Approach to the CV Pt

Question 1

Cardiac causes of chest pain (3)

Answer 1

-myocardial ischemia/infarction
-acute pericarditis
-aortic dissection

Question 2

Non-cardiac causes of chest pain (7)

Answer 2

-PE
-pneumonia
-pleural effusion
-reactive airway disease (asthma, “tightness”)
-GI disease (GERD)
-Anxiety
-musculoskeletal disorders —reproduced with palpation/ROM

Question 3

“pressure on chest”

Answer 3

myocardial ischemia/infarction

Question 4

what may a sharp pain, worse w/ inspiration and supine position be a sign of

Answer 4

acute pericarditis

Question 5

tearing or ripping sensation that radiates to the back may be a sign of _______

Answer 5

aortic dissection

Question 6

Chest pain PE (exam is often normal but what should you look for)

Answer 6

-look for elevated BP or retinal abnormalities (AV nicking, “copper” wiring, hemorrhages)
-asymmetric peripheral pulses and diastolic murmur (aortic dissection)
-xanthomas (yellow plaques around eyes) indicating elevated cholesterol
-femoral, carotid, or renal a. bruits
-tenderness to palpation - Musculoskeletal cause
-3rd heart sound (S3) (assoc. w/ HF) (and 4th heart sounds - S4)
- Holosystolic murmur of mitral regurgitation (papillary m. dysfunction)

Question 7

what are two physical exam findings that may be present in someone with an aortic dissection

Answer 7

1. asymmetric peripheral pulses
2. diastolic murmur

Question 8

what are xanthomas and what causes this

Answer 8

yellow plaques around the eyes caused by elevated cholesterol

Question 9

where would dysfunction be if a pt had a holosystolic murmur of mitral regurgitation

Answer 9

papillary muscles (hold valves open when relaxed and close when contracted, if there is dysfxn then the valve can’t close and regurgitation occurs)

Question 10

AV nicking

Answer 10

hard, calcified artery pushes on vein (seen on ophthalmic exam)

Question 11

Cotton wool spot on eye exam

Answer 11

indicate spots of infarction

Question 12

copper vs. silver wiring

Answer 12

atherosclerotic vessel wall thickening
-copper: partially occluded retinal a.
-silver: fully occluded retinal a.

Question 13

S3

Answer 13

Ventricular gallop
“Ken Tuc KY”
-occurs in early diastole during PASSIVE LV filling
-may be normal
-requires a very COMPLIANT LV
-can be sign of SYSTOLIC HF

Question 14

S4

Answer 14

Atrial gallop
“TE Nuh See”
-occurs in late diastole during ACTIVE LV filling
-almost always ABNORMAL
-requires a NONCOMPLIANT LV
-can be sign of DIASTOLIC HF

Question 15

what disease process should you suspect if you hear a murmur radiating to the carotids

Answer 15

aortic stenosis

Question 16

what murmur increases with valsalva maneuver and why is this

Answer 16

hypertrophic cardiomyopathy (HCM)
-because holding your breath and bearing down will decrease BF to the heart –> less blood in heart causes the blood flow to become more audible as it hits and goes around an obstruction (like a thickened LV or ventricular septum)

-less audible w/ increased BF (squatting or lying down, offsets gravity)

Question 17

what heart condition would sound like a leather-like or scratchy/squeaky sound?

Answer 17

pericardial rub like in pericarditis

Question 18

Dx tests for chest pain

Answer 18

-EKG
-CXR (look for enlarged heart, pulmonary congestion)
-Stress test (Chemical or physical)
-Coronary angiogram (“gold standard” for CAD dx)
-Coronary artery calcification (CAC)

Question 19

What to look at on EKG ordered for chest pain

Answer 19

-Q waves (significant if 0.03 sec+ AND 1/3 the vertical deflection length of R wave - sign of PREVIOUS MI)
-ST segment depression
-T wave abnormalities

Question 20

what test is the gold standard for diagnosis CAD

Answer 20

coronary angiograms

Question 21

what is a “gold standard”

Answer 21

if all cost, risk, and availability considerations are eliminated, which test would be the best?

-most accurate but not always practical/realistic

Question 22

sx of dyspnea that indicate cardiac cause

Answer 22

-paroxysmal nocturnal dyspnea
-orthopnea
-nocturia
-recent wt gain (poor BF to kidneys causes fluid retention)
-leg edema

*In elderly, dyspnea may be only sx of MI

Question 23

PE findings that may help to rule out cardiac cause of dyspnea

Answer 23

-normal level of jugular venous pulsations
-normal point of maximal cardiac impulse (if far left then heart may be enlarged)
-lack of S3 or cardiac murmurs
-absence of rales (crackles)
-absence of peripheral edema

Question 24

DX tests for pt with dyspnea

Answer 24

-EKG
-CXR

Others:
-echo (valve and ventricular fxn; TEE down esophagus, TTE US over heart)
-PFTs
-stress EKG
-serum natriuretic peptide (BNP) levels: BNP and NT-proBNP (increase when heart is repairing/remodeling, keep remodel process in check)

Question 25

what to look for on EKG when evaluating dyspnea

Answer 25

-Q waves
-BBB
-LVH (deep S wave in V1 &/or large R wave in V5/6)
-atrial chamber enlargement

Question 26

what to look for on CXR when evaluating dyspnea

Answer 26

-enlarged heart
-edema
-aortic valve calcification
-lung mass
-pneumonia
-pleural effusion
-hyperinflation, bullae (gas-containing cystic structure), flattened diaphragms (COPD)

Question 27

Describe palpitations sensation

Answer 27

fluttering, pounding, or uncomfortable sensation

Question 28

What diseases should you consider if a pediatric patient c/o palpitations or has h/o palpitations

Answer 28

-Wolff-Parkinson-White syndrome (WPW) (congenital)
-Congenital long QT

Question 29

What diseases should you consider in a pt with FH of sudden cardiac death &/or FH/PH of CHF or syncope

Answer 29

consider dilated or hypertrophic cardiomyopathy

Question 30

if palpations resolve with Valsalva maneuver what was the likely cause

Answer 30

paroxysmal supraventricular tachycardia (SVT)

Question 31

PE for palpitations

Answer 31

-check for displaced PMI, S3
-midsystolic murmur along the L sternal border that increases in intensity w/ Valsalva (indicating possible HCM)

Question 32

Dx tests for pt c/o palpitations

Answer 32

-EKG
-WPW: short PR interval, delta wave
-long QT syndrome: prolonged QT interval
-structural heart dz: L BBB, LVH
-Ambulatory EKG (ex. holter monitor)

Question 33

syncope

Answer 33

transient LOC accompanied by loss of postural tone

Question 34

causes of syncope

Answer 34

-cardiac
-neuro
-volume depletion
-drugs
-hypoglycemia
-anxiety
-psychogenic

Question 35

what info to collect for pt hx if they c/o syncope

Answer 35

-obtain list of drugs
-FH of sudden death, syncope or HF (HCM, inherited dilated cardiomyopathy, long QT syndrome)

Question 36

Syncope: PE

Answer 36

-orthostatic vital signs (BP)
-neurologic deficits
-CV exam: delayed carotid upstroke (AV stenosis), abnormal PMI (cardiomyopathy), irregular or bradycardic rhythm, S3, murmurs

Question 37

Syncope: Diagnostics

Answer 37

-EKG (necessary in all pts w/ syncope)
-Others: echo, coronary angiogram, stress EKG, holter monitor, brain CT or MRI, carotid doppler, EEG, tilt table testing

Question 38

Claudication

Answer 38

pain associated w/ decreased perfusion

Question 39

S/S of claudication

Answer 39

-pain/cramping in buttocks, thighs, and calf muscles (can occur anywhere though)
-sx occur w/ ambulation and resolve w/ rest (if severe, sx may persist at rest)
-impotence in men
-diminished or absent peripheral pulses
-pallor, cool skin, ulcers
-bruits (build up in arteries, turbulent flow)

Question 40

Dx testing for claudication

Answer 40

-ankle-to-brachial index (ABI): ratio of systolic pressure in ankle to SBP in arm; normal if >1.0