Track 1: Obtaining a Comprehensive Patient History in Cardiac Disease Flashcards
OBTAINING A COMPREHENSIVE PATIENT HISTORY IN CARDIAC DISEASE
6 key features of the history
- Character (+ location, radiation, severity, *anginal equivalent?)
- Timing (including onset, progression)
- Duration
- Associated sxs
*SOB, pain with respiration, orthopnea, edema, diaphoresis, nausea, palpitations, LH, change in functional activities - Mitigating factors
- Alleviating factors
*Lead time (weeks leading up)
*Self treatment
Cardiac physical exam (systematic approach) (8)
- Vital signs
- General appearance
- Head/Neck
- Cardiac Exam
- Lungs
- Abdomen
- Extremities
- Neurological
Physical exam vital signs
- Febrile?
- Rate? Rhythm?
- BP in both arms (especially when dissection is on ddx)
- RR
- O2 sat
Physical exam general appearance
- Diaphoretic
- Distressed
- Cold
- Warm
- Restless
- Sitting up, comfortable?
- Obvious rashes, trauma, wounds
Physical exam head and neck
- Color of face (cyanosis, flushing, jaundice, structural abnormalities)
- Neck (thyromegaly, lymphadenopathy)
(JVD/Bruits are a nice segue into cardiac exam)
Physical exam cardiac
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
Physical exam lungs
- 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
Physical exam abdomen
- 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)
Physical exam extremities
- Rashes, petechiae, ecchymosis, splinter hemorrhages, nodules, erythema nodosum (sarcoid)
- Edema
- Cool or warm
- Clubbing
Physical exam neurological
- 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
Evidence for correlations between history and physical exam findings. and cardiovascular disease severity and prognosis have been developed most rigorously for what conditions? (3)
- Heart failure
- Valvular disease
- Coronary artery disease
Name 3 key physical exam features that contribute to bedside risk assessment in patients with ACS
Vital signs
Presence of MR
Detection of pulmonary congestion
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
- Dyspnea at one flight of stairs
- Orthopnea
- PND
- Displaced apex beat
- Rales
- Irregularly irregular pulse
- Murmur suggestive of MR
- HR > 60
- Elevated JVP
Typical angina should satisfy 3 characteristics. Name them
- Substernal discomfort
- Initiated by exertion or stress
- 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
Name some characteristics that increase or decrease the likelihood for ACS in setting of chest pain
- Sharp, pleuritic, reproducible with palpation- decreased likelihood
- Radiation to both arms or shoulders, precipitated by exertion- increased likelihood
Name some anginal equivalents
- Indigestion
- Belching
- Dyspnea
In what 3 special populations must you keep a high suspicion for ACS despite a “classic” presentation
- Women
- Elderly
- Diabetics
Dyspnea upon standing
Platypnea
Describe characteristics of PND of cardiac origin
- Usually occurs 2-4 hours after onset of sleep
- Severe enough to compel pt to sit upright or stand
- Subsides gradually over several minutes
Regular, rapid-pounding sensation in the neck or visible neck pulsations associated with palpitations
Increased likelihood for:
Atrioventricular nodal reentrant tachycardia (AVNRT)
*Absence of “neck pounding sensation” makes AVNRT less likely
Syncope w/ early warning signs (nausea, yawning), ashen and diaphoretic, slow to revive
Syncope w/ sudden onset, rapid restoration of full consciousness thereafter
More likely neurocardiogenic
More like cardiac
Chest pain diminishes with sitting up, leaning forward or breathing shallowly
Pericarditis
Pursing of the lips, breath quality to voice, increased AP chest diameter
Favors pulmonary etiology