CVPR 04-02-14 08-09am Cardiac History and Physical Exam - Horwitz Flashcards
“Stable angina”
Recurrent chest pain of at least 2mo in duration, related in a predictable fashion to a given level of exercise or emotional stress, and fairly constant in its degree of intensity, duration, location and quality… Does not require emergency assessment of coronary artery patency
“Atypical angina”
May be unrelated to exertion or have unusual quality or location… Implies high risk of an impending acute coronary syndrome & warrants immediate aggressive action, including consideration of emergency cardiac catheterization.
“Acute coronary syndrome” defn.
Comprises a spectrum of recent onset presentations ranging from “unstable angina” w/ischemia w/out irreversible damage to “myocardial infarction” involving myocardial necrosis.
Acute coronary syndromes – associations
Associated w/unstable atherosclerotic plaques where platelets aggregate, causing coronary obstruction…..Many begin at rest, but occurrence with stresses(exercise, shoveling snow, sex) does occur
Acute coronary syndromes – mechanism
Mechanism is obscure, but appears that acute coronary vascular inflammation or endothelial injury can be a response to physical or emotional stress on occasion…..The tendency for pain to involve more severe or more widely radiating pain than occurred during preceding anginal events probably reflects greater tissue release of the chemical mediators that stimulate nociceptors.
Acute coronary syndromes – symptoms
Pain more severe or more widely radiating than occurred during preceding angina events….. Dyspnea, diaphoresis, nausea, vomiting, profound weakness, or gaseous distention (while gaseous distention or nausea are common in gastroesophageal disease, diaphoresis or dyspnea are more likely to be cardiac in origin)….. Palpitations, lightheadedness, dizziness or syncope due to arrhythmias are common ….. Inferior infarcts may present w/ hiccups due to diaphragmatic irritation.
Distribution of pain in acute ischemic cardiac event
Usually, neck to sternum to left arm… Also, can less commonly radiate to jaw, epigastrum , right arm, back
Chest discomfort in acute ischemic cardiac event
“Like an elephant sitting on my chest”…”Burning sensation.”… “Choking feeling”… “Toothache”… “Bra too tight”
Common causes of chest pain other than acute coronary syndromes:
MSK pain (discomfort localized to muscle/costochondral joint & precipitated by palpation)….. Pericarditis (exacerbated by cough/deep breath & by position change)….. Pneumonia (associated w/localized rales, productive cough & fever)….. Gastroesophageal reflux disease (worse at night & after spicy foods or alcohol)
Symptoms to be sought in presumed cardiac pt:
Discomfort or pain in chest?… Faintness or dizziness? ….. Stroke Hx or symptoms (paralysis, suddenly unable to talk)? … Irregular heart beat? … SOB during physical activity?….. Swelling of feet?…..SOB awakening from sleep? (paroxysmal nocturnal dyspnea)… Trouble sleeping while lying flat? (orthopnea; lungs fill w/fluid)… Pain in legs (esp. calves) during physical activity? (atherosclerotic disease)
Faintness/dizziness/syncope – causes
Low CO (HF)…Overtreating HF (diuretics)… Syncope (actual fainting) b/c of arrhythmias
Shortness of breath during physical activity – causes
Cardiac (HF, valvular disease w/poor CO) or Pulmonary disease
Swelling in the feet (edema)
Edema in HF – volume overload, continues throughout the day w/out much change, requires dieresis….. Edema in elderly often due to valvular insufficiency, not HF; usually worsens during the day & disappears at night
Other useful questions to ask pt w/any form of cardiac disease:
Have you ever been told of: A “heart attack“ or a “heart murmur”?….. An abnormal ECG?….. High BP? ….. High cholesterol/blood lipids?….. Diabetes or high blood sugar? …..A problem w/your thyroid gland?…..Rheumatic fever?
Family Hx implicated in Cardiac disease
FHx of heart disease, high BP, diabetes/high blood sugar, strokes, or sudden unexpected death?
Personal habits implicated in Cardiac disease
Smoke or have ever smoked?… Regularly alcohol consumption?…Regular consumption of 3+ cups of coffee/tea?… Weight change in past year?
Feel the radial pulse for…
Rate & rhythm
Palpate the right carotid or brachial artery for…
Amplitude, upstroke, character… carotid w/pt supine & chin elevated…
Palpate for the apex
Normally in midclavicular line, 5th intercostals space… Can go laterally & down if heart is enlarge… 1+ = barely palpable, quarter sized… 4+ or more if can see it… If can’t feel it, can tilt pt ~15 degrees on left side
Palpate right ventricle
Feel in epigastric region in adults; Lower left sterna area in kids (congenital)
Other pulses to palpate
Dorsalis pedis, Posterior tibial
Look at internal jugular venous pulse for…
Distention, a & v waves…. Look on right side (easier to see)!…. A wave = increased atrial contraction; tells you the sinus rhythm….V wave = simultaneous w/the pulse = tricuspid insufficiency
Auscultate both carotids for…
Bruits (evidence of carotid obstructions or of radiation from the murmur of aortic stenosis)
Auscultate the lungs for…
With pt sitting, from front & rear, for Rales, Wheezes, Absent sounds at bases due to effusions, Pleural rubs
With patient supine, feel for…
Apex & assess amplitude, character, displacement
Fell for a right ventricular lit at the…
Lower left sterna border or in the epigastrium
Feel the pulmonic and aortic areas for…
Palpable lifts
Listen to S2 in the…
Pulmonic area (analyze split & amplitude)
Listen to S1 in the
Tricuspid area
Listen for S4 in the
Tricuspid area
Listen for S3 in the…
Mitral area (at the apex)
Listen for systolic murmurs in the…
aortic & pulmonic areas and then the tricuspid & mitral areas
Listen at the left sternal border for….
Pulmonic & aortic diastolic regurgitant murmurs….. heard best when pt sits up.
Listen in tricuspid & mitral areas for…
Tricuspid & mitral regurgitant murmurs and for low pitched murmurs of tricuspid & mitral stenosis or rapid early filling after regurgitant murmurs
If pericarditis is suspected, listen in/for…
Listen in several precordial sites for a rub.
Examine the abdomen, legs & feet for…
Abdomen: Hepatomegaly or ascites….. Legs & feet: Edema & arterial pulses
Systolic ejection murmurs – examples& shape
Aortic stenosis, Pulmonic stenosis…. Diamond shape (builds up to halfway between S1 & S2, then diminishes)
Aortic stenosis (a systolic ejection murmur) – location to hear –> radiation
2nd right intercostals space —> neck (but may radiate widely)
Pulmonic stenosis (a systolic ejection murmur) – location to hear
2nd-3rd left intercostals spaces
Holo/Pansystolic murmurs – examples & shape
Mitral regurgitation, Tricuspid regurgitation… Plateau shaped (constant from S1 to S2)
Mitral regurgitation (a pansystolic murmur) – location to hear –> radiation
Apex —> axilla
Tricuspid regurgitation (a pansystolic murmur) – location to hear –> radiation
Left lower sterna border —> right lower sterna border
Late systolic murmurs – examples
Mitral valve prolapsed (problem w/papillary muscles that keep valve closed during systole)… start halfway between S1 & S2….
Mitral valve prolapsed (late systolic murmur) – location to hear –> radiation
Apex —> axilla … Hear click + murmur (if no click, probably due to some sort of coronary disease that has damage papillary muscle)
Early diastolic murmurs – example
Aortic regurgitation, Pulmonic regurgitation (use bell)
Increasing murmur during inspiration/Decreasing during expiration
Murmur coming from right side of heart
Aortic regurgitation (an early diastolic murmur) – location to hear –> radiation
Along left side of sternum (hard to tell from pulmonic regurgitation) – use bell
Pulmonic regurgitation (an early diastolic murmur) – location to hear –> radiation
Upper left side of sternum (hard to tell from aortic regurgitation) – use bell
Mid-to-late diastolic murmurs – examples
Mitral stenosis
Mitral stenosis (mid-to-late diastolic murmur) – location to hear –> radiation
Apex … a “rumble”… best heard if turn pt on their left side
Aortic stenosis
can’t hear; only hear pulmonic closure; normally can hear splitting of S2 on inspiration
Paradoxical Splitting of S2 on expiration
big afterload (high pressure) on lt ventricular OR left bundle branch block (including from pacemakers in rt ventricle)
Aortic regurgitation
Firmly press 3-4 intercostal space along lt sterna border; rapid rise & fall of pulse in neck.. lub dub whoosh?… softer sound
Aortic stenosis
Harsh sound (galloping)… lub drum… aortic area (in pulmonic area almost sounds like horse walking, w/click = ejection click = comes from a valvular prob)
Mirtal regurgitation
Sounds like horse heavy breathing (huff) or blowing on microphone… at apex
Mitral stenosis
Pulmonic area, w/bell lightly (low pitched)…
S3 - where to hear
bell over apex
Pulmonic HTN
extentuated pulmonic sound (can hear splitting of S2 at apex; usually only aortic is able to be heard at apex) = lung disease of some sort
S4
Augmented blood in late diastole (hear flow during atrial contraction) = common after 55yo; sometimes in children or teen athlete; otherwise, abnormal (ventricle is stiff)
Holocystolic murmur (go steady from S1 to S2)
Can be: 1. Mitral regurgitation (at apex) OR 2. Tricuspid regurgitation (epigastrium/lower left sterna border increasing w/inspiration) OR 3. Ventricular septal defect (lt sternal border, 4th? Intercostals space, may be palpable)
Ejection murmurs
Aortic outflow obstruction or high flow into pulmonary artery; aortic stenosis – harsh w/crescendo/descrescendo-crescendo, radiates to neck, often associated w/S2 abnormalities (single b/c only pulmonic heard)
Aortic/pulmonic insufficiencies
high pitched, deep crescendo, left sternal border
