Week 7: Cardio/Peripheral Vascular

Question 1

What would symptoms or peripheral artery disease include? 6)

Answer 1

1. Pain or swelling in the legs or arms
2. Discoloration
3. Pain/Cramping at rest or exertion
4. Cold, numbness, pallor
5. Hair loss
6. Abdominal, flank or back pain (relates to perfusion of the organs)

Question 2

What is claudication? What are the types of claudication? What do they indicate?

Answer 2

• Claudication: pain caused by too little blood flow to muscles during activity
• Exertional claudication: Pain in the legs during exertion that is relieved within 10 minutes of rest
• Neurogenic claudication: pain with walking or prolonged standing radiating from the spinal area into the buttocks, thighs, lower legs or feet

Question 3

What symptoms and exam findings would you expect in peripheral arterial disease? (10)

Answer 3

1. exertional claudication
2. atypical leg pain
3. local fatigue
4. numbness
5. cool dry hairless skin
6. trophic nail changes
7. diminished to absent pulses
8. pallor with elevation
9. ulceration
10. gangrene

Question 4

What symptoms and exam findings would you expect in DVT? (2)

Answer 4

1. painful or painless calf swelling with erythema
2. asymmetric calf diameters

Question 5

What symptoms and exam findings would you expect in thrombophlebitis? (2)

Answer 5

1. swelling
2. redness and warmth with a possible subcutaneous cord

Question 6

What symptoms and exam findings would you expect in cellulitis? (4)

Answer 6

1. erythema
2. edema and warmth
3. involves deeper dermis, adipose tissue
4. may include enlarged, tender lymph nodes and fever

Question 7

What symptoms and exam findings would you expect in lymphangitis? (4)

Answer 7

1. infection spreads up the lymphatic channels from a distal portal of entry
2. red streaks on the skin with tenderness
3. enlarged, tender lymph nodes
4. fever

Question 8

What symptoms and exam findings would you expect in compartment syndrome? (5)

Answer 8

1. tight bursting pain in calf muscles, usually in anterior tibial compartment
2. overlying dusky red skin
3. tingling, burning sensations in calf
4. muscles may feel tight or full
5. numbness, paralysis if unrelieved

Question 9

What symptoms and exam findings would you expect in Buerger disease (thromboangiitis obliterans)? (3)

Answer 9

1. digit or toe pain progressing to ischemic ulcerations
2. gangrene at the tips of digits
3. migratory phlebitis and tender nodules along blood vessels

Question 10

What symptoms and exam findings would you expect in Raynaud disease?

Answer 10

1. reversible vasoconstriction in the fingers and toes
2. distinct digital color changes of pallor, cyanosis and hyperemia; if secondary - ischemia, necrosis and loss of digits, capillary loops distorted

Question 11

What is the Allen test? What does a positive test indicate?

Answer 11

• Compares patency of the ulnar and radial arteries
• Technique
  
  1. Make a tight fist with one hand then compress both radial and ulnar arteries firmly between thumbs and fingers
  2. Ask patient to open hand into a relaxed, slightly flexed position - palm should be pale
  3. Release pressure over the ulnar artery
     
     • Results: palm should flush within 3-5 seconds which indicates a patent ulnar artery
  4. Release radial artery while compressing ulnar artery
     
     • Results: palm should flush within 3-5 seconds which indicates a patent radial artery

Question 12

What are the American Heart Association Cardiovascular Categories for Women?

Answer 12

• High Risk
  
  • ≥1 of the high-risk states, including existing CHD, CVD, peripheral arterial disease, abdominal aortic aneurysm, diabetes mellitus, or end-stage or chronic renal disease
  • 10-year predicted risk of >10%
• At Risk
  
  • ≥1 major risk factors including smoking, blood pressure ≥120/≥80 or treated hypertension, total cholesterol ≥200 mg/dL, HDL-c <50 mg/dL, or treated dyslipidemia, obesity, poor diet, physical inactivity, or family history of premature CVD
  • Evidence of advanced subclinical atherosclerosis (e.g., coronary calcification, carotid plaque, intima-media thickness), metabolic syndrome, or poor exer-cise capacity on a treadmill test
  • Systemic autoimmune collagen vascular disease (e.g., lupus or rheumatoid arthritis)
  • History or preeclampsia, gestational diabetes, or pregnancy-induced hyper-tension

Question 13

What are the values that fall under the stages of hypertension? Normal, elevated, stage 1, stage 2, hypertensive crisis

Answer 13

Normal: Less than 120/80 mm Hg

Elevated: Systolic between 120-129 and diastolic less than 80

Stage 1: Systolic between 130-139 or diastolic between 80-89

Stage 2: Systolic at least 140 or diastolic at least 90 mm Hg

Hypertensive crisis: Systolic over 180 and/or diastolic over 120, with patients needing prompt changes in medication if there are no other indications of problems, or immediate hospitalization if there are signs of organ damage

Question 14

What type of cardiac screening do athletes require?

Answer 14

H&P, no imaging unless risk factors or physical exam abnormalities

Question 15

Sports physicals - questions to ask regarding personal history (6)

Answer 15

1. Chest pain
2. Exercise intolerance
3. Lightheadedness?
4. Birth history
5. Previous identified murmur
6. Congenital heart defects

Question 16

Sports physicals - questions to ask regarding family history (3)

Answer 16

1. History of sudden cardiac death?
2. Sudden cardiac death before the age of 50?
3. Heart disease identified before the age of 50?

Question 17

Sports physicals - special considerations for exam (3)

Answer 17

1. Auscultate heart at all five points while sitting and lying down
2. Listen with bell AND diaphragm
3. Palpate for heaves and lifts

Question 18

What are the events of the cardiac cycle?

Answer 18

Systole: ventricular contraction - L ventricle ejects blood into the aorta

Diastole: ventricular relaxation - ventricular pressure falls and blood flows from atrium to vesicle; later, ventricular pressure rises slightly as it fills with blood from atrial contraction

Question 19

How do you calculate cardiac output?

Answer 19

CO = Heart rate x Stroke Volume

Question 20

Where would the FNP assess for the aortic, pulmonic, mitral, tricuspid, and Erb’s point?

Answer 20

Aortic: R second intercostal space

Pulmonic: L second and third intercostal spaces

Erb’s point: 3rd left intercostal space at the medial left sternal border - can only be heard in the L lateral recumbent position

Tricuspid: near the lower left sternal border

Mitral: cardiac apex; 5th left intercostal space at the midclavicular line

Question 21

What do heaves, lifts and thrills indicate? How would you assess for each?

Answer 21

• Heaves/lifts = sustained impulses that rhythmically lift fingers
  
  • Technique: use palm and/or hold finger pads flat or obliquely against the chest
• Thrills = buzzing or vibratory sensation
  
  • Technique: press the ball of your hand firmly on the chest

Question 22

What do the results of the JVP measurement indicate?

Answer 22

JVP will decrease with hypovolemia, increase with hypervolemia - closely parallels aortic pressure

Question 23

What do results of the carotid pulse assessment indicate?

Answer 23

Provides information regarding aortic abnormalities

• will be delayed from S1 on auscultation in aortic stenosis

Question 24

What would S3, S3 opening snap and S4 indicate?

Answer 24

1. S3: suggestive of volume overload from L ventricle
2. S3 opening snap: suggestive of mitral valve stenosis
3. S4: suggestive of aortic or pulmonic stenosis

Question 25

How would the FNP elicit murmurs?

Answer 25

* Pt should lean forward and exhale, listen along the L sternal border and at the apex * Pt can turn to the left lateral decubitus position, listen at the apical impulse

Question 26

How are murmurs graded?

Answer 26

Grade 1: heard in expert optimum conditions Grade 2: Heard by non-expert in optimum conditions Grade 3: easily heard, no thrill Grade 4: loud murmur, palpable thrill Grade 5: very loud murmur, often heard over a wide area, palpable thrill Grade 6: extremely loud, heard without a stethoscope

Question 27

What would a systolic click indicate?

Answer 27

Mitral valve prolapse Extracardiac or mediastinal origin

Question 28

What are the symptoms of an acute MI?

Answer 28

Ischemic chest pain, may be silent and can occur in any position

Question 29

What physical exam findings would be associated with aortic stenosis? (Location, radiation, intensity, pitch, quality, maneuvers, cause)

Answer 29

* Location: 2nd and 3rd R interspaces * Radiation: to carotids, down left sternal border, even to the apex; if severe may radiate to L 2nd and 3rd interspaces * Intensity: sometimes soft, often loud with a thrill * Pitch: medium, harsh, crescendo-decrescendo may be higher at the apex * Quality: often harsh, may be more musical at the apex * Maneuvers: heard best with patient sitting and leaning forward * Delayed carotid upstroke * Cause: most common is bicupsid aortic valve

Question 30

What physical exam findings would be associated with pulmonic stenosis? (Location, radiation, intensity, pitch, quality, cause)

Answer 30

* prominent ejection click in early systole * Location: Left 2nd and 3rd interspaces * Radiation: If loud, toward the left shoulder and neck * Intensity: Soft to loud; if loud, associated with a thrill * Pitch: Medium; crescendo–decrescendo * Quality: Often harsh * JVP normal * Right ventricular impulse is sustained * In severe stenosis, S2 is widely split and P2 softens * Causes: Primarily congenital

Question 31

What physical exam findings would be associated with mitral regurgitation? (Location, radiation, intensity, pitch, quality, maneuvers, cause)

Answer 31

* Location: Apex * Radiation: To the left axilla, less often to the left sternal border * Intensity: Soft to loud; if loud, associated with an apical thrill * Pitch: Medium to high * Quality. Harsh, holosystolic * Maneuvers: Unlike tricuspid regurgitation, the intensity of the murmur does not change with inspiration * The apical impulse may be diffuse and laterally displaced * Causes * structural: MVP, infectious endocarditis, rheumatic heart disease, and collagen vascular disease * functional: ventricular dilatation and dilatation of the mitral valve

Question 32

What physical exam findings would be associated with tricuspid regurgitation? (Location, radiation, intensity, pitch, quality, maneuvers, cause)

Answer 32

* Location: LLSB; if right ventricular pressure is high and the ventricle is enlarged, the murmur may be loudest at the apex and confused with mitral regurgitation * Radiation: To the right of the sternum, to the xiphoid area, and at times to the left midclavicular line, but not into the axillae * Intensity: Variable * Pitch: Medium * Quality: Blowing, holosystolic * Maneuvers: Unlike mitral regurgitation, the intensity increases with inspiration * Causes: right ventricular failure and dilatation, with resulting enlargement of the tricuspid orifice, often induced by pulmonary hypertension or left ventricular failure; and endocarditis

Question 33

What physical exam findings would be associated with Still's murmur? (Location, radiation, intensity, pitch, quality, maneuvers, cause)

Answer 33

* normal, innocent murmur in a pediatric patient; musical quality * Location: Left 2nd to 4th interspaces between the left sternal border and the apex * Radiation: Minimal * Intensity: Grade 1 to 2, possibly 3 * Pitch: Soft to medium; “musical” * Quality: Variable * Maneuvers: Usually decreases or disappears on sitting * Causes: Turbulent blood flow, probably generated by ventricular ejection of blood into the aorta from the left and occasionally the right ventricle

Question 34

What physical exam findings would be associated with left ventricular hypertrophy?

Answer 34

* PMI \>2.5cm * Displacement of PMI lateral to midclavicular line * A sustained, high-amplitude PMI * Causes: Heart failure, cardiomyopathy, ischemic heart disease, HTN

Question 35

What exam findings are consistent with coarctation of the aorta?

Answer 35

* Arises from narrowing of the thoracic aorta * Presents with systolic hypertension greater in the arms than the legs * diminished or delayed femoral pulses, sometimes termed femoral delay * Causes sustained HTN in the newborn

Question 36

What physical exam findings are consistent with venous hum? (Timing, location, radiation, intensity, quality, pitch, maneuvers)

Answer 36

* Timing: Continuous murmur without a silent interval. Loudest in diastole. * Location: Above the medial third of the clavicles, especially on the right, often when the head is turned in the opposite direction. * Radiation: Right or left 1st and 2nd interspaces * Intensity: Soft to moderate. The hum is obliterated by pressure on the internal jugular vein * Quality: Humming, roaring * Pitch: Low * Maneuvers: Best heard when patient in sitting position; disappears when patient supine

Question 37

What physical exam findings are consistent with pericardial friction rub? (location, radiation, intensity, quality, pitch, causes)

Answer 37

* Location: Usually best heard in the left 3rd interspace next to the sternum * Radiation: Minimal * Intensity: Superficial * Quality: Scratchy, scraping, grating * Pitch: High (heard best with diaphragm) * Maneuvers: patient sitting and leaning forward with breath held after forced expiration * Causes: pericarditis

Question 38

What are general physical exam findings in the pediatric patient with congenital heart disease?

Answer 38

* Heart murmur + Central cyanosis without respiratory symptoms * Absence of femoral pulses (Coarctation of aorta)

Question 39

What are physical exam findings consistent with heart failure?

Answer 39

cough, orthopnea, paroxysmal nocturnal dyspnea, edema

Question 40

What is paroxysmal nocturnal dyspnea?

Answer 40

sudden dyspnea that awakens the patient at night, might be accompanied by coughing and wheezing

Question 41

Ideal cardiovascular health recommendations from the AHA: cholesterol, BP, glucose, BMI, smoking status, activity and diet recommendations

Answer 41

1. Total cholesterol \<200 mg/dL (untreated) 2. BP \<120/\<80 (untreated) 3. Fasting glucose \<100 mg/dL (untreated) 4. Body mass index \<25 kg/m2 5. Abstinence from smoking 6. Physical activity at goal: ≥150 minutes/week moderate intensity, ≥75 minutes/ week vigorous intensity, or combination 7. Healthy diet

Question 42

What are the systolic and diastolic murmurs? **Hint** Systolic: MR Peyton Manning AS MVP Diastolic: ARMS

Answer 42

Systolic: Mitral regurgitation, physiologic murmur, aortic stenosis, mitral valve prolapse Diastolic: aortic regurgitation, mitral stenosis