OHCEPS - Cardiovascular System Flashcards
MC and most important CV symptom?
Chest pain
History for chest pain?
Same as for any other pain:
- Nature
- Site
- Any radiation
- Severity (1-10)
- Mode and rate of onset - What was the patient doing at the time?
- Duration (if now resolved)
- Exacerbating/Relieving factors
- Associated symptoms
True angina - features?
- Retrosternal
- “Crushing”, “Heaviness”,”like a tigh band”.
- Worse with physical or emotional exertion, cold weather and after eating.
- Relieved by rest and nitrate spray (within a couple of minutes)
- Not affected by respiration or movements.
- Sometimes associated with breathlessness
In patients with known angina - important?
A change in the nature of the symptom is important. How much exercise they can do before feeling the discomofort and whether this has changed.
Pain of MI?
Similar to angina but much more severe, persistent (Despite GTN spray) - associated with nausea, sweating, and vomiting.
Patients also, describe a feature of impending doom or death - “angor animi”.
MCCs of pericarditis?
- Viral/Bacterial infections
- MI
- Uremia
Pericarditis pain - features?
- Constant retrosternal “soreness”.
- Worse on inspiration (pleuritic).
- Relieved slightly by sitting forwards.
- Not related to movement or exertion.
Often mistaken for MI or angina?
Esophageal spasm.
Esophageal spasm - Features of pain?
- Severe, retrosternal burning pain.
- Onset after eating or drinking.
- May be associated with dysphagia
- May have a history of dyspepsia
- May be relieved by GTN as this is a smooth muscle relaxant (hence the confusion with angina) but GTN will take up to 20min to relieve this pain whereas angina is relieved within a few minutes.
GERD pain?
- Retrosternal, burning pain.
2. Relieved by antacids, onset after eating.
Aortic dissection - pain?
- Severe tearing pain.
- Felt posteriorly - classically between the shoulderblades.
- Persistent, most severe at onset.
- Patient is usually hypertensive and “marfanoid”.
Aortic dissection mistaken for MI - Problem?
Thrombolysis here may prove fatal.
Pleuritic (respiratory) pain - causes?
- Pulmonary embolus
2. Pneumothorax
Pleuritic pain - features?
- Sharp pain, worse on inspiration and coughing.
- Not central - may be localized to one side of the chest.
- No radiation
- No relief from GTN
- Associated with breathlessness, cyanosis etc.
Musculoskeletal chest pain - caused?
Injury
Trauma
Chondritis etc.
Musculoskeletal chest pain - features?
- Localized to a spot.
- Worsened by movement and respiration.
- May be tender to palpation.
Tietze’s syndrome?
Costochondritis - inflammation of the costal cartilages at ribs 2,3,4.
Will be associated with tender swelling over the costo-sternal joints.
New York Heart Association classification of breathlessness?
I - nil at rest, some on vigorous exercise.
II - nil at rest, breathless on moderate exercise.
III - mild breathlessness at rest, worse on mild exertion.
IV - significant breathlessness at rest and worse on even slight exertion (patient is often bed-bound).
What to ask in order to quantify breathlessness?
- How far can they walk on the flat before they have to stop? (“march tolerance”)
- What about stairs and hills? Can they make it up a flight?
- Are they sure that they stop due to breathlessness or is it some other reason (arthritic knees for example)?
- Has the patient had to curtail their normal activities in any way?
Orthopnea?
Breathlessness when lying flat.
Orthopnea - will patient tell you?
NO - should be asked.
How many pillows to sleep?
PND?
Episodes of breathlessness occuring at night - usually thought to be due to pulmonary edema.
PND - will the patient tell?
NO - Should be asked.
PND - what happens?
Sufferers will experience waking in the night spluttering and coughing - they find they have to sit up or stand and many go to the window for “fresh air” in an attempt to regain their normal breathing.
PND - questions?
- Do they wake up in the night coughing and trying to catch their breath?
- If so, glean as much detail as you can - including how often and how badly the symptom is disturbing the patient’s sleep cycle.
Cough in pulmonary edema?
Productive - frothy white sputum - may be flecked with blood (pink) due to ruptured bronchial vessels, but this is not usually a worrying sign in itself.
Questions regarding ankle edema?
- How long?
- Worse any particular time of day? (cardiac edema worse toward the evening, resolves overnight)
- Exactly, how extensive is the swelling?
- Is there evidence of abdominal swelling and ascites?
Palpitations?
Awareness of one’s own heart beat.
Questions for palpitations - difficult topic - difficult to clarify exact nature.
- When did the sensation start/stop?
- How long does it last?
- Did it come on suddenly or gradually?
- Did the patient blackout? If so, for how long?
- Was the heart beat felt as fast, slow, or some other pattern?
- Was it regular or irregular? - Ask to tap out on their knee what felt.
- What was the patient doing when palpitations started?
- Any relationship to eating or drinking? (tea, coffe, wine, chocolate?)
- Could this be from medication?
- Has this ever happened before? If so, what were the circumstances?
- Any associated symptoms? (chest pain, shortness of breath, syncope, nausea, dizziness)
- Did the patient stop their activities or lie down?
- Was the patient able to stop palpitations somehow?
Syncope?
Faint or swoon.
Pre-syncope?
The feeling that the patient is about to faint.
Questions about syncope?
- Gradual/sudden onset?
- How long was the loss of consciousness?
- What was the patient doing when it happened (standing, urinating, coughing)?
- Were there any preceding or associated symptoms such as chest pain, palpitations, nausea, sweating?
- Any medication relationship? (antihypertensives, GTN)
- When patient came round, were there any other symptoms remaining?
- Was there any tongue-biting or urinary or fecal incontinence?
- Was there any motor activity during the episode?
- How long did it take for the patient to feel “back to normal”?
True claudication - what does patient tell?
- Feels like a tight ‘cramp’ in the muscle.
- Usually calf, thigh, buttock, and foot.
- ONLY in exercise.
- Disappears at rest.
- May also be numbness or pins-and-needles on the skin of the foot (blood is diverted from the skin to the ischemic muscle).
Claudication - quantify?
If possible, the claudication “distance” - for judging the severity.
If very severe leg ischemia (rest pain), what will some patient do to relieve pain at night?
Hang the affected leg off the side of the bed.
Cardiac risk factors?
- Age
- Gender
- Obesity
- Smoking - don’t be caught out by the ‘ex-smoker’ that gave up yesterday!
- HTN - When it was diagnosed, how treated, monitored?
- HyperCH - Same.
- Diabetes - what type? diagnosed? treated? monitored? usual glucose readings?
- FHx - 1st degree relatives who had CV events before 60.
PMH - Cardiac problems?
Ask especially about:
- Angina - If they have GTN spray how often they need to use it and whether this has changed significantly recently.
- MI - when? How treated?
- Ischemic Heart disease? - diagnosed? Any angiograms? Other investigations?
- Cardiac surgery? - bypass? How many arteries?
- AF or other cardiac rhythm disturbance - what treatmet? On warfarin?
- RF
- Endocarditis
- Thyroid disease
Framework for the cardiovascular examination?
- General inspection
- Hands
- Radial pulse
- Brachial pulse
- Blood pressure
- Face
- Eyes
- Tongue
- Carotid pulse
- Jugular venous pressure and pulse waveform
- Inspection of precordium
- Palpation of the precordium
- Auscultation of precordium
- Auscultation of neck
- Dynamic manoeuvres (if appropriate)
- Lung bases
- Abdomen
- Peripheral pulses (lower limbs)
- Edema
- Peripheral veins
Positioning of the cardiac patient for examination.
Leaning back to 45 degrees supported by pillows.
What must be done if BP standing and seated is intended to be measured?
Make patient stand for 3 min before measuring - it may be wise to do this at the beginning of the examination.
General inspection of cardiac patient.
- Do they look ill? If so, in which way?
- Are they short of breath at rest?
- Is there any cyanosis
- What is their nutritional state?
- Are they overweight?
- Are they cachectic? - Other syndrome: Marfan, Turner, Down?
Cardiac patient - exam of the hand.
- Temperature - may be cold in CHF.
- Sweat
- State of nails - blue discoloration if peripheral blood flow is poor/ splinter hemorrhages (small streak-like bleeds in the nail bed) - especially in bacterial endocarditis, but may also be seen in RA, vasculitis, trauma, sepsis from any source.
- Finger clubbing - IE, cyanotic CHD.
- Xanthomata - often on tendons at the wrist.
- Osler’s nodes - rare manifestation in IE - Red, tender nodules on the finger pulp or thenar eminence.
- Janeway lesions - non-tender macular-papular erythematous lesions seen on the palm or finger pulps as a rare feature of bacterial endocarditis.
How many rhythm patterns are there for the pulse?
- Regular
- Irregularly irregular
- Regularly irregular
- Regular with ectopics
Regular pulse increase or decrease with inspiration?
Decrease.
Regular pulse increase or decrease with expiration?
Increase.
Example of irregularly irregular pulse?
A-fib
Example of regularly irregular pulse?
- Pulsus bigeminus –> regular ectopic beats resulting in alternating brief gaps + long gaps between pulses.
- In Wenkenbach’s phenomenon –> Incr. time between each pulse until one is missed and then the cycle repeats.
Chracter/waveform of pulse - Aortic stenosis?
Slow rising pulse, maybe with a palpable shudder - sometimes called “anacrotic” or a “plateau” phase.
Character/Waveform of pulse - Aortic regurgitation?
A collapsing pulse which feels as those it suddenly hits your fingers and falls away just as quickly - “Waterhammer” pulse.
Pulsus bisferiens?
Waveform with 2 peaks, found where aortic stenosis and regurgitation co-exist.
HCM pulse?
May feel normal at first but peters out quickly - often described as jerky.
Pulsus alternans?
An alternating strong and weak pulsation - synonymous with severely impaired left ventricle in a failing heart.
Pulsus paradoxus?
Pulse is weaker during inspiration.
Causes of pulsus paradoxus?
- Cardiac tamponade
- Status asthmaticus
- Constrictive pericarditis
Radio-radial pulse delay?
Pulses should occur simultaneously - pathology include:
- Aneurysm of the aortic arch
- Subclavian artery stenosis
Radio-femoral pulse delay?
If exist –> aortic coarctation (radial and femoral of the SAME side).
CV exam - face:
Eyes - Mouth - Neck.
Be sure to ask:
1. Look up –> conjunctiva.
2. “Open wide” –> inside mouth and tongue.
CV exam –> especially look for:
- Jaundice
- Anemia
- Xanthelasma
- Corneal arctus
- Mitral facies
- Cyanosis
- High arched palate
- Dental hygiene
Corneal arcus??
Yellow ring seen overlying the iris - significant in patients <40 but not in older persons.
High arched palate suggests?
Marfan
Centre of the RA in relationship to the sternal angle?
5cm below.
Normal JVP?
3cm above the sternal angle (8cm of blood).
Standard position for JVP measurement?
Tilted at 45.
Features of jugular pulsation?
- 2 peaks (in sinus rhythm)
- Impalpable
- Obliterated by pressure
- Moves with respiration
Carotid pulsation - features?
- 1 peak
- Palpable
- Hard to obliterate
- Little movement by respiration
Hepatojugular reflex?
- Watch the neck pulsation
- Exert pressure over the liver with the flat of your right hand.
JVP should RISE approx. 2cm, the carotid pulse will not.
Character of the jugular venous pulsation?
Jugular pulsation has 2 main peaks –> establish the timing of the peaks in the cardiac cycle by palpating the carotid pulse at the SAME time.
Key features of jugular venous pulsation?
- a wave –> atrial contraction.
- c point –> slight A-V-ring bulge during ventric. contraction.
- x decent –> atrial relaxation.
- v wave –> tricuspid closure + atrial filling.
- y decent –> ventricular filling as tricuspid opens.
a wave - when?
Seen JUST BEFORE the carotid pulse.
Raised JVP - means?
- RVF
- Tricuspid stenosis
- Tricuspid regurgitation
- SVC obstruction
- Pulm. embolus
- Fluid overload
Large a waves - means?
Hypertrophied RA:
- Pulm. HTN
- Pulm. stenosis
- Tricuspid stenosis
Absent a wave - means?
A-fib
Cannon a waves - means?
Large, irregular waves caused by contraction of the atrium against a closed tricuspid valve –> Seen in COMPLETE HEART BLOCK.
Large v waves - means?
Regurgitation of blood through an incompetent TV.
Sharp y decent - means?
Constrictive pericarditis.
Sharp x decent - means?
Cardiac tamponade
JVP will decrease or increase during inspiration in the normal state?
Decrease.
Kussmaul’s sign?
JVP RISES during inspiration in the presence of:
- Pericardial constriction
- RV infarction
- Cardiac tamponade - rarely
Inspection of the precordium?
- Scars
- Any abnormal chest shape or movements
- Pacemaker or implantable defibrillator
- Any visible pulsations
Scars on the precordium?
- Sternal split –> CABG
- Left lateral thoracotomy may be evidence of previous closed mitral valvotomy.
- Resection of coarctation
- Ligation of PDA
General palpation of the precordium?
- Explain what you doing - particularly to female patients.
- Place the flat of your right hand on the chest wall - to the left/right of the sternum - Any pulsations?
- “Heave” - this is sustained, thrusting pulsation usually felt at the left sternal edge indicating RV enlargement.
- “Thrill” - Palpable murmur - severe valvular disease.
Palpating the apex beat?
Usually at the 5th intercostal space in the mid-clavicular line.
Palpation of the precorium - Findings?
- Abnormal position of the apex beat - usually more lateral than expected.
- No apex beat felt - usually caused by heavy padding with fat or internal padding with an over-inflated emphysematous lung.
- Sometimes can be felt by asking the patient to lean forwards or laterally.
Character of the apex beat?
- Stronger, more forceful
- Sustained
- Double impulse
- Tapping
- Diffuse
- Impalpable
Stronger, more forceful apex beat?
Hyperdynamic circulation - sepsis, anemia.
Sustained apex beat?
- LVH
- AV stenosis
- HCM
- Hyperkinesia
Double impulse (apex beat)?
Palpable atrial systole - characteristic of HCM.
Tapping apex beat?
Description given to a palpable S1 in SEVERE MITRAL STENOSIS.
Diffuse apex beat?
Poorly localized beat caused by LV aneurysm.
Impalpable apex beat?
- Emphysema
- Obesity
- Pericardial effusion
- Death
Apex beat - what should be kept in mind?
Beware of DEXTROCARDIA. If no beat is felt - check the right side.