16 - Physical Diagnosis of CV System Flashcards
What is a fundamental part of cardiovascular physical diagnosis that cannot be replaced by testing?
A good history
What are the cardinal symptoms of cardiovascular disease?
- Chest pain or discomfort
- Dyspnea, orthopnea, paroxysmal nocturnal dyspnea, wheezing
- Palpitations, dizziness, syncope
- Cough, hemophysis
- Fatigue, weakness
- Pain in extremities with exertion (claudication)
What is chest pain a cardinal manifestation of?
Myocardial ISCHEMIA
- This means there is an imbalance of myocardial oxygen demand and supply
Describe chest pain in relation to an MI
- 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!
What questions do you need to ask about chest pain when your patient is experiencing it?
- Onset
- Duration
- Frequency
- Quality
- Precipitating or relieving factors
- Location
- Radiation
- Severity (1-10)
- Associated symptoms
What sort of precipitating or relieving factors would be relevant?
- Activity (does it go away when you rest?)
- Food ingestion (not heart)
- Deep breathing (not heart)
- Coughing (not heart)
- Cold temperatures
What are some common locations of chest pain?
- Substernal
- Epigastric
- Under left breast
Where are common locations for chest pain to radiate?
- Neck
- Jaw
- Down either upper extremity
- Around to the back
What are some common associated symptoms?
- Lightheadedness
- Nausea
- Diaphoresis
- Loss of consciousness
- Dyspnea
List all of the differential diagnoses for chest pain (cardiovascular, non-cardiovascular and miscellaneous)
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
Describe angina pain
- 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
Describe unstable angina pain
- 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
Describe acute myocardial infarction pain
- 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
Describe aortic stenosis pain
- Recurrent pain similar to angina
- Quality similar to angina
- Location similar to angina
- Systolic murmur will be present
Describe pericarditis pain
- 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
Describe an aortic dissection pain
- 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
Describe pulmonary embolism pain
- 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
Describe pulmonary hypertension pain
- Variable duration
- Feels like pressure
- Substernally located
- Associated with dyspnea, signs of increased venous pressure (edema, jugular venous distention)
Describe pneumonia or pleuritis pain
- Variable duration
- Pleuritic quality
- Unilateral and localized
- Associated with dyspnea, cough, fever, rales, occasional rub
Describe spontaneous pneumothorax pain
- 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
Describe esophageal reflux pain
- Lasts 10-60 min
- Burning quality
- Located in substernal and epigastric region
- Worsened by postprandial decumbency
- Relieved by antacids
Describe esophageal spasm pain
- Lasts 2-30 min
- Feels like preassure, tightness or burning
- Located in the retrosternal region
- Can closely mimic angina
Describe peptic ulcer pain
- Prolonged duration
- Feels like burning
- Located in epigastric, substernal area
- Relieved with fods or antacids
Describe gall bladder disease pain
- Prolonged duration
- Feels like burning or pressure
- Located in epigastric region, right upper quadrant and substernal region
- May follow a meal
Describe musculoskeletal disease pain
- Variable duration
- Aching quality
- Variable location
- Aggravated by movement
- May be reproduced by localized pressure on examination
Describe herpes zoster “Shingles” virus
- Variable duration
- Sharp or burning quality
- Dermatomal distribution
- Vesicular rash in the area
Describe emotional and psychiatric pain
- Variable duration
- Variable quality
- Variable location, but may be retrosternal
- Situational factors may precipitate symptoms
- Anxiety or depression often detectable with careful history
Describe chronic dyspnea
- 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
What is paroxysmal nocternal dyspnea?
- 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.
Describe orthopnea and platypnea
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
Describe palpitations
- Fluttering or unpleasant awareness of heartbeat
- Can be associated with chest pain, dyspnea, lightheadedness or syncope
- Need more evaluation
Describe edema
- Sudden increase in weight
- Swelling in the lower extremities and abdomen
Describe syncope
- 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)
Describe fatigue, cough and hemoptysis as associated symptoms
- 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
What type of family medical history is important?
- 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
What are non-modifiable risk factors for coronary artery disease (CAD)?
- Age
- Family history of CAD
- Gender
- Ethnicity
What are modifiable risk factors for CAD?
- Hypertension
- Hyperlipidemia
- Diabetes
- Obesity
- Diet
- Tobacco
- Physical activity
- Type A personality (stress/anger/anxiety)
What is the first step in CV physical diagnosis?
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
What do you examine in the head and neck region for a CV exam?
- Oral hygiene and configuration of palate
- Fundoscopic examination (in patients with hypertension, diabetes and suspected endocarditis)
- Jugular venous pressure (JVP) and wave form
What should you suspect if you see roth spots on a fundoscopic examination?
Endocarditis
How do you measure jugular venous pressure?
Measured by adding 5 cm to the height of the observed jugular venous distention above the sternal angle of Louis at 45 degrees
What is considered to be jugular venous distenion
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)
Describe how you examine the carotid pulse
- 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
Describe how you examine the chest
- 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
What are the thoracic cage abnormalities?
- Barrel chest (chronic lung disease)
- Pectum carnatu (pigeon chest)
- Pectum excavatum (funnel chest)
Describe what you are looking for with chest palpation
Tactile fremitus and percussion are especially useful in detecting pleural effusions.
Describe the lung examination
Listen 4 places in front, one along each side, and six places in back. Crackles are indicative of pulmonary edema, pneumonia or pleuritis.
Describe the palpation of the heart
Palpation should be done with the patient in supine position at 30 degrees and enhanced by placing the patient in the left lateral decubitus
Describe the PMI
- 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
What if the PMI is located elsewhere?
Other locations of PMI are abnormal, pulsations along the chest wall can be indicative of an enlarged right ventricle, aortic aneurysm, etc.
What occurs during S1 and S2?
S1 = mitral and tricuspid valve closure
S2 = aortic and pulmonic valve closure
What is ventricular systole and diastole?
- Ventricular systole - interval between S1 and S2
- Ventricular diastole – interval between S2 and S1
What is S3?
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
What is S4?
A sound heard in late ventricular diastole - Always pathologic
Seen in CAD, HTN, HF
What are cardiac murmurs?
- Audible vibrations due to increased turbulence
How do you detect a cardiac murmur?
- Listen carefully in all four areas with both bell and diaphragm
- Certain positions and maneuvers will augment or decrease murmurs and extra heart sounds
Which murmurs are systolic?
MR AS
- Mitral regurgitation
- Aortic stenosis
Remember aortic goes with pulmonic and mitral goes with tricuspid…
- Pulmonic stenosis
- Tricuspid regurgitation
Which murmurs are diastolic?
MS AR
- Mitral stenosis
- Aortic regurgitation
Remember aortic goes with pulmonic and mitral goes with tricuspid…
- Pulmonic regurgitation
- Tricuspid stenosis
Which murmur is continuous?
Patent ductus arteriosus
What will you see in pericardial disease?
- Pericardial friction rub
- ST elevation in electrocardiogram (different looking than in MI)
Describe the pericardial friction rub
- 100% specific for teh diagnosis of acute pericarditis
- It is necessary to listen to the heart in different positions to elicit the rub
What are the portions of an abdominal exam?
- Look for scars, ascities, etc.
- Palpate
- Auscultate
Describe abdominal palpation
- 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
Describe auscultation of the abdomen
Assess for abdominal aortic or rental artery bruits
Describe physical examination of the extremities
- 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
What does clubbing indicate?
Many diseases…
- lung cancer
- interstitial pulmonary fibrosis
- lung abscess
- pulmonary tuberculosis
- pulmonary lymphoma
- congestive heart failure
- infective endocarditis
- cyanotic congenital heart disease
What does peripheral edema indicate?
indicative of heart failure and/or constrictive pericarditis if bilateral, symmetrical, upward from ankles
What does muscle atrophy and absence of hair indicate?
Peripheral vascular disease
What does a delayed pulse indicate?
- Coarctation or dissection of the aorta
