cardiac case study

Question 1

SOB common causes

Answer 1

1. pulmonary
2. cardiac
3. hematologic
4. endocrine

Question 2

s3

Answer 2

heart failure

occurs early in diastole. In young people and athletes it is a normal phenomenon. In older individuals it indicates the presence of congestive heart failure. The third heart sound is caused by a sudden deceleration of blood flow into the left ventricle from the left atrium.

Question 3

s4

Answer 3

usually pathologic finding

low frequency sound, that occurs immediately prior to the first heart sound. It is best heard with the stethoscope’s bell. The S4 heart sound creates a cadence which is like the word ‘Tennessee’, where the syllable ‘Ten’ is S4. It is almost always pathological

Question 4

PMI displaced and mid axillary

Answer 4

maybe hypertrophy is present

Question 5

pale conjuctiva

Answer 5

hallmark of anemia

Question 6

musculoskeletal chest pain

Answer 6

is it reproducible

Question 7

aortic dissection pain

Answer 7

pain straight through to scapula

Question 8

PMI displaced beyond 5th ICS LMCL

Answer 8

suggestive of LVH

Question 9

diastolic murmur is always

Answer 9

pathologic

ie. AR- doe and fatigue most common

Question 10

aortic stenosis

Answer 10

systolic murmur

most common valvular lesion requiring OHS

risk factors- smoking, HTN, HPL, hypertrophic CM

Question 11

MVP

Answer 11

may have regurg, can be symptomatic or asymptomatic
think chest pain, dyspnea, fatigue, or palpitaitons

most common in young females

as it worsens with age, it gets louder in systole and is accentuated in standing position of Valsalva maneuver

Question 12

NT-PRO BNP Gives what

Answer 12

12 HOUR PICTURE OF LEFT VENTRICULAR FILLING IF CONCERNS WITH CHF IN THE ABSENCE OF CKD

Question 13

labs in setting of arrhythmia

Answer 13

TSH,

BMP - e-lytes, fluid status

Question 14

anemia is a leading DD to consider in setting of new SOB

ROS questions

Answer 14

Ask about Fatigue
Screen for blood in urine, stool, coughing up blood
Females: menses
Known h/o anemias
May ask about types of food eaten as a vegan is at risk for anemia

Question 15

What diagnostic testing would you include with high suspicion of anemia as the source of your patients SOB?

Answer 15

CBC
guiaic stools
cscope

Question 16

What endocrine disorders would you screen for in the ROS questions to rule out endocrine causes of SOB?

Answer 16

hypo- hyper- thyroidism

Question 17

most common causes of chest pain in ambulatory setting

Answer 17

1) MSK
* non specific chest wall pain, costochondritis
2) GERD
3) Stable angina
4) Unstable angina
5) Psychogenic causes
6) Respiratory conditions: PE/PNA/Exac COPD/asthma/PNTX
7) 1.5 % of visits are due to acute coronary syndrome
Others: pericarditis, aortic dissection, panic disorder etc.

Question 18

stable angina

Answer 18

Substernal chest discomfort + precipitated by exertion/stress + relief with rest

Question 19

keys to ROS with CP

Answer 19

must determine if pain is exertion, relieved by rest, how often it occurs and if the quality or frequency has been increasing over time.

Question 20

gerd pain

Answer 20

burning pain with eating or supine position

Question 21

pericarditis pain

Answer 21

pleuritic relieved by leaning forward and aggravated laying supine

Question 22

aortic dissection hallmark

Answer 22

PAIN RADIATING TO THE BACK WITH A 20MHG DIFFERENCE IN SBP LEFT/RIGHT

Question 23

pna PE

Answer 23

egophony and dullness to percussion

Question 24

costochondritis PE

Answer 24

palpate chest wall

reproducible MSK

Question 25

concerns on ECG

Answer 25

ST elevation
New LBBB
ST depression
T wave inversions or new Qwaves
These would result in ASA in office 911 to ER
ST elevation across all leads: pericarditis
Flattening of T wave ischemia
Some literature would support a troponin if moderate risk of CAD and a normal ECG but it is best done and sent to th eER.