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2H. Physical Diagnosis > CVS- IM > Flashcards

CVS- IM Flashcards

1
Q

Causes of cardiovascular symptoms:
myocardial ischemia (___________-
abnormal contraction/relaxation of the myocardium _____________
obstruction to blood flow _______________
abnormal cardiac rate and rhythm _____________
inflammation _________

A

chest pain of CAD)

(dyspnea of CHF)

(dyspnea of valvular heart disease)

(palpitations)

(chest pain)

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2
Q

Cardinal Symptoms of Heart Disease

A

chest pain/discomfort
dyspnea
palpitations
edema
cyanosis
syncope
claudication

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3
Q

Pressing
•squeezing
•Constricting
•burning
•band across the chest
•“mabigat”
•“nakadagan”
•“sinasakal”

A

Typical Angina

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4
Q

exertion (ie. walking fast or up an incline)
emotional excitement
heavy meals
cold exposure
smoking a cigarette

usually retrosternal
diffuse, most patients cannot localize the pain to a particular area
may radiate to neck, jaw, teeth, arms and shoulders

A

Angina

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5
Q

_____________
dyspnea (more localized )
discomfort in areas of secondary radiation (e.g. ulnar aspect of left arm, lower jaw, teeth, neck, shoulders, gas and belching, nausea, indigestion, “dizziness”, diaphoresis”)
Usually limited to the area from the mandible to the umbilicus

A

Anginal equivalent

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6
Q
A

Levine’s sign: clenched fist to middle of chest

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7
Q
A
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8
Q

uncomfortable awareness of breathing
it can occur in normal individuals
abnormal if:
a**t rest or
at a level of activity not expected to cause this **
in cardiac patients, most commonly associated with pulmonary congestion (heart failure)

may come from diseases of:
heart
lungs
chest wall
respiratory muscles
may be associated with anxiety

A

dyspnea

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9
Q

forms of dyspnea in heart disease:
___________________

A

exertional dyspnea
dyspnea at rest
orthopnea
paroxysmal nocturnal dyspnea (PND)

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10
Q

________________
dyspnea on lying flat
due to redistribution of fluid from the lower extremities to the lungs

A

orthopnea

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11
Q

___________
a variant of orthopnea
patient awakens from sleep after 2-4 hours
dyspneic
with cough, wheezing and sweating
relieved by upright position

A

PND

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12
Q

____________
unpleasant awareness of forceful or rapid beating of the heart
pounding, jumping, racing, irregularity of heart beat, pounding in the neck
caused by disorders of cardiac rhythm and rate, augmented stroke volume and hyperkinetic states (increased cardiac output)
accompanied by or caused by anxiety, panic reactions, emotionally stressful situations

A

Palpitations

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13
Q

Palpitations History

anxiety/panic attacks

syncope on standing

postural hypotension

tobacco, coffee, tea, alcohol intake

medications

epinephrine, aminophylline, MAO

I illegal drugs

cocaine, shabu

middle aged women, associated flushes and sweats menopausal syndrome

thyrotoxicosis, anemia

family history of arrhythmia, syncope, sudden cardiac death

A

Palpitations

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14
Q

Localization is important!

A

Edema

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15
Q

starts around the face and eyes
____________________________

A

usually non-cardiac
~ renal, angioneurotic, hypoproteinemia, myxedema

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16
Q

EDEMA

limited to the face and neck______________

A

superior vena cava syndrome

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17
Q

EDEMA

unilateral extremity
_______________________________

A

deep venous thrombosis, cellulitis, lymphedema

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18
Q

peripheral, bilateral

A

cardiac failure
chronic venous insufficiency
hypoalbuminemia - nephrotic syndrome, liver disease, protein losing enteropathy

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19
Q

_______________
usually a feature of heart failure (ask for symptoms of CHF)
due to weakened contractility of the heart
bilateral and ascending
ambulatory patients
found on the ankles, legs, thighs and lower abdomen
bedridden patients (found over the sacrum)
usually pitting, except if long standing

A

Cardiac edema

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20
Q

__________________
bluish discoloration of the skin and mucus membranes
may be unnoticed by patient (sometimes reported by relative)
if present since infancy/childhood
- think congenital heart disease

A

Cyanosis

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21
Q

______________
due to decreased arterial saturation
right-to-left shunting in congenital heart disease
 impaired pulmonary function

A

Central Cyanosis

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22
Q

_____________
due to vasoconstriction
exposure to cold
shunting due to low blood
pressure

A

​Peripheral Cyanosis

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23
Q

_______________
transient loss of consciousness usually from reduced brain perfusion
disorders of vascular tone or volume
cardiovascular disorders
cerebrovascular disorders

A

Syncope

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24
Q

____________________
rapid onset
no aura
not associated with convulsive movements, urinary incontinence or post-ictal confusion
consciousness regained promptly

A

Cardiac syncope:

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25
Q

Syncope
Important to ask for :

A

family history of syncope
some forms of are genetic and may be fatal
(ie. Brugada syndrome)
intake of medications
previous episodes

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26
Q

________________-
Intermittent pain in the legs, usually the calf, occurring during activity forcing the patient to rest
Located usually at the calf but may vary depending on level of obstruction
Episodic muscular ischemia induced by exercise due to obstruction of large or medium-sized arteries by atherosclerosis

A

Claudication

27
Q

Other Symptoms
_______________-
pink frothy sputum of pulmonary edema
associated with heart failure symptoms
_______________-
non-specific
decreased cardiac output

A

Cough

Fatigue

28
Q

Other Symptoms
_________________-
common in early heart failure
anorexia
abdominal fullness
right upper quadrant abdominal discomfort
weight loss
cardiac cachexia

A

nocturia

29
Q

Some patients may be asymptomatic!
incidental finding of elevated blood pressure, heart murmur, abnormal ecg, elevated cholesterol, elevated glucose
first event can by catastrophic such as massive myocardial infarction

A
30
Q

Personal & Social History
cigarette smoking
active vs. sedentary lifestyle
diet
drug use, alcohol intake
occupation
psychosocial impact of disease

A

IMPORTANT: Lifestyle has a big impact on cardiovascular diseases!

31
Q

__________________
Ask about use of oral contraceptives
Ask about conditions during pregnancy:
Pregnancy-induced Hypertension (PIH)
Pre-eclampsia / Eclampsia
Peripartal Cardiomyopathy
Gestational Diabetes mellitus
Ask about manner of delivery, large birth weight babies
Ask about menopause, medications taken

A

OB-Gyne History

32
Q

_______________
Heart disease (be specific!)
coronary artery disease, valvular heart disease, congestive heart failure, etc.

 Concomittant disease
diabetes
dyslipidemia
hyper/hypothyroidism
PTB
asthma/COPD
* include hospitalizations, medications (note disparities in drug taken from that prescribed)

A

Past Medical History

33
Q

_______________
Familial clustering/transmission
CAD (esp. early CAD)
Dyslipidemia
Hypertension
Diabetes mellitus
Sudden Cardiac Death (SCD)

A

Family Medical History

34
Q

THE CARDIOVASCULAR EXAM
SEQUENCE:

A
  • General Survey
  • Vital Signs
  • Carotid Artery and JVP
  • Anterior Chest
  • Peripheral Vessels
  • Extremities
35
Q

_____________

Best examined with SCM relaxed, patient’s head slightly facing examine

r Check for bruits bilaterally first.

If no bruits noted, palpate both carotids with thumb or index fingers, ONE AT A TIME.

Note rate, rhythm, quality.

A

Arterial Pulses Carotid Artery

36
Q
A
37
Q

Arterial Pulses

Normal

  • _________________
A
  • Rapid upstroke, gradual downstroke
38
Q

Abnormal

Pulsus parvus – ___________________

A

diminished LV stroke volume, increased vascular resistance

39
Q

Arterial Pulse Abnormality

Bisferiens pulse – ______________

A

2 systolic peaks, seen in AR and HOCM

40
Q

Pulsus alternans –______________________-

A

alternating amplitudes despite regular rhythm, seen in severe LV impairment

41
Q

______________
Estimating JVP important and frequently used skill

A

Jugular Venous Pressure (JVP)

42
Q

What are the main objectives in JVP

A

Main objectives:
inspection of waveforms
estimate the central venous pressure (CVP)

43
Q

Jugular Venous Pressure (JVP)
NORMAL JVP: _____________

Significance: estimates the central venous pressure (CVP) estimates the hydration status of patient and pressure in right atrium

A

3-4 cm H20 at 30 deg

44
Q

What is the signifcance of JVP?

A

Significance:

estimates the central venous pressure (CVP

) estimates the hydration status of patient and pressure in right atrium

45
Q
A

a wave = right atrial contraction

c wave = bulging of TV into RA

x descent = atrial relaxation

v wave = increasing volume in RA during atrial filling

y descent = opening of the TV and rapid flow into LV

46
Q

Jugular Venous Pressure Technique

Elevate the head of the bed to 30 degrees (may adjust as necessary).

Turn patient’s head slightly away from the side you are inspecting

Use tangential lighting to identify the jugular venous pulsations.

Identify the highest point of pulsation in the right internal jugular vein

. Measure JVP at the level of the sternal angle.

A
47
Q
A
48
Q

__________________

Done in patients suspected of having RV failure but have normal CVP at rest

Palm of examiner’s hand is placed over abdomen, firm pressure for 10 seconds

Positive test: sustained increase in JVP of >3 cm for 15 sec after 10 sec firm

, RUQ pressure followed by rapid drop in pressure of 4 cm on release of compression

A

Jugular Venous Pressure (JVP) Abdominojugular or Hepatojugular Reflux Test

sustained increase in JVP of >3 cm for 15 sec after 10 sec firm

49
Q

THE CARDIAC EXAM

A

Inspection
Palpation

Auscultation

50
Q

Patient Position

Supine, head elevated 30 deg

Left lateral decubitus

Supine, head elevated 30 deg

Sitting, leaning forward, exhalation

A
51
Q

Inspection

A

Pectus Excavatum (Funnel Chest)

52
Q
A

Pectus Carinatum (Pigeon Breast)

53
Q
A

Inspection
Xanthelasmas

54
Q
A

Inspection
Xanthomas

55
Q

bulbous uniform swelling of the soft tissue of the terminal phalanx of a digit with subsequent loss of the normal angle between the nail and the nail bed

. hypoxia may activate local vasodilators, consequently increasing blood flow to the

A

Inspection Clubbing

56
Q

Inspection
Edema
Grading:
_______________

A

Gr 1 – up to ankles
Gr 2 – up to knees
Gr 3 - above the knees

57
Q

Palpation

A

Heaves

Thrills

PMI

58
Q

Where do you palpate?

A
59
Q

___________

Forceful, sustained systolic lift due to increased cardiac mass or force

Felt best by the palm of examiner’s hand

Depends on location

: LPSB: RV heave

Apex: LV heave

A

Heaves/Lifts Thrills

60
Q

Palpable, low frequency vibrations felt over the precordium (like a purring cat)
Felt best by palmar bases of fingers
Denotes turbulent flow of blood coursing through abnormal valves or heart chambers
Associated with Gr 4-6 murmurs

A

Thrills

61
Q

Palpation___________

Brief, early pulsation of the LV as it moves anteriorly during contraction and touches the chest wall

Normally located at 5th left intercostal space midclavicular line or 7-9 cm from the midsternal line Usually known as the________________

- PMI = most prominent pulsation

 AB = most lateral pulsation

Visible pulsations anywhere other than the normally located ventricular apex beat are ABNORMAL.

A

: Apical Impulse

**point of maximal impulse (PMI) or apex beat **

62
Q

Palpation:

Apical Impulse Technique

: Palpate for impulses using your fingerpads.

Note:

Location

Diameter: usually <2.5 cm and occupies only 1 interspace

Amplitude: brisk, tapping

Duration

If apical impulse cannot be identified, ask patient to roll to left lateral decubitus position

A
63
Q
A

2H. Physical Diagnosis (5 decks)

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