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
