Lecture One (Cardio)-Exam 1 Flashcards
What is stable angina? Is it common or uncommon? What has not changed?
Stable angina chest pain with stress and activity. It is the most common type of angina in the United States. It follows a pattern that has been consistent for at least 2 months. That means the following factors have not changed:
* How often your angina events occur
* What causes or triggers your angina
* How long your angina events last
* How well your angina responds to rest or medicines
What is Unstable Angina?
does not follow a pattern. It may be new or occur more often and be more painful than stable angina. Unstable angina can occur with or without physical exertion. Rest or medicine may not relieve the pain
Vasospastic Angina (aka Prinzmetal angina)
* What is it characterized by?
* Attributed to what?
* What happens?
* What can it be to?
- Characterized by chest discomfort/pain at rest with transient EKG changes and a prompt response to nitrates
- Attributed to coronary artery spasm
- Transient decrease in the blood supply to the heart
- Can happen due to exposure to cold, exercise. Cocaine use
What are all the causes of Chest pain? (5 groups)
- Cardiac: angina, MI, pericarditis
- Musculoskeletal: costochondritis, rib problem, muscle strain
- Thoracic problem: pleuritis, pneumonia, pulmonary embolism, pneumothorax
- GI: GERD, esophageal contraction disorders, ulcer
- Other: panic attack, anxiety, shingles
Dyspnea
* What is it?
* What are the two types?
Dyspnea – an uncomfortable awareness of breathing, difficult or labored breathing
* Exertional Dyspnea (Most common): Requires the increased demand of exertion to precipitate symptoms
* Dyspnea at rest: Suggests severe cardiac disease
Paroxysmal nocturnal dyspnea
* What is it?
* What is it caused by?
* Suggests what?
Paroxysmal nocturnal dyspnea (Second most common)
* Patient awakening after being asleep or recumbent for 1 hour or more
* Caused by redistribution of body fluids from the lower extremities into the vascular space and back to the heart, resulting in volume overload
* Suggests a more severe condition
Different than sleep apnea
Orthopnea
* What is this?
* What does it increase?
* What does it suggest?
* Documented based on what?
- Dyspnea that occurs immediately on assuming the recumbent position
- Mild increase in venous return before any redistribution
- Suggests even more severe disease
- Documented based on how many pillows used at night
Syncope and Presyncope (described as lightheadedness and/or dizziness)
* What does it indicate?
Indicates a reduction in cerebral blood flow.
* could also be CNS dx, metabolic conditions, dehydration, inner-ear, orthostatic hypotension, arrhythmia, aortic stenosis, HOCM, vasovagal
Syncope and Presyncope (described as lightheadedness and/or dizziness)
* Usually need to ask more what?
Usually need to ask more questions about what precipitated the symptoms:
* Syncope associated with an arrhythmia is usually sudden
* Syncope from AS or orthostatic hypotension could be experienced upon standing from a seated position quickly
* Syncope from inner ear could be changing overall positions
* Syncope from vasovagal would be from bearing down
Edema (Fluid Retention)
* What can peripheral edema be caused by? (3)
- Congestive heart failure
- Valvular heart disease
- Venous insufficiency: Creates issues with lower extremity wounds, ambulation
Edema (Fluid Retention)
What can be cause Abdominal edema/ascites/bloating?
- Valvular heart disease
- Congestive heart failure
- Liver disease : Edema can create abdominal pain, enlarged liver, decreased appetite, diarrhea, jaundice, gut and hepatic dysfunction due to fluid engorgement (hepatic congestion)
When it comes to edema, what is important to ask patients?
Weight gain- important to ask patients about weight gain. How much and over what amount of time?
In order to know which kind of edema, what does it require you to ask?
◦ Timing?
◦ Position changes?
◦ Unilateral (DVT) or bilateral?
◦ Generalized edema or in one area? Onset acute or chronic?
◦ Medication history?
◦ Systemic disease?
What do you need to be worried about with position changes?
* When will edema not improve?
- Dependent edema caused by venous insufficiency improves with elevation or compression hose
- Edema associated with decreased plasma oncotic pressure (malabsorption, liver failure, nephrotic syndrome) does not change with dependency and will only improve once underlying condition addressed
Palpitations
* What is this?
* What cannot be appreciated?
- a subjective sensation of an irregular or abnormal heartbeat
- Normal resting cardiac activity usually cannot be appreciated
Palpitations:
* What does the patient feel?
* What is more and less common causes?
Perceived heart stopping transiently (pausing) or the occurrence of isolated forceful beats or both:
* More commonly caused by premature ventricular contractions PVC’s or PACs
* Pt feels either the compensatory pause or the resultant more forceful subsequent beat or both
* Less commonly caused by SVT or AF ( a sensation of a rapid heart rate that may be regular or irregular)
What is an hpi? What does it start with?
- Chronology of the events leading up to the patient’s current complaints.
- Start with chief complaint (CC) and then ask pertinent questions
Cardiac History:
* What is it important to assess?
Important to assess Cardiac/Atherosclerotic risk factors
* Atherosclerotic cardiovascular disease is the most common form of heart disease in industrialized nations
* Presenting signs and symptoms can range from unimpressive and minimal to sudden death.
What are the risk factors for cardiac disease? (8)
- Early FH of atherosclerotic disease, Men <55 years old, women <65
- DM, uncontrolled. Duration of time with DM
- Lipid disorders (especially elevated LDL)
- HTN, controlled vs uncontrolled
- Smoking
- Functional status: Lack of exercise
- high stress levels
- Obesity
Inspection for cardio:
* What do you need to look at for general appearance
* What are the two different chest wall deformities?
General appearance:
* distress? Skin (temperature, color), nails (splinter hemorrhages, Janeway lesions)
Chest wall deformities:
* Pectus excavatum – sternum sinks into the chest, concave
* Pectus carinatum- sternum projects forward, convex
Inspection for cardio:
* What may not be visible?
* What is used to estimate RA filling pressures? What can it be seen with?
PMI (point of maximal impulse) – may not be visible (feel like a pulse)
* You feel it if heart is enlarged and in HF
JVP – used to estimate RA filling pressures
* Can be seen with right sided HF, pericardial tamponade, PE
Palpations of cardio:
* What does the PMI give an estimate of?
* What is the location?
- Gives estimate on size of the heart
- Location: 4-5th intercostal space (nipple level) in mid clavicular line
Palpation: Thrills
* What is it?
* What does it signify?
* Cen be felt when?
Thrills – palpable murmur (Feels like a vibration, cat purring)
* Signifies at least a grade IV/VI murmur
* Can be felt in disease peripheral arterial vessels as well
Auscultation of cardio
* What are the points?
* What are the positions?
* Use both what and why?
- Listening to the key cardiac auscultation points
- Positional: seated upright, supine, left lateral decubitus
- Use both the bell and diaphragm
* The bell is most effective at transmitting lower frequency sounds
* diaphragm is most effective at transmitting higher frequency sounds.
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Vital signs: Blood Pressure
* What is one of the keystones of the of the cardiovascular physical exam?
* What is imperative?
* Dx of systemic HTN involves what?
* Orthostatic BP, the pt should be what?
Again: she skipped
Fill in
When checking a peripheral pulses, it tells you what? (3)
- Cardiac rate and rhythm
- Average of the blood pressure
- Assessment of the adequacy of the arterial conduit
What is the allen test?
Fill in
Vital signs:
Peripheral Pulse: Cardiac Rate and Rhythm
* Determine where?
* How do you find the rate?
- Determine in a convenient peripheral artery, such as radial
- Count for 15 seconds, then multiply x 4. Normal 60-100bpm
What are causes of tachy and bradycardia?
- Tachycardia: Strenuous exercise, fever, stress,anxiety, certain medications, street drugs can lead to sinus,anemia, overactive thyroid, or damage from aMI or CHF
- Bradycardia: SSS, complete heart block, natural aging, A response of the vagus nerve affecting the heart, High pressure inside the skull (intracranial pressure), MI, OSA, medications, hypothyroid
Rhythm
* Can assess what?
* Some cardiac contractions during rhythm disturbances do not do what?
- Can assess if pulse is regular, NSR or irregular, Afib
- Some cardiac contractions during rhythm disturbances do not generate a stoke volume sufficient to cause a palpable peripheral pulse
KNOW
Different strokes, different folks
* What does a Bounding high-amplitude carotid pulse mean?
* What does a weak carotid pulse mean?
* What does a low amplitude, slow rising pulse mean?
- Bounding high-amplitude carotid pulse suggest an increase in stroke volume and should be accompanied by a wide pulse pressure.
- Weak carotid pulse suggests a reduced stroke volume
- A low-amplitude, slow-rising pulse, may have thrill, suggests aortic stenosis
Strength of the pulse is graded how?
graded 1-4 on documentation for physical exam
* 1 is weak
* 2 is normal
* 3-4 is hyperdynamic
KNOW
Different strokes, different folks
* What does bifid pulse mean?
* What does dicotic pulse mean?
* What does Pulsus alternans pulse mean?
- A bifid pulse (beating twice in systole) can be a sign of hypertrophic obstructive cardiomyopathy, severe aortic regurgitation, or combo moderately severe aortic stenosis and regurgitation
- Dicrotic pulse (an exaggerated, early, diastolic wave) is found in severe heart failure
- Pulsus alternans (alternate strong and weak pulses) also a sign of severe ventricular heart failure, pericardial effusion
Vital signs: Peripheral pulse
* What should you check and why? What age group is this important in?
Special situations may check abdominal aorta and others
* Particularly important to palpate the abdominal aorta in older individuals because increase risk of abdominal aortic aneurysms in those >70 years old.
Vital signs: Peripheral pulse
* What are bruits? How do you hear it?
Bruits are a clue to significantly obstructed large arteries
* Bruits are sought with the stethoscope over carotids, abdominal aorta, and femoral arteries.
Vital signs: Jugular venous pulse
* What does it provide information about?
* Right internal jugular ideal for what?
* Characteristics of the right IJ pulse is valuable to assess what? What are the normal two waves?
- Provide information about the central venous pressure and right-heart function
- Right internal jugular ideal for assessing central venous pressure (attached directly to the SVC)
- Characteristics of the right IJ pulse is valuable for assessing right-heart function
* Normal venous pulse has two distinct waves: a and v
What are the jugular venous pressure waveform?
Physical exam: Edema
* What is edema?
* What is generalized edema? When does it occurs?
Edema- affecting 1 or 2 body areas
Generalized edema- affecting the whole body- more severe
* Anasarca: generalized accumulation of fluid in the interstitial space
* Occurs when there is a difference in oncotic pressure between the intravascular blood vessel and surrounding tissue. Hint: albumin
* Seen in: HF, renal failure, liver failure, or lymph conditions
Physical exam: Edema
* What happens with the heart?
Right-heart failure or venous return restricted from entering the heart
* venous pressure in the abdomen increases
* Leads to hepatosplenomegaly and eventually ascites
Physical exam: Edema
* Should focus on what?
* How do you document edema?
- Should focus on identifying the pattern of edema: bilateral, unilateral, etc
- Documenting edema: should identify the area, side, severity, warmth, redness, pain
Peripheral edema
* Detected by what?
* Pitting reflects what? Usually seen where?
* What does nonpitting edema suggest?
* Acute onset of unexplained Unilateral leg edema should raise suspicion of what?
* Ascites and then lower extremity edema in who?
- Detected by presence of pitting (pressure applied to area for at least 5 seconds)
- Pitting reflects movement of the excess interstitial water in response to pressure. Usually seen in dependent areas (lower extremities or in bed-bound, sacrum . Scrotal edema in males.
- Nonpitting edema suggests lymphatic obstruction or hypothyroidism
- should raise suspicion of DVT
- Ascites and then lower extremity edema in cirrhotic patients because of increased venous pressure below the diseased liver.
Physical Exam:Edema
* What can it be with redness, pain, warmth over area? (2)
* What does chronic venous insufficiency cause?
Redness, pain, warmth over area
* Acute DVT
* cellulitis
Chronic venous insufficiency:
* causes skin to have a brawny, reddish hue and commonly involves the medial malleolus
* Worsening has marked sclerotic and hyperpigmented tissue, may lead to venous ulcers over the medial malleolus. Ulcerations may progress to deep, weeping erosions.