edema, temperature, moisture.

Question 29

What are critical conditions to report immediately in regards to the CV system?

Answer 29

Symptomatic tachycardia at rest (HR greater than 100 bpm)
Symptomatic bradycardia (HR less than 60 bpm at rest)
New systolic blood pressure less than 100 mmHg
New irregular heart rhythm
New extra heart sounds such as murmur, S3 or S4
New abnormal cardiac rhythm changes
Reported chest pain, calf pain, or worsening or shortness of breath
Orthostatic blood pressure changes

Question 30

What blood pressure is a contraindication to exercise prescription?

Answer 30

Distolic pressure or diastolic pressure greater than 200/100 mmHg is a relative contraindication to exercise testing.

Question 30

What would you want to know in a Cardiovascular disease risk assessment?

Answer 30

Risk factors: age, hypertension, cholesterol, diabetes, smoking, history, previous event

Symptoms: chest pain, falls, asthma

Examinations: CV, resp, MSK, blood pressure, blood glucose, cholesterol, ECG, exercise ECG, stress test

Family history of a sudden unexplained death when young.

Question 31

How is age a risk factor for a myocardial infarction?

Answer 31

Associated with the build up of fatty deposits, cholesterol and other substances (plaques) on the artery walls, known as atherosclerosis. Can narrow arteries and reduce blood flow to the heart.

Blood vessels may become less elastic and more rigid, increased resistance to blood flow and higher blood pressure

Heart muscle becomes stiffer, so less able to respond to demand, so heard is more susceptible to ischemia (reduced blood supply)

Associated with increased prevelence of other health conditions eg diabetes, hypertension and obesity

Question 32

How is family history a risk factor for myocardial infarction?

Answer 32

If individuals have a first degree relative who has experienced a heart attack, their risk may be elevated. May be due to genetic predisposition, hereditary factors or shared environmental lifestyle factors.

Question 33

How is hypertension a risk factor for myocardial infarction?

Answer 33

Increased cardiac workload: forces the heart to work harder to pump blood. Increased workload can lead to thickening of the heart muscle making the heart more susceptible to ischemia or MI.

Atherscelerosis: key contributor to the development of athersceloris. Plaques may rupture, causing bloackages in coronary arteries.

Endothelial dysfunction: the inner lining of the blood vessels, associated with inflammation and impaired regulation of blood vessel tone, which can contribute to development of atherscelorois.

Question 34

How is an increased risk of thrombosis a risk factor for MI?

Answer 34

hypertension is associated with an increased tendency for blood to clot (hypercoagulability). Can lead to formation of thrombi (blood clots), causing bloackages and maybe MI.

Question 35

How is hypercholesterolaemia a risk factor for MI?

Answer 35

High levels of LDL cholesterol (bad) contribute to the formation of athersclerotic plaques in the walls of arteries. Plaques can narrow the arteries, and cause damage to blood vessels.

Question 36

How is diabetes a risk factor for a MI?

Answer 36

Associated with hyperglycemia (high levels of blood glucose) which contributes to the development of atheroscelorsis.
Often associated with elevated levels of triglycerides and LDL. High lipid profile can also contribute to the development of atherscelorsis.
Can lead to microvascular complications affecting small blood vessels. Microvascular disease may contribute to myocardial ischemia and increase risk of MI.
Often associated with abnormalities in the clot formation, leading to hypercoagulable state.

Question 37

How is obesity a risk factor for a MI?

Answer 37

Associated with diabetes, hypertension and hypercholesterolaemia.
Chronic low grade inflammation, increasing risk of plaque rupture and MI.
Risk factor for obstructive sleep apnoea (interrupted breathing during sleep. Associated with increased risk of hypertension and CV events.

Question 38

How is smoking a risk factor for a MI?

Answer 38

Contributor to the development and acceleration of atherscelosis. Causes blood vessels to constrict or narrow, increasing blood pressure.
Vasoconstrictive effect reduces blood flow, making the heart muscle more susceptible to ischemia.
Promotes a pro-thrombotic (clotting) state. Increases platelet aggregation and activates clotting factors. Clots can obstruct coronary arteries, causing reduction or cessation of blood flow to the heart.

Carbon monoxide in cigarette smoke binds to haemoglobin more readily than oxygen does. Reduces the ocyegn carrying capacity of blood.

Reduces levels of HDL (good) cholesterol

Induces inflammation in the body. Inflammation plays a role in the initiation, progression and destabilisation of atheroscelerotic plaques.

Question 39

How is a sedentary lifestyle a risk factor for a MI?

Answer 39

Can contribute to weight gain and obesity.
Abdominal fat associated with increased risk of atherscelorisis, hypertension, diabetes and dyslipidemia.

Exercise has anti inflammatory effects, while sedentary lifestyle is associated with chronic low grade inflammation. Inflammation plays a role in progression of atherscelorisis.
Physical activity promotes the development of collateral vessels, which can provide alternative routes for blood flow in case of blockages. Sedentary lifestyle may limit development of collateral circulation. Will increase severity of MI if it occurs.

PA helps regulate blood clotting system.

Question 40

How is excessive alcohol a risk factor for a MI?

Answer 40

Can lead to alcoholic myopathy, a condition where the heart muscle is damaged. It weakens the heart’s ability to pump blood efficiently, contributing to heart failure and increased risk of MI.

Alcohol can disrupt the normal electrical signalling, leading to arrythmia. Certain arythmias, such as atrial fibrilation, are associated with increased risk of blood clots, can lead to a MI.

Promotes pro thrmbotic state, increasing risk of blood clot formation.

Question 41

How is chronic stress a risk factor for a MI?

Answer 41

Stress activates the sympathetic nervous system, leading to releases of stress hormones eg adrenaline and cortisol. These can increase heart rate, blood pressure and the workload of the heart.
Also associated with increased inflammatory response in the body.
Shown to activate blood platelets, increased tendency for blood clots . Also a risk for coronary thrombosis, where a blood clot forms in coronary arteries.

Can lead to sleep disturbances and insomnia, associated with increased risk of CV events, including MI.

Can contribute to anxiety and depression.

Question 42

Why do you check hands and feet in a CV assessment?

Answer 42

Tissue perfusion - passage of fluid through the circulatory system or lymphatic system to an organ or tissue (delivery of blood to a capillary bed). Capillary refill test measures efficacity of the vascular system in hands and feet as they are far from the heart.

Peripheral Odema - accumulation of fluid in the intersitial space that occurs as capillary filtration axceeds limit of lympthatic space.

Deep Vein Thrombosis - a blood clot forms in a deep vein, usually lower leg, thigh or pelvis (or sometimes arm).

Question 43

How do we monitor fluid balance?

Answer 43

Fluid balance charts
Physical assessment of fluid balance
Monitoring of blood results

Physical asessment of fluid stats:
Vital signs - overload = tachycardia, hypertension, increased respiratory rate. Depletion = hypotension, lowering pulse pressure, rapid shallow respirations.
Skin: elasticity, CRT, Jugular/Venous pressure.
Urine Output.
Weight
Facial-Oral assessment: mucous membranes dry/moist. Oedema.

Question 44

Explain some indications for fluid balance?

Answer 44

Increased fluid output: diarrhoea and vomitting
High urine output
High output stoma
Urinary catheter, convene, urostomy or irrigation.

Reduced Urine Output:
Oliguria (low urine control, potential poor renal perfusion)
Anuria (absence of urine)
Acute kidney injury/chronic kidney disease

Post operative patients: large open wounds, drains, increased insensible losses.

Decreased oral intake