CVS- IM Flashcards
Causes of cardiovascular symptoms:
myocardial ischemia (___________-
abnormal contraction/relaxation of the myocardium _____________
obstruction to blood flow _______________
abnormal cardiac rate and rhythm _____________
inflammation _________
chest pain of CAD)
(dyspnea of CHF)
(dyspnea of valvular heart disease)
(palpitations)
(chest pain)
Cardinal Symptoms of Heart Disease
chest pain/discomfort
dyspnea
palpitations
edema
cyanosis
syncope
claudication
Pressing
•squeezing
•Constricting
•burning
•band across the chest
•“mabigat”
•“nakadagan”
•“sinasakal”
Typical Angina
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
Angina
_____________
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
Anginal equivalent
Levine’s sign: clenched fist to middle of chest
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
dyspnea
forms of dyspnea in heart disease:
___________________
exertional dyspnea
dyspnea at rest
orthopnea
paroxysmal nocturnal dyspnea (PND)
________________
dyspnea on lying flat
due to redistribution of fluid from the lower extremities to the lungs
orthopnea
___________
a variant of orthopnea
patient awakens from sleep after 2-4 hours
dyspneic
with cough, wheezing and sweating
relieved by upright position
PND
____________
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
Palpitations
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
Palpitations
Localization is important!
Edema
starts around the face and eyes
____________________________
usually non-cardiac
~ renal, angioneurotic, hypoproteinemia, myxedema
EDEMA
limited to the face and neck______________
superior vena cava syndrome
EDEMA
unilateral extremity
_______________________________
deep venous thrombosis, cellulitis, lymphedema
peripheral, bilateral
cardiac failure
chronic venous insufficiency
hypoalbuminemia - nephrotic syndrome, liver disease, protein losing enteropathy
_______________
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
Cardiac edema
__________________
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
Cyanosis
______________
due to decreased arterial saturation
right-to-left shunting in congenital heart disease
impaired pulmonary function
Central Cyanosis
_____________
due to vasoconstriction
exposure to cold
shunting due to low blood
pressure
Peripheral Cyanosis
_______________
transient loss of consciousness usually from reduced brain perfusion
disorders of vascular tone or volume
cardiovascular disorders
cerebrovascular disorders
Syncope
____________________
rapid onset
no aura
not associated with convulsive movements, urinary incontinence or post-ictal confusion
consciousness regained promptly
Cardiac syncope:
Syncope
Important to ask for :
family history of syncope
some forms of are genetic and may be fatal
(ie. Brugada syndrome)
intake of medications
previous episodes
________________-
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
Claudication
Other Symptoms
_______________-
pink frothy sputum of pulmonary edema
associated with heart failure symptoms
_______________-
non-specific
decreased cardiac output
Cough
Fatigue
Other Symptoms
_________________-
common in early heart failure
anorexia
abdominal fullness
right upper quadrant abdominal discomfort
weight loss
cardiac cachexia
nocturia
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
Personal & Social History
cigarette smoking
active vs. sedentary lifestyle
diet
drug use, alcohol intake
occupation
psychosocial impact of disease
IMPORTANT: Lifestyle has a big impact on cardiovascular diseases!
__________________
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
OB-Gyne History
_______________
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)
Past Medical History
_______________
Familial clustering/transmission
CAD (esp. early CAD)
Dyslipidemia
Hypertension
Diabetes mellitus
Sudden Cardiac Death (SCD)
Family Medical History
THE CARDIOVASCULAR EXAM
SEQUENCE:
- General Survey
- Vital Signs
- Carotid Artery and JVP
- Anterior Chest
- Peripheral Vessels
- Extremities
_____________
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.
Arterial Pulses Carotid Artery
Arterial Pulses
Normal
- _________________
- Rapid upstroke, gradual downstroke
Abnormal
Pulsus parvus – ___________________
diminished LV stroke volume, increased vascular resistance
Arterial Pulse Abnormality
Bisferiens pulse – ______________
2 systolic peaks, seen in AR and HOCM
Pulsus alternans –______________________-
alternating amplitudes despite regular rhythm, seen in severe LV impairment
______________
Estimating JVP important and frequently used skill
Jugular Venous Pressure (JVP)
What are the main objectives in JVP
Main objectives:
inspection of waveforms
estimate the central venous pressure (CVP)
Jugular Venous Pressure (JVP)
NORMAL JVP: _____________
Significance: estimates the central venous pressure (CVP) estimates the hydration status of patient and pressure in right atrium
3-4 cm H20 at 30 deg
What is the signifcance of JVP?
Significance:
estimates the central venous pressure (CVP
) estimates the hydration status of patient and pressure in right atrium
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
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.
__________________
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
Jugular Venous Pressure (JVP) Abdominojugular or Hepatojugular Reflux Test
sustained increase in JVP of >3 cm for 15 sec after 10 sec firm
THE CARDIAC EXAM
Inspection
Palpation
Auscultation
Patient Position
Supine, head elevated 30 deg
Left lateral decubitus
Supine, head elevated 30 deg
Sitting, leaning forward, exhalation
Inspection
Pectus Excavatum (Funnel Chest)
Pectus Carinatum (Pigeon Breast)
Inspection
Xanthelasmas
Inspection
Xanthomas
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
Inspection Clubbing
Inspection
Edema
Grading:
_______________
Gr 1 – up to ankles
Gr 2 – up to knees
Gr 3 - above the knees
Palpation
Heaves
Thrills
PMI
Where do you palpate?
___________
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
Heaves/Lifts Thrills
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
Thrills
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.
: Apical Impulse
**point of maximal impulse (PMI) or apex beat **
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
