CA powerpoints! Flashcards
Immediate thoughts when assessing someone with chest pain
STEP ONE
what are the 5 questions you want to ask for quality of chest pain?
STEP ONE – QUANTIFY THE PAIN
- How severe is the pain?
- Is the pain pleuritic?
- Is the pain reproducible?
- Does it radiate?
- What was patient doing at onset?
Severe pain supports what type of etiology?
What type of pain is considered aortic dissection until proven otherwise?
- Severe pain supports a critical etiology
- Tearing, shearing pain radiating to the back is an aortic dissection until proven otherwise – immediate threat to life
Pleuritic Pain (describe this pain … please)
What do you explore if it is associated with fever, cough SOB?
- Typically sharp, STABBING, unilateral, made worse with effort of deep breath
- If associated with fever, cough, shortness of breath, explore infectious process (pneumonia)
Angina Pectoris
what is this pain from?
what are some charecteristics of the pain?
what dont you forget about with angina pectoris?
- Chest pain due to ischemia of the heart muscle – generally due to obstruction or spasm of the coronary arteries
- Pain characteristics – tightness, constricting type pain, “elephant sitting on my chest”
- problem with angina: atypical presentations (eg, women, diabetes)
Symptoms of Angina Pectoris (8)
- Dull
- Tight
- Pressing
- Squeezing
- Burning
- Heaviness
- Band across the chest
- Weight in center of chest
Associated Symptoms of Angina (5)
where can it travel?
when does it happen?
what can cause it?
what makes it better?
- Dyspnea – considered an “angina equivalent” and may be the ONLY symptom
- Radiation – often radiates (most prevalent spots – left arm, left shoulder)
- Pain occurring with exertion, abating with rest (differentiates it from MI)
- Patients often report exacerbating factors – emotionally upset, heavy meals, cold weather
- Relieving factors – rest and nitrates
Chronic Stable (3) vs. Unstable Angina (5)
Chronic Stable
- Predictably provoked by exertion
- Relieved by rest
- Etiology – chronic stable coronary stenosis
Unstable
- Occurs with minimal exertion and rest
- Pain is new in onset
- Pain is increasing intensity
- Etiology – associated with ruptured plaques and thrombi, causing obstruction
- Spasms may contribute
“Angina Equivalents”
Definition
what are 4 equivalents?
who is more likely to present with equivalents?
•Definition – symptom that a patient has instead of chest pain that may be indicative of CVD, myocardial infarction
•Equivalents – shortness of breath, indigestion, weakness, malaise
•Women are much more likely to present without chest pain, but with “equivalents”
if someone says i have been nauseous and jsut not feeling well….wht do we always go
GET AN EKG FOOL!
Pericarditis
what does it feel like?
how long does it last?
what are aggravating factors: (2)
Risk factors (5)
How is the pain relieved?
Associated symptoms?
- Sharper and more tearing than ischemic pain
- Lasts for hours
- Aggravating factors – changing body position (KEY), breathing
- Risk factors – lupus, RA, kidney failure, cancer, trauma (steering wheel to chest)
- Pain is sharp and intense – RELIEVED by leaning forward, worse laying down
- Associated symptoms may include fever, malaise
Key points for Pericarditis
(3 things)
what is this usually caused by?
what might your hear?
what might it mimic?
- History - Recent illness? (typically viral)
- Physical Exam – may reveal friction rub
- Diagnostics – may mimic myocardial infarction on an ECG; ECHO helpful for detecting fluid
How does Pericarditis look on an EKG
looks similar to MI
ST elevation in many leads
Diffuse ST elevation throughout EKG
If they just had viral infection with a fever… leaning forward… and sharp pain on inhalation…and ST elevation on EKG
PERICARDITIS
get and echo and really see it!
Waht is Cardiac Tamponade
what is Beck’s Triad?
- Cardiac tamponade is a complication of pericarditis
- Pressure from fluid built up in pericardial sac reaches the point where it r_estricts blood from returning to the heart_
- Beck’s Triad:
- low blood pressure
- distended neck veins
- muffled heart sounds
Aortic Dissection
how does it feel
where does it radiate
what kind of pain
what can it be confused with
what about the pts vitals?
- Sudden onset of sharp ripping, tearing pain
- Typically radiating to the back or felt in the back
- Pain may be constant or pleuritic
- Often confused with MI, esophagitis or pericarditis
- Blood is pooling in the tear… so the patients vitals are decreasing!
- Pain is usually SUDDEN!
- ONSET OF PAIN IS SUDDEN OR SEVERE TEARING PAIN
Physical Exam for Aortic Dissection
(5)
what is the overall mortality rate for aortic rupture?
what are two outcomes that can comr from this?
- Loss or delay of radial, femoral, pedal pulses when comparing one side to the other
- Heart murmur – if it involves the aortic valve
- If blood vessels exiting the aorta are damaged with dissection, paralysis or stroke may occur
- Blood supply to bowel, kidneys or extremities may occur
- Over-all mortality rate for aortic rupture is 80%
Other Causes of Chest Pain (6)
- Pulmonary Emboli
- Esophageal dysfunction, tearing, rupture
- Spine, muscle, nerve
- Rib fracture, costochondritis (these hurt…always palpate)
- Skin – herpes zoster
- Referred pain from abdomen – gallbladder, stomach, pancreas, fluid accumulation (often in geriatric pt)
Ask about Chest Pain
alright so just think of some questions you could ask relating to this!
dont memorize this card silly…. just think about it
- Onset
- Quality (stabbing, burning, tearing, crushing)
- How long does it last?
- Does it come and go? (intermittent)
- What makes it better?
- What makes it worse?
- Does it radiate? Where?
- Any preceding illness?
- Any trauma?
- Similar episodes in the past?
- Is it different from previous episodes (if patient has had previous episodes)
what about Associated Symptoms with chest pain that you would want to ask your patient if they have (8)?
what are some questions to ask your future patients?
- Palpitations? sustained or intermittent
- Shortness of breath?
- –Dyspnea
- –Orthopnea
- –Paroxysmal nocturnal dyspnea (PND)?
- Swelling or edema? where specifically
- Abdominal, back pain or arm pain?
- Fever or chills?
- Cough?
- Nausea or vomiting?
- Sweating?
Ask about Risk Factors for CAD
so what are the risk factors? (5)
- Hypertension
- Smoking
- Hyperlipidemia
- Diabetes
- Family history of premature CHD
Ask about Risk Factors for PE (5)
- Recent surgery
- Fractures
- Prolonged inactivity – long flights, bed rest
- Oral contraceptive use
- Cancer diagnosis
Ask about Risk Factors for Aortic Dissection (6)
- Hypertension
- Marfans Syndrome (Abraham Lincoln)
- Ehlers-Danlos Syndrome – extreme laxity of joints
- Polycystic kidney disease
- Pregnancy
- Cocaine use
Auscultation of the Heart
….sequence of exam….
- Visualize the underlying structures
- Sequence of exam:
- –Supine with head of bed elevated 30˚
- –Left lateral decubitus
- –Sitting, leaning forward
Heart Sounds & Circulation
S1 & S2
what are these noises from? and where are they heard loudest?
what is splitting of S2 mean? when is this heard?
- As the heart valves close, S1 and S2 heart sounds result (“lub-dub”)
- S1 results from closure of mitral valve (heard loudest at apex)
- S2 results from closure of aortic valve (heard loudest at base)
- Physiology splitting of S2
- A2 and P2 (heard during inspiration)
Extra Heart sounds
what are they?
what are they correlated with (2)
what are the two sounds caused by?
what words can these sounds be associated with
- Pathologic extra sounds: S3 and S4
- Highly correlated with HF and myocardial ischemia
- S3 (aka S3 “gallop”) caused by abrupt deceleration of inflow across mitral valve
- S4 caused by increased LV and diastolic stiffness
S3 – sounds like “Kentucky”
S4 – sounds like “Tennessee”
Diaphragm vs. Bell
Which tupe of pitch do you hear with either side?
which heart sounds?
and what valvular conditions?
- Use DIAPHRAGM to hear…
- High-pitched sounds of S1 and S2
- Aortic and mitral regurg
- Pericardial friction rubs
- Use BELL to hear…
- Low-pitched sounds of S3 and S4
- Mitral stenosis murmur
Heart Murmurs
•Techniques to better hear and identify murmurs: (4)
•Techniques to better hear and identify murmurs:
- Remember the locations on the chest wall (eg, apex) to help identify the valve where it originates
- Identify S1 & S2 to determine if murmur is systolic, diastolic or pansystolic
- Diaphragm vs. Bell
- Positional changes
Identifying Heart Murmurs : 7 things to look at
- Timing
- Shape
- Location of maximal intensity
- Radiation
- Intensity (grade 1-6)
- Pitch
- Quality
How do you document a murmur
example of documentation…(just flip the card)
random questions:
where does aortic stenosis radiate
where does mitral regurg radiate
•Document murmur in chart based on its anatomical location (eg, 2nd intercostal space, LSB, base: AORTIC REGURG)
•Example of documentation:
Heart: high-pitched, grade 2/6, blowing decrescendo diastolic murmur, heard best in the 4th intercostal space, with radiation to the apex
aoritic regerg
AORTIC STENOSIS: TO NECK
MITRAL REGURG: AXILLA
Putting it all together: the physcial exam.
waht do you look for in the systems (6)
•Vital signs – BP, HR, RR, temperature
•O2 sat
•Skin – look for rashes (herpes zoster) or findings indicative of hypercholesterolemia
•Head & Neck – check JVP, listen to carotid arteries for bruits or radiating heart murmurs
•Thorax – palpate for rib or muscle tenderness
•Lungs – listen for crackles, wheeze, rhonchi, decreased breath sounds on inspiration
•Cardiac – listen for S1 and S2 heart sounds and murmurs/rubs/gallops, palpate PMI
•Abdomen – palpate for tenderness or mass, listen for bruits over the aorta
•Extremity/Peripheral vascular – check pulses, check for edema
what could you see on the skin?
Hypercholesterolemia
xanthomas
Cardiac Biomarkers:
what are 2 of them?
which one is perferred? why?
what is required for diagnosis of AMI
when should you check for troponin?
when do levels increase? when do they peak? when do they return to baseline?
- Troponins (gold standard) & CK-MB released with myocardial cell death
- Tropnonin – preferred marker (more specific and sensitive for AMI)
- Elevation in the concentration of troponin or CK-MB is required for the diagnosis of AMI (Am College of Cardiology)
- General approach: check troponin at first presentation, if normal repeat at 4-6 hr, could repeat at 12-24 hr if high level of suspicion
- Troponin levels increase w/n 3-12 hrs from pain onset, peak at 24-48 hrs**, return to baseline over **5-14 days
Specifically, cardiac troponins I and T as well as the MB isoenzyme of creatine kinase (CK-MB)
Troponin (2 important concepts to remember)
who is it not necssary for the diagnosis of
what do we persue even if Troponin labs are pending
- Don’t wait on it – not necessary for diagnosis in patients with ST-segment elevation on ECG and ischemic chest pain
- Don’t delay – pursue thrombolytic therapy or coronary angioplasty if warranted (even when troponins are pending)