Approach to the CV Pt Flashcards
Cardiac causes of chest pain (3)
-myocardial ischemia/infarction
-acute pericarditis
-aortic dissection
Non-cardiac causes of chest pain (7)
-PE
-pneumonia
-pleural effusion
-reactive airway disease (asthma, “tightness”)
-GI disease (GERD)
-Anxiety
-musculoskeletal disorders —reproduced with palpation/ROM
“pressure on chest”
myocardial ischemia/infarction
what may a sharp pain, worse w/ inspiration and supine position be a sign of
acute pericarditis
tearing or ripping sensation that radiates to the back may be a sign of _______
aortic dissection
Chest pain PE (exam is often normal but what should you look for)
-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)
what are two physical exam findings that may be present in someone with an aortic dissection
- asymmetric peripheral pulses
- diastolic murmur
what are xanthomas and what causes this
yellow plaques around the eyes caused by elevated cholesterol
where would dysfunction be if a pt had a holosystolic murmur of mitral regurgitation
papillary muscles (hold valves open when relaxed and close when contracted, if there is dysfxn then the valve can’t close and regurgitation occurs)
AV nicking
hard, calcified artery pushes on vein (seen on ophthalmic exam)
Cotton wool spot on eye exam
indicate spots of infarction
copper vs. silver wiring
atherosclerotic vessel wall thickening
-copper: partially occluded retinal a.
-silver: fully occluded retinal a.
S3
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
S4
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
what disease process should you suspect if you hear a murmur radiating to the carotids
aortic stenosis
what murmur increases with valsalva maneuver and why is this
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)
what heart condition would sound like a leather-like or scratchy/squeaky sound?
pericardial rub like in pericarditis
Dx tests for chest pain
-EKG
-CXR (look for enlarged heart, pulmonary congestion)
-Stress test (Chemical or physical)
-Coronary angiogram (“gold standard” for CAD dx)
-Coronary artery calcification (CAC)
What to look at on EKG ordered for chest pain
-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
what test is the gold standard for diagnosis CAD
coronary angiograms
what is a “gold standard”
if all cost, risk, and availability considerations are eliminated, which test would be the best?
-most accurate but not always practical/realistic
sx of dyspnea that indicate cardiac cause
-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
PE findings that may help to rule out cardiac cause of dyspnea
-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
DX tests for pt with dyspnea
-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)
what to look for on EKG when evaluating dyspnea
-Q waves
-BBB
-LVH (deep S wave in V1 &/or large R wave in V5/6)
-atrial chamber enlargement
what to look for on CXR when evaluating dyspnea
-enlarged heart
-edema
-aortic valve calcification
-lung mass
-pneumonia
-pleural effusion
-hyperinflation, bullae (gas-containing cystic structure), flattened diaphragms (COPD)
Describe palpitations sensation
fluttering, pounding, or uncomfortable sensation
What diseases should you consider if a pediatric patient c/o palpitations or has h/o palpitations
-Wolff-Parkinson-White syndrome (WPW) (congenital)
-Congenital long QT
What diseases should you consider in a pt with FH of sudden cardiac death &/or FH/PH of CHF or syncope
consider dilated or hypertrophic cardiomyopathy
if palpations resolve with Valsalva maneuver what was the likely cause
paroxysmal supraventricular tachycardia (SVT)
PE for palpitations
-check for displaced PMI, S3
-midsystolic murmur along the L sternal border that increases in intensity w/ Valsalva (indicating possible HCM)
Dx tests for pt c/o palpitations
-EKG
-WPW: short PR interval, delta wave
-long QT syndrome: prolonged QT interval
-structural heart dz: L BBB, LVH
-Ambulatory EKG (ex. holter monitor)
syncope
transient LOC accompanied by loss of postural tone
causes of syncope
-cardiac
-neuro
-volume depletion
-drugs
-hypoglycemia
-anxiety
-psychogenic
what info to collect for pt hx if they c/o syncope
-obtain list of drugs
-FH of sudden death, syncope or HF (HCM, inherited dilated cardiomyopathy, long QT syndrome)
Syncope: PE
-orthostatic vital signs (BP)
-neurologic deficits
-CV exam: delayed carotid upstroke (AV stenosis), abnormal PMI (cardiomyopathy), irregular or bradycardic rhythm, S3, murmurs
Syncope: Diagnostics
-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
Claudication
pain associated w/ decreased perfusion
S/S of claudication
-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)
Dx testing for claudication
-ankle-to-brachial index (ABI): ratio of systolic pressure in ankle to SBP in arm; normal if >1.0
