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Cardio Exam 2 > 16 - Physical Diagnosis of CV System > Flashcards

16 - Physical Diagnosis of CV System Flashcards

1
Q

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

A

A good history

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2
Q

What are the cardinal symptoms of cardiovascular disease?

A
  • Chest pain or discomfort
  • Dyspnea, orthopnea, paroxysmal nocturnal dyspnea, wheezing
  • Palpitations, dizziness, syncope
  • Cough, hemophysis
  • Fatigue, weakness
  • Pain in extremities with exertion (claudication)
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3
Q

What is chest pain a cardinal manifestation of?

A

Myocardial ISCHEMIA

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

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4
Q

Describe chest pain in relation to an MI

A
  • 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!

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5
Q

What questions do you need to ask about chest pain when your patient is experiencing it?

A
  • Onset
  • Duration
  • Frequency
  • Quality
  • Precipitating or relieving factors
  • Location
  • Radiation
  • Severity (1-10)
  • Associated symptoms
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6
Q

What sort of precipitating or relieving factors would be relevant?

A
  • Activity (does it go away when you rest?)
  • Food ingestion (not heart)
  • Deep breathing (not heart)
  • Coughing (not heart)
  • Cold temperatures
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7
Q

What are some common locations of chest pain?

A
  • Substernal
  • Epigastric
  • Under left breast
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8
Q

Where are common locations for chest pain to radiate?

A
  • Neck
  • Jaw
  • Down either upper extremity
  • Around to the back
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9
Q

What are some common associated symptoms?

A
  • Lightheadedness
  • Nausea
  • Diaphoresis
  • Loss of consciousness
  • Dyspnea
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10
Q

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

A

Cardiovascular

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

Non-cardiovascular

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

Miscellaneous

  • Musculoskeletal disease
  • Herpes zoster - “Shingles”
  • Emotional and psychiatric conditions
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11
Q

Describe angina pain

A
  • 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
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12
Q

Describe unstable angina pain

A
  • 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
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13
Q

Describe acute myocardial infarction pain

A
  • 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
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14
Q

Describe aortic stenosis pain

A
  • Recurrent pain similar to angina
  • Quality similar to angina
  • Location similar to angina
  • Systolic murmur will be present
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15
Q

Describe pericarditis pain

A
  • 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
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16
Q

Describe an aortic dissection pain

A
  • 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
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17
Q

Describe pulmonary embolism pain

A
  • 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
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18
Q

Describe pulmonary hypertension pain

A
  • Variable duration
  • Feels like pressure
  • Substernally located
  • Associated with dyspnea, signs of increased venous pressure (edema, jugular venous distention)
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19
Q

Describe pneumonia or pleuritis pain

A
  • Variable duration
  • Pleuritic quality
  • Unilateral and localized
  • Associated with dyspnea, cough, fever, rales, occasional rub
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20
Q

Describe spontaneous pneumothorax pain

A
  • 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
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21
Q

Describe esophageal reflux pain

A
  • Lasts 10-60 min
  • Burning quality
  • Located in substernal and epigastric region
  • Worsened by postprandial decumbency
  • Relieved by antacids
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22
Q

Describe esophageal spasm pain

A
  • Lasts 2-30 min
  • Feels like preassure, tightness or burning
  • Located in the retrosternal region
  • Can closely mimic angina
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23
Q

Describe peptic ulcer pain

A
  • Prolonged duration
  • Feels like burning
  • Located in epigastric, substernal area
  • Relieved with fods or antacids
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24
Q

Describe gall bladder disease pain

A
  • Prolonged duration
  • Feels like burning or pressure
  • Located in epigastric region, right upper quadrant and substernal region
  • May follow a meal
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25
Q

Describe musculoskeletal disease pain

A
  • Variable duration
  • Aching quality
  • Variable location
  • Aggravated by movement
  • May be reproduced by localized pressure on examination
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26
Q

Describe herpes zoster “Shingles” virus

A
  • Variable duration
  • Sharp or burning quality
  • Dermatomal distribution
  • Vesicular rash in the area
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27
Q

Describe emotional and psychiatric pain

A
  • Variable duration
  • Variable quality
  • Variable location, but may be retrosternal
  • Situational factors may precipitate symptoms
  • Anxiety or depression often detectable with careful history
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28
Q

Describe chronic dyspnea

A
  • 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
29
Q

What is paroxysmal nocternal dyspnea?

A
  • 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.
30
Q

Describe orthopnea and platypnea

A

Orthopnea

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

Platypnea

  • Platypnea is SOB when standing up
  • This happens with liver disease
  • Patient will need to lay flat to alleviate symptoms
31
Q

Describe palpitations

A
  • Fluttering or unpleasant awareness of heartbeat
  • Can be associated with chest pain, dyspnea, lightheadedness or syncope
  • Need more evaluation
32
Q

Describe edema

A
  • Sudden increase in weight

- Swelling in the lower extremities and abdomen

33
Q

Describe syncope

A
  • Fainting
  • Can be caused by anything that decreases CO2, vasomotor instability or orthostatic hypotension
  • Can occur during or after exertion
  • Can be caused by aortic stenosis or hypertrophic cardiomyopathy (HOCM)
34
Q

Describe fatigue, cough and hemoptysis as associated symptoms

A
  • A non-productive cough can be the first symptom of HF or elevated venous pressure
  • Hemoptysis is coughing up blood and can be seen in PE, pulmonary edema, mitral stenosis and malignancies
35
Q

What type of family medical history is important?

A
  • Premature coronary artery disease (CAD) which occurred in a first degree relative under the age of 55 (male) or 65 (female)
  • A sudden cardiac death which occurred in ANY relative
36
Q

What are non-modifiable risk factors for coronary artery disease (CAD)?

A
  • Age
  • Family history of CAD
  • Gender
  • Ethnicity
37
Q

What are modifiable risk factors for CAD?

A
  • Hypertension
  • Hyperlipidemia
  • Diabetes
  • Obesity
  • Diet
  • Tobacco
  • Physical activity
  • Type A personality (stress/anger/anxiety)
38
Q

What is the first step in CV physical diagnosis?

A

Look at the pateint!

General appearance

  • ABCs first
  • Vital signs
  • Take BP in both arms and one leg, especially in aortic dissection or coarctation
  • Visible pain
  • Dyspneic or diaphoretic
  • Position or avoidance of certain position to eliminate pain
  • Skin pallor, cyanosis, jaundice
  • Chronically ill appearing
  • Height and weight
39
Q

What do you examine in the head and neck region for a CV exam?

A
  • Oral hygiene and configuration of palate
  • Fundoscopic examination (in patients with hypertension, diabetes and suspected endocarditis)
  • Jugular venous pressure (JVP) and wave form
40
Q

What should you suspect if you see roth spots on a fundoscopic examination?

A

Endocarditis

41
Q

How do you measure jugular venous pressure?

A

Measured by adding 5 cm to the height of the observed jugular venous distention above the sternal angle of Louis at 45 degrees

42
Q

What is considered to be jugular venous distenion

A

When the engorgement of the internal jugular vein is present more than 5 cm above the sternal angle at 45 degrees

This means that when you measure, JVD is present when you see 8 or 9 cm (if you added 5) or 5 cm (if you didn’t add 5)

43
Q

Describe how you examine the carotid pulse

A
  • Examine frequency and intensity
  • If there is an increase in frequency and intensity, the patient has a higher stroke volume
  • This can indicate aortic regurgitation, arteriovenous fistula, hyperthyroidism, fever or anemia
  • The carotid pulse can be delayed in patients with valvular aortic stenosis
  • Always listen for bruits
44
Q

Describe how you examine the chest

A
  • Look for scars (evidence of heart surgery)
  • Look for thoracic cage abnormalities
  • Determine respiratory rate, depth of respiration, audible wheezing or stridor
  • Palpation
  • Listen to lungs
45
Q

What are the thoracic cage abnormalities?

A
  • Barrel chest (chronic lung disease)
  • Pectum carnatu (pigeon chest)
  • Pectum excavatum (funnel chest)
46
Q

Describe what you are looking for with chest palpation

A

Tactile fremitus and percussion are especially useful in detecting pleural effusions.

47
Q

Describe the lung examination

A

Listen 4 places in front, one along each side, and six places in back. Crackles are indicative of pulmonary edema, pneumonia or pleuritis.

48
Q

Describe the palpation of the heart

A

Palpation should be done with the patient in supine position at 30 degrees and enhanced by placing the patient in the left lateral decubitus

49
Q

Describe the PMI

A
  • The left ventricle apex beat may be seen in the left midclavicular line and the 5th intercostal space (Point of maximal impulse)
  • Point of maximal impulse is less than 2 cm and it moves quickly away from the fingers. Size, amplitude and rate of force can be noted
50
Q

What if the PMI is located elsewhere?

A

Other locations of PMI are abnormal, pulsations along the chest wall can be indicative of an enlarged right ventricle, aortic aneurysm, etc.

51
Q

What occurs during S1 and S2?

A

S1 = mitral and tricuspid valve closure

S2 = aortic and pulmonic valve closure

52
Q

What is ventricular systole and diastole?

A
  • Ventricular systole - interval between S1 and S2

- Ventricular diastole – interval between S2 and S1

53
Q

What is S3?

A

Rapid filling phase of ventricular diastole. Can be normal and children and young adults

Pathologic after 40, in heart failure patients or in mitral regurgitation

54
Q

What is S4?

A

A sound heard in late ventricular diastole - Always pathologic

Seen in CAD, HTN, HF

55
Q

What are cardiac murmurs?

A
  • Audible vibrations due to increased turbulence
56
Q

How do you detect a cardiac murmur?

A
  • Listen carefully in all four areas with both bell and diaphragm
  • Certain positions and maneuvers will augment or decrease murmurs and extra heart sounds
57
Q

Which murmurs are systolic?

A

MR AS

  • Mitral regurgitation
  • Aortic stenosis

Remember aortic goes with pulmonic and mitral goes with tricuspid…

  • Pulmonic stenosis
  • Tricuspid regurgitation
58
Q

Which murmurs are diastolic?

A

MS AR

  • Mitral stenosis
  • Aortic regurgitation

Remember aortic goes with pulmonic and mitral goes with tricuspid…

  • Pulmonic regurgitation
  • Tricuspid stenosis
59
Q

Which murmur is continuous?

A

Patent ductus arteriosus

60
Q

What will you see in pericardial disease?

A
  • Pericardial friction rub

- ST elevation in electrocardiogram (different looking than in MI)

61
Q

Describe the pericardial friction rub

A
  • 100% specific for teh diagnosis of acute pericarditis

- It is necessary to listen to the heart in different positions to elicit the rub

62
Q

What are the portions of an abdominal exam?

A
  • Look for scars, ascities, etc.
  • Palpate
  • Auscultate
63
Q

Describe abdominal palpation

A
  • Liver enlargement is a sign of heart failure
  • Hepatojugular reflux can be elicited by pressing on the liver and showing an increase in the jugular venous pressure
  • Spleen enlargement can occur in advanced heart failure
64
Q

Describe auscultation of the abdomen

A

Assess for abdominal aortic or rental artery bruits

65
Q

Describe physical examination of the extremities

A
  • Temperature and color (for signs of diminished perfusion)
  • Clubbing
  • Capillary refill time
  • Peripheral edema
  • Muscle atrophy or absence of hair
  • Blood pressure and arterial pulse
66
Q

What does clubbing indicate?

A

Many diseases…

  • lung cancer
  • interstitial pulmonary fibrosis
  • lung abscess
  • pulmonary tuberculosis
  • pulmonary lymphoma
  • congestive heart failure
  • infective endocarditis
  • cyanotic congenital heart disease
67
Q

What does peripheral edema indicate?

A

indicative of heart failure and/or constrictive pericarditis if bilateral, symmetrical, upward from ankles

68
Q

What does muscle atrophy and absence of hair indicate?

A

Peripheral vascular disease

69
Q

What does a delayed pulse indicate?

A
  • Coarctation or dissection of the aorta

Cardio Exam 2 (12 decks)

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