Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Mayo Cardiology Core Competencies > Track 1: Obtaining a Comprehensive Patient History in Cardiac Disease > Flashcards

Track 1: Obtaining a Comprehensive Patient History in Cardiac Disease Flashcards

1
Q

OBTAINING A COMPREHENSIVE PATIENT HISTORY IN CARDIAC DISEASE

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

6 key features of the history

A
  1. Character (+ location, radiation, severity, *anginal equivalent?)
  2. Timing (including onset, progression)
  3. Duration
  4. Associated sxs
    *SOB, pain with respiration, orthopnea, edema, diaphoresis, nausea, palpitations, LH, change in functional activities
  5. Mitigating factors
  6. Alleviating factors

*Lead time (weeks leading up)
*Self treatment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Cardiac physical exam (systematic approach) (8)

A
  1. Vital signs
  2. General appearance
  3. Head/Neck
  4. Cardiac Exam
  5. Lungs
  6. Abdomen
  7. Extremities
  8. Neurological
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Physical exam vital signs

A
  • Febrile?
  • Rate? Rhythm?
  • BP in both arms (especially when dissection is on ddx)
  • RR
  • O2 sat
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Physical exam general appearance

A
  • Diaphoretic
  • Distressed
  • Cold
  • Warm
  • Restless
  • Sitting up, comfortable?
  • Obvious rashes, trauma, wounds
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Physical exam head and neck

A
  • Color of face (cyanosis, flushing, jaundice, structural abnormalities)
  • Neck (thyromegaly, lymphadenopathy)
    (JVD/Bruits are a nice segue into cardiac exam)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Physical exam cardiac

A

Vascular assessment, inspect and palpate precordium, then auscultate

VASCULAR ASSESSMENT
- JVD (light chin tilt up w/ head to left, 45 degree angle)
Point of reference is RA or sternal angle (5cm), add anything above this point to 5cm. > 9cm is elevated *tip look at ear lobe and jaw line
- Carotid (listen for bruit, evaluate for upstroke: brisk, delayed, normal)
- Abdominal and femoral pules (strength, bruit)
- Peripheral pulses (absent to bounding scored 0-4+, symmetry, irregularity)
*Radial and femoral pulses are especially important if pt undergoing cath or other procedure requiring arterial access. Need to know baseline

INSPECT PRECORDIUM
- Chest wall deformities
- Rashes or wounds
- Scars

PALPATE CHEST WALL
- Chest wall tenderness
- Heave of lift
- Apical impulse (~10cm down from mid-sternal line in 4th-5th ICS) should be gentle and nonsustained

AUSCULTATE

EXTREMITIES
- Capillary refill
- Hair growth
- Nails (clubbing etc)
- Edema

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Physical exam lungs

A
  • Respiratory effort, labored? tachypneic
  • Retraction
  • Symmetry with expansion
  • Auscultate for crackles, wheezes, rales, rubs (*See if sounds are resolved by cough)
  • Diminished lung sounds
  • Cough (productive? non productive? hemoptysis?)
  • Lay flat if concern for orthopnea
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Physical exam abdomen

A
  • Auscultate before palpating
  • Size, shape, soft, distended
  • Tenderness
  • Ascites
  • Hepatojugular reflux (firm pressure over liver, hold for 30 seconds +, good test for RV failure, TR, constrictive pericarditis)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Physical exam extremities

A
  • Rashes, petechiae, ecchymosis, splinter hemorrhages, nodules, erythema nodosum (sarcoid)
  • Edema
  • Cool or warm
  • Clubbing
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Physical exam neurological

A
  • Orientation, cranial nerves, motor function
  • Focal neurological deficits (especially if ao dissection is on ddx, * chest pain + neuro deficits)
  • Establish good baseline, cardiac procedures harbor small stroke risk. Good documentation of baseline can help assess subtle changes after any procedure
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Evidence for correlations between history and physical exam findings. and cardiovascular disease severity and prognosis have been developed most rigorously for what conditions? (3)

A
  • Heart failure
  • Valvular disease
  • Coronary artery disease
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Name 3 key physical exam features that contribute to bedside risk assessment in patients with ACS

A

Vital signs
Presence of MR
Detection of pulmonary congestion

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Heart failure in the ambulatory patient
Name 3 basic elements of the history that support dx
Name 6 validated elements of the PE that support dx

A
  • Dyspnea at one flight of stairs
  • Orthopnea
  • PND
  • Displaced apex beat
  • Rales
  • Irregularly irregular pulse
  • Murmur suggestive of MR
  • HR > 60
  • Elevated JVP
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Typical angina should satisfy 3 characteristics. Name them

A
  1. Substernal discomfort
  2. Initiated by exertion or stress
  3. Relieved with rest or sublingual nitro
    *chest discomfort w/ 2 of the 3 criteria is considered atypical angina, pain with 1 or none of these features is considered nonanginal
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Name some characteristics that increase or decrease the likelihood for ACS in setting of chest pain

A
  • Sharp, pleuritic, reproducible with palpation- decreased likelihood
  • Radiation to both arms or shoulders, precipitated by exertion- increased likelihood
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Name some anginal equivalents

A
  • Indigestion
  • Belching
  • Dyspnea
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

In what 3 special populations must you keep a high suspicion for ACS despite a “classic” presentation

A
  • Women
  • Elderly
  • Diabetics
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Dyspnea upon standing

A

Platypnea

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Describe characteristics of PND of cardiac origin

A
  • Usually occurs 2-4 hours after onset of sleep
  • Severe enough to compel pt to sit upright or stand
  • Subsides gradually over several minutes
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Regular, rapid-pounding sensation in the neck or visible neck pulsations associated with palpitations
Increased likelihood for:

A

Atrioventricular nodal reentrant tachycardia (AVNRT)
*Absence of “neck pounding sensation” makes AVNRT less likely

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Syncope w/ early warning signs (nausea, yawning), ashen and diaphoretic, slow to revive

Syncope w/ sudden onset, rapid restoration of full consciousness thereafter

A

More likely neurocardiogenic

More like cardiac

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Chest pain diminishes with sitting up, leaning forward or breathing shallowly

A

Pericarditis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Pursing of the lips, breath quality to voice, increased AP chest diameter

A

Favors pulmonary etiology

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

In pt with palpitations, resting heart rate < 60 bpm increases likelihood of

A

clinically significant arrhythmia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Name some criteria to evaluate fragility (useful tool in eval of pt w/ HF and pre procedural appraisal)

A
  • Unintentional weight loss
  • Grip strength
  • Gait speed
  • Exhaustion (self reported)
  • Inactivity
  • Serum albumin
  • Hemoglobin
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Central cyanosis, consider:

A
  • Right to left shunt
  • Hereditary methemoglobinemia
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

Peripheral cyanosis

A
  • Reduced blood flow that accompanies small vessel constriction seen in severe HF, shock, or PVD
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

Cyanosis affecting the lower but not the upper extremities

A
  • PDA
  • Pulmonary artery hypertension (PAH)
  • Right to left shunting at the great vessel level
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

Lace-like purplish discoloration of the skin that imparts a mottled or reticulated appearance

A

Livedo reticularis
Can occur on exposure to cold in normal individuals
Also observed in a variety of conditions resulting in sluggish cutaneous blood flow (cardiogenic shock, certain autoimmune disorders, polyarteritis nodosum, antiphospholipid etc.)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

Telangiectasias

A
  • Scleroderma
  • Pulmonary hypertension
  • Cirrhosis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

Ecchymoses:
Petechiae:
Purpura:

A
  • OAC, antiplatelet use
  • Thrombocytopenia
  • Infective endocarditis, other causes of leukocytoclastic vasculitis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

Tanned/bronzed discoloration of the skin in unexposed areas

A
  • Iron overload
  • Bronze discoloration
    (*Bronzed diabetic)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

Xanthomas

A
  • Various lipid disorders
  • Located subcutaneously along tendon sheaths or over extensor surfaces of extremities
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

Lupus pernio, erythema nodosum, or granuloma annulare

A

Sarcoid

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

What head/neck PE component should be assessed both as a source of infection and as an index of general health and hygiene

A

Dentition

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

Large protruding tongue
Parotid enlargement
* Carpal tunnel

A

Amyloidosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

High arched palate

A

Marfran + other CT disorders

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

Bifid uvula

A

Loeys-Dietz syndrome
* CT disorder, enlarged aorta

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

Blue sclera
MR or AR
Recurrent non traumatic skeletal fractures

A

Osteogenesis imperfecta

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

Lacrimal gland hyperplasia my be associated with

A

sarcoid

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

“Mitral facies”

A
  • Rheumatic mitral stenosis. Also pulmonary hypertension and reduced cardiac output
  • Pink-purplish patches with telangiectasias over the malar eminences
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

Proptosis, lid lag, stare

A

Graves hyperthyroidism

44
Q

Nail clubbing

A

Central shunting

45
Q

Arachnodactyly

A

Long, slender, curved fingers
Marfan

46
Q

Contender, slightly raised areas of hemorrhage on the palms and soles

A

Janeway lesions

47
Q

Tender, raised nodules on the pads of the fingers or toes

A

Osler nodes

48
Q

Ulcerations and tissue loss of the fingertips may suggest

A

thromboangiitis obliterates

49
Q

Normal JVP
Extensive varicosities, medial ulcers, brownish pigmentation from hemosiderin deposition

A

Chronic venous insufficiency

50
Q

Muscular atrophy
Loss of hair
Dependent rubor

A

Chronic arterial insufficiency

51
Q

Redistribution of fat from extremities to central abdominal stores

A

lipodystrophy
(pt with HIV infection related to antiretroviral therapy, insulin resistance, metabolic syndrome)

52
Q

Cutaneous venous collaterals over the anterior chest

A

Chronic obstruction of superior vena cava or subclavian vein (especially in presence of indewlling catheters or leads from cardiac implantable electrical devices)

53
Q

Pectus carinatum or pectus excavatum

A

May suggest connective tissue disorder

54
Q

Barrel chest of emphysema or advanced kyphoscoliosis may be associated with

A

cor pulmonale

55
Q

Severe kyphosis of ankylosing spondylitis, cardiac abnormalities possible?

A
  • AR
  • First degree AV block
56
Q

“Straight back syndrome”, loss of normal kyphosis of thoracic spine. May accompany what cardiac abnormality?

A

MVP

57
Q

Prominence of cardiac impulse in the epigastrium

A

Emphysema

58
Q

Liver enlarged and tender

A

Heart failure
(or other hepatic pathology)

59
Q

Systolic hepatic pulsations

A

Severe TR

60
Q

Splenomegaly

A

Long standing infective endocarditis

61
Q

Ascites

A

Advanced and chronic right heart failure
Constrictive pericarditis

62
Q

The dx of heart failure is fundamentally made at the bedside from the sxs and signs that reflect (2)

A
  • Congestion
  • End organ perfusion
63
Q

Name 8 history and exam findings suggestive of cardiac syncope

A
  1. Known heart disease
  2. Abnormal CV PE
  3. Family hx of sudden death or drowning
  4. Male sex
  5. Age > 35 years at time of syncope
  6. ≤ 2 previous episodes
  7. Palpitaitons
  8. Chest pain or dyspnea
64
Q

In evaluating JVP, the estimated height of the venous pressure indicates:

A

the CVP or right atrial pressure

65
Q

Venous waveform characteristic features (4)

A

a wave
c wave
v wave
x descent
y descent

66
Q

Describe the technique to measure venous pressure/JVP

A

Estimated by the vertical distance between the top of the venous pulastion and the sternal inflection point (where the manubrium meets the sternum/angle of Louis)
*Distance > 3cm is considered elevated

67
Q

Define elevated JVP

A

Venous pulsation > 3cm from angle of Louis
*But note distance between angle of Louis and mid-right atrium varies considerably as a function of body size and position

68
Q

Distance from right atrium to clavicle

A

At least 10cm

69
Q

venous waveforms
reflects right atrial presystolic contraction, occurs just after the ECG P wave and precedes the first heart sound (S1)

A

a wave

70
Q

prominent venous a wave suggests

A

Reduced RV compliance

71
Q

Cannon a wave

A

AV dissociation and right atrial contraction against a closed tricuspid valve

72
Q

The presence of cannon a waves in a patient with wide complex tachycardia identifies the rhythm as

A

ventricular in origin

73
Q

Describe the a wave in JVP eval

A

reflects right atrial presystolic contraction, occurs just after the ECG P wave wave, precedes S1

74
Q

The a wave is absent in what rhythm

A

AF

75
Q

Venous pulsations
Reflects the fall in right atrial pressure after the a wave
Atrial diastolic suction created by ventricular systole pulling the tricuspid valve downward
In normal persons this is the predominant waveform in the jugular venous pulse

A

X descent

76
Q

Venous pulsations
Interrupts the x descent as ventricular systole pushes the closed valve into the right atrium

A

C wave

77
Q

Venous pulsations
Represents atrial filling, occurs at the end of ventricular systole and follows just after S2
Height determined by atrial compliance and by volume of blood returning to right atrium

A

V wave

78
Q

V wave is accentuated in

A

TR

79
Q

Describe a and v wave in evaluating JVP

A

a wave: reflects right atrial presystolic contraction, occurs after P wave, precedes S1

v wave: represents atrial filling, occurs at the end of ventricular systole, follows just after S2

80
Q

Venous pulsations
Follows the v wave peak and reflects the fall in right atrial pressure after tricuspid valve opening

A

y descent

81
Q

Normal venous pressure should fall by at least how many mmHg during inspiration?

A

3 mmHg

82
Q

Rise in venous pressure (or its failure to decrease) with inspiration

A

Kussmaul sign
- Constrictive pericarditis
- Restrictive CMP
- Pulmonary embolism
- RV infarction
- Advanced systolic heart failure
*Seen with right sided volume overload and reduced RV compliance

83
Q

Kussmaul sign
Describe:
When can this be seen? General and specific.

A

Rise in venous pressure (or failure to decrease) with inspiration

Seen with right sided volume overload and reduced RV compliance

Constrictive pericarditis, restrictive CMP, PE, RV infarction, advanced systolic HF

84
Q

Describe the pathophysiology behind Kussmaul sign

A

Normally the inspiratory increase in right sided venous return is accommodated by increased RV ejection, facilitated by an increase in the capacitance of pulmonary vascular bed

In states of RV diastolic dysfunction and volume overload, the RV cannot accommodate the enhanced volume and the pressure rises

Increased pulmonary vascular resistance may also limit the RV ejection and contribute to phenomenon

85
Q

Describe technique for proper abdominojugular reflux

What tips should you tell your pt?

A

Firm and consistent pressure over the right upper quadrant for at least 10 seconds

Refrain from valsalva or holding breath during procedure, can falsely elevate

86
Q

Postitive abdominojugular reflux

A

rise in more than 3cm in the venous pressure sustained for at least 15 seconds

87
Q

+ abdominojugular reflux sign can predict

A
  • heart failure
  • pulmonary artery wedge pressure higher than 15 mmHg
88
Q

On occasion when taking BP, the Korotkoff sounds my disappear soon after the first sound, only to recur later before finally disappearing.
This auscultatory gap is more likely to occur in what population?

A

Older, hypertensive patients with target organ damage

89
Q

In what patient populations may you hear Korotkoff sounds all the way down to 0 mmHg w/ cuff completely deflated

A
  • Chronic severe AR
  • AV fistula
  • Pregnant
  • Children
90
Q

A BP differential between arms of > 10 mmHg may be associated with:
*Note ~20% of normal subjects w/o sxs will have a difference > 10 mmHg

A
  • Subclavian a. disease
  • Supravalvular AS (SVAS)
  • Aortic coarctation
  • Aortic dissection
91
Q

Systolic leg pressures may exceed arm pressures by as much as 20 mmHg
Measurements > 20 mmHg difference may be seen in

A
  • Severe AR (Hill sign)
  • Extensive calcification of LE arterials (severe PAD), arteries are noncompressible
92
Q

Hill sign

A
  • Systolic leg pressures exceed arm pressures by > 20 mmHg
  • Severe AR
93
Q

Define orthostatic hypotension

A

Fall in blood pressure of more than 20 mmHg systolic and/or more than 10 mmHg diastolic

94
Q

If orthostatic hypotension is accompanied by lack of compensatory tachycardia, what might you suspect

A

autonomic insufficiency (consider diabetes, parkinsons)

95
Q

In pt’s with POTS does blood pressure usually fall on standing?

A

Generally no, more about inappropriate heart rate response

96
Q

Wide pulse pressure
(valvular abnormality)

A

Aortic regurgitation

97
Q

Increase in pulse pressure can represent

A
  • Increased vascular stiffness (aging, atherosclerosis)
98
Q

A bounding pulse may occur in

A
  • Hyperkinetic states (fever, anemia, thyrotoxicosis)
  • Pathologic states (ie severe bradycardia, AR, or arteriovenous fistula)
99
Q

A fall in systolic pressure of > 10 mmHg during inspiration

A

Pulsus paradoxus
- Pericardial tamponade
- Severe pulmonary disease
- Massive pulmonary embolism, hemorrhagic shock, severe obstructive lung disease, tension PTX
- *Can also occur in obesity and pregnancy without clinical disease

100
Q

Beat-to-beat variability of the pulse amplitude
Every other phase Korotkoff sound is audible as cuff pressure slowly lowered

A

Pulsus alternans
- Severe heart failure, severe AR, hypertension, hypovolemic states
- Attributed to cyclic changes in intracellular calcium and action potential duration

101
Q

Weak and delayed carotid pulse
Appreciated by careful palpation of carotid during simultaneous auscultation of the heart sounds

A

Pulsus parvus et tardus
- Severe AS
- *Less specific finding in older, hypertensive patients with reduced vascular compliance and stiffer carotid arteries

102
Q

Abrupt carotid upstroke with rapid fall off

A

Chronic AR

103
Q

Left parasternal lift suggests

A

RV pressure or volume overload

104
Q

Pt positioning for palpation of heart

A

Supine, leaning forward 30 degrees

105
Q

PMI location

A

Midclavicular line, 5th intercostal space
Best heard at end of exhalation (heart closest to chest wall)

106
Q

PMI displaced leftward and downward

A

LV cavity enlargement

107
Q

Sustained apical impulse

A

LV pressure overload (AS, HTN)

Mayo Cardiology Core Competencies (14 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions