Week 5 Guiding Q's (Exam 1)

Question 1

List the signs and symptoms of cardiovascular disease. (10)

Answer 1

1. Chest Pain or Discomfort
2. Palpitation
3. Dyspnea
4. Cardiac Syncope
5. Fatigue
6. Cough
7. Cyanosis
8. Edema
9. Claudication
10. Vitals Signs

Question 2

Chest Pain or Discomfort

• what would cardiac related occur secondary to? SxS?
• what would non cardiac related occur secondary to?

Answer 2

Can be cardiac or non cardiac in nature

May radiate to neck, jaw, upper trap, upper back, shoulder or arms (most commonly L arm)

Remember that this is secondary to the heart being supplied by C3-T4 spinal segments

Cardiac-related chest pain can occur secondary to angina, MI, pericarditis, endocarditis or dissecting aortic aneurysm; often accompanied by nausea, vomiting, diaphoresis, dyspnea, fatigue, pallor or syncope

Non-cardiac-related chest pain can occur secondary to cervical disk disease with arthritic changes, anxiety, pec strain, rib dysfunction or trigger points

Question 3

Palpitation

-what 2 things (other symptoms) are often associated with it?

Answer 3

irregular heart beat (described as a bump, pound, jump, flop, flutter, or racing sensation in heart)

may also be associated with lightheadedness or syncope

Question 4

Dyspnea (when is a medical referral required)

Answer 4

Breathlessness or shortness of breath (SOB)

Could also be indicative of pulmonary pathologic condition

Medical referral required if a patient cannot climb a single flight of stairs without feeling moderately to severely winded or a patient who reports waking at night with SOB or experiencing SOB when lying down

Question 5

Cardiac Syncope

• what are some cardiac conditions that can cause this?
• snycope w/o warning indicates what type of conditon?
• when is a referral required?

Answer 5

Fainting due to cardiac condition

Arrhythmias, orthostatic hypotension, poor ventricular function, coronary artery disease or vertebral artery insufficiency

Syncope that occurs without warning of lightheadedness, dizziness or nausea could indicate heart valve or arrhythmic problems

Medical referral required for unexplained syncope

Question 6

Fatigue

• what 4 things is cardiac fatigue often accompanied by?
• what heart med can cause unusal fatigue?

Answer 6

Provoked by minimal exertion may indicate cardiac origin

Fatigue of cardiac nature often accompanied by dyspnea, chest pain, palpitations or headache

Fatigue that exceeds normal expectations during or after exercises requires close monitoring especially in patients with cardiac conditions

Be sure to monitor vital signs

What medication commonly prescribed for cardiac problems can also cause unusual fatigue? – Beta blockers (use RPE to monitor)

Question 7

Cough

Answer 7

Most commonly associated with pulmonary conditions

Left ventricular dysfunction resulting in pulmonary edema or L ventricular CHF may cause cough

Especially with exercise, metabolic stress or being in the supine position

Cough is described as hacking, may produce frothy, blood-tinged sputum

Question 8

Cyanosis

Answer 8

Bluish discoloration of lips and nailbeds, secondary to inadequate blood oxygen levels

Most often accompanies cardiac or pulmonary conditions

Question 9

Edema, what is it a red flag for? What are 2 accompanying symptoms?

Answer 9

3-pound or greater weight gain or gradual, continuous gain over several days causing swelling in ankles, abdomen and hands especially in the presence of SOB, fatigue and dizziness= red flag symptoms of CHF

Edema and other accompanying symptoms that persists with rest require medical referral

Accompanying symptoms include jugular vein distention and cyanosis

Question 10

Claudication

Answer 10

Leg pain that occurs with PVD

Can be functionally debilitating

Common to also have pitting edema in associating with leg pain and common to be accompanied by skin discoloration/trophic changes

Abrupt onset of ischemic resting pain or sudden worsening of claudication requires immediate referral (risk of thromboembolism)

Question 11

Vital Signs

Answer 11

• Heart rate and BP should be taken at IE for all patients to establish a baseline
• Monitor for abnormal responses of cardiovascular system to exercise
• Everyone with known heart disease should be monitored throughout course of care

Abnormal responses

• Heart rate that is too high or too low
• Irregular pulse rate
• SBP does not rise progressively with work level
• SBP that falls during exercise
• Change in diastolic pressure greater than 10 mm Hg

Question 12

Radiating chest pain into the arm occurs in what nerve distribution?

Answer 12

Ulnar nerve distribution

Question 13

If a patient noted heart palpitations, what would warrant a medical evaluation/referral?

Answer 13

Palpations lasting for hours with pain, shortness of breath, fainting or severe lightheadedness require medical evaluation

Also requires immediate referral in patient with positive family history of unexplained sudden death

More than 6 palpitations occurring in a minute should be reported to the physician

Question 14

List the red flag symptoms of CHF. (5)

Answer 14

1. 3-pound or greater weight gain or gradual, continuous gain over several days causing
2. Swelling in ankles, abdomen and hands (pitting edema)
3. SOB
4. Fatigue and dizziness
5. Jugular distention

Question 15

List abnormal vital sign responses (5)

Answer 15

1. Heart rate that is too high or too low
2. Irregular pulse rate
3. SBP does not rise progressively with work level
4. SBP that falls during exercise
5. Change in diastolic pressure greater than 10 mm Hg

Question 16

What are the most common cardiac conditions that could mimic MSK dysfunction? (4)

Answer 16

1. Angina
2. MI
3. Pericarditis
4. Dissecting Aortic Aneurysm

Question 17

Angina

(what is it a symptom of? how is it relieved? what should you do if it’s not relieved? what are 3 non MSK findings that are a red flag for angina?)

Answer 17

symptom of obstructed or decreased blood flow to heart muscle; angina is relieved by rest or by taking nitroglycerin

Pain not relieved by rest or up to 3 nitroglycerin tablets in 10 to 15 minutes requires sending patient to ED and notifying the patients MD

PT is not administering nitroglycerin

Lack of objective musculoskeletal findings would be a red flag (indicates angina)

• AROM does not reproduce the symptoms
• Resisted motions do not reproduce the symptoms
• Onset of symptoms occurs with 5-10 minutes of activity and not immediately

Question 18

Clinical signs and symptoms of angina (9)

Answer 18

1. Gripping, viselike feeling of pain or pressure behind the breast bone
2. Pain that may radiate to the neck, jaw, back, shoulder or arms
3. most commonly L arm in men
4. Toothache
5. Burning indigestion
6. Dyspnea; exercise intolerance
7. Nausea
8. Belching
9. Females may report extreme fatigue, lethargy, breathlessness, or weakness

Question 19

MI (definition; clinical signs and symptoms-9)

Answer 19

development of ischemia and necrosis of myocardial tissue

Clinical Signs/Symptoms of MI:

1. Prolonged or severe substernal chest pain or squeezing pressure
2. Pain radiating down one or both arms or up to throat, neck, back, jaw, shoulders or arms
3. Feeling of nausea or indigestion
4. Angina lasting for 30 mins or more
5. Angina unrelieved by rest, nitroglycerin or antacids
6. Pallor
7. Diaphoresis
8. SOB
9. Weakness, numbness and feelings of faintness

Question 20

Pericarditis (definition, causes)

Answer 20

Inflammation of the pericardium

MI, chest injury, chest radiation or cardiac surgery can cause pericarditis

Be alert to possibility of pericarditis in a patient presenting to PT with new onset of chest, neck or L shoulder pain with history of recent pericarditis

Question 21

Clinical Signs and Symptoms of Pericarditis (11)

Answer 21

1. Chest pain
2. Dyspnea
3. Increased pulse rate
4. Rise in temperature
5. Malaise
6. Myalgia
7. Made worse or reproduced with coughing
8. May be relieved by kneeling on all fours, leaning forward or sitting upright
9. Made worse with breathing, swallowing, belching or neck/trunk movement (ie side bending/rotation)
10. Reports pain to be sharp or cutting

Question 22

Aneurysm (definition, difference in thoracic and abdominal, referral patterns)

Answer 22

Abnormal dilation in wall of artery, vein or heart

Designated as either venous or arterial and described by the vessel in which they develop

Thoracic Aneurysms: Involve ascending, transverse, or descending portion of aorta from heart to top of diaphragm

Abdominal Aneurysms: Aorta below the diaphragm between the renal arteries and iliac branches

Referral patterns include the neck, jaw, shoulder, chest, and/or back pain

Question 23

What signs and symptoms should we be aware of for patients taking statin medications? (5)

Answer 23

Hyperlipidemia is one of the primary risk factors for CAD à Statins used to reduce LDL cholesterol

Screening for side-effects of statins

1. Myalgia
2. Arthralgia
3. Rhabdomyolysis
4. Excessive muscle soreness after exercise (persisting after several days of rest)
5. Also important to screen for liver impairment in patients taking statins

Question 24

What are the symptoms of an MI in a woman 1 month prior to an MI? (7)

Answer 24

1. Unusual fatigue (71%)
2. Sleep disturbance (48%)
3. Dyspnea (42%)
4. Indigestion (39%)
5. Anxiety (36%)
6. Heart racing (27%)
7. Arms weak/heavy (25%)

Question 25

What are the symptoms of an MI in a woman during the MI? (7)

Answer 25

1. Dyspnea (58%) 2. Weakness (55%) 3. Unusual fatigue (43%) 4. Cold Sweat (39%) 5. Dizziness (39%) 6. Nausea (36%) 7. Arms weak/heavy (35%)

Question 26

Pain location for an MI in a woman/atypical MI presentation (4)

Answer 26

1. Upper abdominal/epigastric 2. Neck, jaw and tooth 3. Interscapular and mid to lower thoracic 4. R arm pain (possibly isolated in biceps)

Question 27

Questions for women presenting with L sided chest pain, upper abdominal pain, mid-back pain, shoulder pain, jaw or arm pain (isolated R biceps pain) (7)

Answer 27

In the past month, have you experienced any of the following 1. Unusual fatigue 2. Sleep disturbance 3. Dyspnea 4. Indigestion or GERD 5. Anxiety 6. Heart racing 7. Arm weakness or heaviness

Question 28

List the risk factors and signs/symptoms associated with AAA. Risk factors (5) Clinical sxs (8)

Answer 28

* Most common site is just below the kidney immediately below the renal arteries * Referring pain to TL junction * AAA defined as vessel diameter \>3 cm or more * Risk of rupture increases as diameter approaches 5-6 cm * **Most AAAs are asymptomatic** The most common symptoms is a pulsating mass in the abdomen _Risk Factors_ 1. Age (60 and older) 2. Male gender 3. History of smoking 4. History of hyper cholesterol and coronary heart disease 5. Family history of AAA _Clinical Signs/Symptoms:_ 1. Pulsating mass in abdomen 2. Abdominal “heartbeat” felt when lying down 3. If pain is present, most likely back pain 4. Abdominal, hip, groin or buttock pain also possible 5. Nonmechanical properties 6. Insidious onset 7. May report early satiety, weight loss and nausea 8. Described as sharp, intense, severe or knifelike

Question 29

What does a ruptured AAA feel like?

Answer 29

* Pain described as tearing/ripping * Sudden and severe chest pain with a tearing sensation

Question 30

What signs/symptoms are associated with Right Ventricular Failure? Left Ventricular Failure?

Answer 30

Right Ventricular Failure: * Edema in the LE and viscera * Pitting Edema Left Ventricular Failure * Pulmonary congestion/edema * Problems with respiratory control

Question 31

What is HTN? Why do we care?

Answer 31

HTN = Consistently elevated DBP, SBP or both measured over a period of time Major risk factor for MI, stroke, PVD and death

Question 32

Clinical signs and symptoms of HTN

Answer 32

1. Occipital Headaches 2. Dizziness 3. Flushed face 4. Spontaneous epistaxis 5. Vision changes

Question 33

Hypertension Guidelines (6) - what is considered HTN in 60+ yo? - what is considered HTN in under 60 yo? What calls for immediate termination of activity and a medical referral? What else would call for a medical referral?

Answer 33

60 years old= 150/90 mm Hg considered hypertensive \<60 years old= 140/90 mm Hg considered hypertensive Patients ≥ 18 years old with chronic kidney disease or diabetes= 140/90 mm Hg considered hypertensive Blood pressure changes in the presence of unstable angina, dizziness, nausea, pallor or extreme diaphoresis at rest or during activity would call for immediate termination of activity and requires a medical referral. A medical referral is warranted in patients with known hypertension who are taking an antihypertensive medication if their blood pressure is \>140/90 mm Hg. Nocturnal urinary frequency

Question 34

Should you refer every time you get a high blood pressure reading? Why or why not?

Answer 34

One high reading is not necessarily cause for a medical referral. Continue to monitor that patient over the course of the next few visits and if blood pressure readings continue to exceed the threshold for that patient’s age group, then a medical referral would be appropriate. The exception to this would be if you noted a single high blood pressure reading in the presence of other signs and symptoms of hypertension pressure including: * Headache * Dizziness * Flushed face * Spontaneous epistaxis * Vision changes * Nocturnal urinary frequency

Question 35

What are abnormal BP responses to physical activity/exercise?

Answer 35

DBP increases more than 10 mm Hg with activity SBP does not rise or it falls (falls \> 10 mmHg) with increasing workload SBP exceeds 200 mm Hg or DBP exceeds 100 mm Hg during activity *NOTE: These readings are the upper limit. Recognize that these values may be too high for a patient’s age, general health or overall condition. Use your clinical judgement.* \*\*Use a manual cuff to measure blood pressure during physical activity/exercise. Automatic units are not designed for this purpose and may result in erroneous readings.

Question 36

What is VBI? What are the 5 D's and 3 N's?

Answer 36

Compromise of the vertebral arteries resulting in occlusion or damage Symptoms sudden in onset typically are brief in duration Cervical rotation and extension can occlude if pathology is present Additional S&S other than 5 Ds and 3 Ns include vertigo, nausea & headache described as subtle, intermittent and chronic in nature 5 D’s Dizziness, drop attacks, diplopia, dysarthria, dysphagia 3 N’s: Nausea, numbness, nystagmus

Question 37

What is CAD (cervical arterial dissection)? What is it's early clinical presentation?

Answer 37

Tear or hematoma in wall of internal carotid or vertebral artery Can occur spontaneously or secondary to minor trauma Most common to occur between 35-50 years of age Precipitating events could be mechanical trauma, infection or pro-inflammatory state _Early clinical presentation_ * Neck pain or headache (may mimic migraine or musculoskeletal disorder) * Symptoms often worsen over hours/days * Neck pain/headache described by patients as unusual, different to any previously experienced * Transient ischemic features may be present or may have preceded neck pain/headache * 5Ds

Question 38

Compare contrast VBI and CAD.

Answer 38

Question 39

How can you differentiate chest pain non-cardiac in nature vs that of cardiac nature?

Answer 39

Chest pain of non cardiac origin: Pain on palpation (musculoskeletal origin) Pain alleviated or increased with body movements Exception= Pericarditis often relieved by leaning forward, sitting upright or leaning on all fours and made worse with sidebending and rotation Chest pain can occur secondary to trauma to intercostals from coughing Reproduction of symptoms in pain pattern associated with angina that begins immediately is more likely musculoskeletal in nature Presence of trigger point in chest wall that reproduces symptoms with palpation and symptoms are eliminated with trigger point deactivation

Question 40

Guidelines for Immediate Medical Attention (5)

Answer 40

1. Sudden worsening of intermittent claudication (call dr.) 2. Suspicion of DVT (call dr.) 3. Anginal attack/changes in the pattern of angina (send to ED) 4. Symptoms of TIA (send to ED) 5. S & S of MI (send to ED)

Question 41

Guidelines for MD Referral (6)

Answer 41

1. Women with chest or breast pain with + cardiovascular family history 2. Palpitations in patients with history of unexplained sudden death in family/prolonged episode of palpitations 3. Anyone who can not climb a single flight of stairs without feeling moderate/severely winded 4. 3-pound or greater weight gain or gradual, continuous gain over several days 5. SOB while lying down 6. Syncope without warning