1
Q
Stable Angina
A
- Most common symptom: chest pain the occurs behind the breastbone or slightly to the left
- begins slowly and gets worse over a few minutes before going away
- usually occurs with exercise, walking up stairs
2
Q
Unstable Angina
A
- sudden chest pain that gets worse over time, lasts longer than 15-20 minutes
- associated with SOB drop in BP
- occurs without cause
- doesn’t respond well to nitroglycerine
3
Q
Variant (Prinzmetal’s angina)
A
- coronary artery spasm
- sudden narrowing of one of the coronary arteries.
- chest pain may occur at same time every day, usually between midnight and 8AM
- not usually with exercise
4
Q
Acute mitral valve prolapse (regurgitation)
A
- one or both mitral valve leaflets ruptures suddenly, blood rushes to the left ventricle
5
Q
Pericarditis
A
- inflammation of the pericardium caused by a virus, bacteria, uremia, lupus or neoplasm, which causes chest pain
- chest pain is pleuritic or crushing in the retrosternal area
6
Q
Dissecting aneurysm
A
- chest pain from tearing of arterial intima
- begins suddenly, tearing quality, sharp pain radiating into back or neck
7
Q
Pulmonary embolism
A
- dyspnea more common
- may be asymptomatic
8
Q
Pleuisy
A
- chest pain is worse with breathing, disappears when hold breath
- preceded by viral infection
9
Q
Pulmonary hypertension
A
- dyspnea is common
- chest pain is described as discomfort, non-raditating tight constricting band across the chest
10
Q
Pneumothorax
A
Air in pleural cavity collapses the lung
11
Q
Mediastinal emphysema
A
- free air in the mediastinum which makes chest tightness and dyspnea
- Hamman’s sign- crunchy sound because heart is beating against air filled cavity
12
Q
Costochonditis
A
- reproducible chest pain
- tenderness over the costochondral rib joint
- point pressure reproduces pain
- usually 3rd rib joint down and can be multi. rib joints
13
Q
Herpes Zoster
A
- chest pain precedes rash
- follows a dermatome distribution
14
Q
Fibromyalgia
A
- second costochondral joint tenderness, seen in 85% of people with fibromyalgia
15
Q
Esophageal spasm
A
- sub-sternal pain and dyspnea
- may mimic angina
16
Q
Esophageal reflux
A
- sub-sternal burning or cramping radiates to arms, neck, and jaw
- relieved with antacids
17
Q
Gallstone Colic
A
RUQ pain radiating to back to right shoulder
18
Q
Dyspnea
A
SOB, uncomfortable awareness of breathing
- feels smothering, causing urgent need to take another breath
19
Q
Orthopnea
A
- Dyspnea occurs soon after lying down and relieved by sitting up or standing
- 2-3 pillows at night
- shift of blood from periphery to pulmonary
- From: COPD, CHF, Mitral Stenosis/Regurg
20
Q
Paroxysmal Nocturnal Dyspnea
A
- Dyspnea after lying down for 1-2 hours
- Usually wakes up at night dyspneic
- Not relieved easily after sitting or standing
- Early signs of CHF or pulmonary edema
- Occurs b/c redistribution of fluid with prolonged supine position
- Differential Dx: nocturnal asthma attack
21
Q
What are two main causes of dyspnea
A
- Pulmonary edema
- Valvular Heart Disease
22
Q
Causes of Pulmonary edema
A
- pulmonary congestion (L- sided HF)
- reduced myocardium contractility
- patient is anxious dyspneic
23
Q
Valvular heart disease
A
Dyspnea is principle symptom of:
- mitral stenosis
- late mitral regurgitation
- late aortic stenosis/regurg
24
Q
How to differentiate pulmonary v. cardiac dyspnea?
A
Pulmonary:
- dyspnea asso. with cough, sputum, COPD
- expectoration relieves dyspnea
- gradual onset: COPD
- abrupt onset: pulmonary emboli, pneumothorax
Cardiac:
- relief with sitting up
- develops over hours or days
25
Paroxysmal supraventricular tachycardia
Palpitations with an abrupt onset, atria rate is higher than the ventricles
- tx: ablation of cells with increased rate
26
Neurally mediated syncope (vasovagal)
- mediated by emotional stress, orthostatic stress
- situation due to coughing, sneeze, defecation, visceral pain, micturition (urination), post micturition, post exercise, post-parandial
27
Cardiovascular causes of syncope
- Arrhythmias, bradycardia, tachycardia
- cardiac outflow obstruction
- aortic stenosis
- mitral valve prolapse
- carotid sinus syncope: hypersensitivity from shaving or tight collar
- hypovolemia
28
Edema
- excess accumulation of fluid in connective tissue's interstitial space
- usually gradual, develops in legs/ankles, worse in evening
- can be pitting (1+, 2+, 3+)
- Most common cause: CHF
29
Hemoptysis
- coughing up blood
- often a sign of pulmonary disease
- if cause is mitral valve stenosis: increased venous congestion will cause ruptured blood vessels or pulmonary infarct
30
Central cyanosis
a drop in the pulmonary venous saturation, due to arterial unsaturation, the aortic blood carries reduced hemoglobin
31
Peripheral cyanosis
normal systemic arterial saturation, but decrease flow through capillaries from decreased cardiac output
32
What are cardiac disease risk factors?
- high blood pressure
- high cholesterol, esp. LDL
- diabetes
- obesity
- smoking
- poor diet
- sedentary lifestyle
- alcohol consumption
33
What does the Framingham Risk Score?
```
Identified 10 year risk for heart attack or stroke
Looks at:
- age
- gender
- smoking
- systolic BP
- total cholesterol
- HDL cholesterol
```
34
what needs to be assessed in patients taking a hypertensive medication?
Orthostatic BP
| - should NOT drop more than 5-10 mmHg with position change
35
Normal BP
less than 120/80 mmHg
36
Pre-hypertension
120-139/80-89 mmHg
| - warrants lifestyle changes
37
Stage 1 HTN
140-159/90-99 mmHg
| - warrants initiation of antihypertensive drugs
38
Stage 2 HTN
160+/100+
| - Need LIFESTYLE changes
39
What is the target BP for diabetics and chronic kidney disease?
less than 130/80
40
What is the target BP for patient over 60 with no DM or CKD?
less than 150/90
41
What are lifestyle modifications to lower blood pressure?
- BMI between 18.5-24.9
- No more than 2.4g sodium per day (about 1 tsp)
- Aerobic exercise 30 min/day, most days of the week
- Moderate alcohol consumption (less than 2 for males and 1 for females per day)
- Vit D. supplement for ppl with low Vit. D
- DASH diet: lots of fruits and veggies, low fat dairy products
42
What can a delayed upstroke be in a carotid pulse be?
aortic stenosis
43
What can a bounding upstroke be in a carotid pulse be?
aortic insufficiency
44
What can a weak amplitude in a carotid pulse be?
cardiogenic shock
45
What can a bounding amplitude in a carotid pulse be?
aortic insufficiency
46
What does it mean if your heart rhythm is regular and your amplitude is alternating?
left ventricular failure
47
What is a paradoxical pulse?
a decrease in amplitude on quiet inspiration
| - found in pericardial tamponade, constrictive pericarditis and obstructive lung disease
48
What is the difference between an internal jugular vein and a carotid artery?
IJV
- rarely palpable
- soft biphasic quality
- eliminate the pulse by pushing on it
- height of pulsation changes with position and inspiration
- height falls with inspiration
Carotid Artery
- palpable
- single thrust
- can't eliminate pulse with pressure
- height does not change, not even with inspiration
49
What is the normal JVP above the sternal angle?
3-4 cm
50
What is the normal JVP above the right atrium?
8-9 cm
51
What is hepatic jugular reflex?
- look at JVP pulsations during quiet inspiration, then press on RUQ or middle abdomen for 10 seconds
- Normal: slight rise then drop in pressure
Positive HJR: increase of JVP of 3cm, indicates fluid overload, usually from right sided heart failure
52
Where is the apical pulse?
5th intercostal space, at the midclavicular line
53
PMI findings?
Normal: tapping
Sustained: suggest LV hypertrophy from HTN or aortic stenosis
Diffuse: dilated ventricle from CHF or cardiomyopathy
54
What does a murmur feel like in the precordium?
- palpable vibration, like purring cat
55
What is the S1 heart sound made by?
Closure of the mitral and tricuspid valves
| - marks the beginning of systole
56
What is the S2 heart sound made by?
Closure of the aortic and pulmonic valves
| - marks end of systole
57
What is a split S2?
hear the pulmonic close before the aortic valve
58
S3- Ventricular Gallop
- due to rapid ventricles filling makes a noise
- just after S2
- dull soft, low pitch sound
- can be normal or abnormal
59
S4- Atrial Gallop
- Ventricles are noncompliant/stiff
- Immediately before S1
- soft low pitch
- heard best with the bell at the apex with patient in left lateral position
- always abnormal
60
Mid-systolic click
- mitral valve prolapse: mitral valve closes and then balloons backwards towards the atria
- sharp, high pitched sound
- heard of apex, usually followed by a murmur
61
How should murmurs be characterized?
- Timing: systolic or diastolic
- Location: apex, LSB, base
- Shape: crescendo-descendo
- Pitch: high, medium, low
- Quality: musical, blowing, harsh
- Intensity: graded I-VI
- Radiation: axillae, neck
62
Shape of murmurs
- determined by its intensity over time
| - crescendo, descendo, or both, plateau
63
Quality of murmurs
harsh, musical, soft, blowing, rumbling
64
Radiation of murmurs
heard in another place
| like the neck, back or axilla
65
What is Grade I murmur?
faintest murmur that can be heard with difficulty
66
What is a Grade II murmur?
murmus is faint, but can be identified immediately
67
What is a Grade III murmur?
murmur is moderately loud
68
What is Grade IV murmur?
murmur is loud and associated with a palpable thrill
69
What is a Grade V murmur?
murmur is very loud but only heard with a stethoscope
70
What is a Grade VI murmur?
murmur is very loud and can be heard without a stethoscope
71
Mid Systolic murmur
- most common murmur
- heard after S1 and peaks near mid systole and stops before S2
- asso. with blood flow across semilunar valves
- can be innocent, physiologic or pathologic
72
Innocent/Physiologic Murmur
- Location: 2nd to 4th rib
- Radiation: little to none
- Intensity: low I-II/ VI
- Quality: variable, vibratory, musical
- decreases or disappears when sitting
- heard best when lying down
- no underlying CVD
73
Aortic Stenosis
- loud harsh, midsystolic, crescendo or decrescendo
- loudest at 2nd right ICS
- intensity: soft to loud
- harsh sound, maybe musical at apex
- calcification of cusps, LVH develops
- fatigue, palpations, dizziness, fainting
- heard best when sitting
- intensity increases with squatting
- often found in older adults
74
Pulmonic Stenosis
- heard midsystolic
- best heard at 2nd ICS
- radiates to neck
- thrill, ejection click, wide split S2, right ventricular after load
- intensity: soft to loud
- Pitch: medium to high
- Quality: harsh, corse
75
Hypertrophic Cardiomyopathy
- genetic disorder (autosomal dominant)
- left ventricular outflow obstruction
- increases R. for life threatening arrhythmia and sudden death
- decreases with squatting
- increases with valsalva
- asso. with S4
76
Pansystolic or Holosystolic murmur
- Pathologic murmur
- comes from blood going from chamber of high pressure to low pressure through a valve
- Begins immediately with S1 and continues to S2
- not louder with inspiration
77
Mitral Regurgitation
- pansystolic
- often loud, blowing, best heard over apex
- radiates to axilla
- S/S: fatigue, palpitation, orthopnea, PND
- blood regurgitation from left ventricle to left atrium when mitral valve fails to fully close and then back into a ventricle during diastole
- results in fluid volume overload on left ventricle with subsequent dilation and hypertrophy
- S3 can be heard
78
Tricuspid Regurgitation
- pansystolic
- soft, blowing, best heard over LL sternal boarder
- gets louder with inspiration
- engorged pulsating neck veins, hepatomegaly
- blood regurgitates from right ventricle to right atrium when valve doesn't fully close
- right ventricular hypertrophy
79
Aortic regurgitation
- murmur starts with S2
- soft, high pitched, blowing diastolic, decrescendo
- best heard at L 3rd ICS at base
- Radiates: down
- Minor symptoms for many years, then rapid deterioration
- Bounding water-hammer pulse in carotids, brachial and femoral arteries, wide pulse pressure
- LVH and dilatation ensue
- blood regurgitates back into left ventricles
- best heard when pt. leaning forward
80
Mitral Stenosis
- low pitch rumble
- doesn't radiate
- S/S: fatigue, palpitation, DOE, orthopnea, occasional PND or pulmonary edema
- diminished, irregular arterial pulse
Results in LA enlargement and LA increased pulse pressure
- heard best at apex in left lateral position
81
Pericardial Friction Rub
- inflammation of pericardium
- high-pitched, scratchy, scraping sound
- heard best: leaning forward at LSB with diaphragm
- 3 components:
1- atrial kick
2- ventricular systole
3- ventricular diastole
82
Peripheral Vascular Disease Risk Factors
- less than 50 years if hx: diabetic, smoker, dyslipidemia, HTN, hyperhomocysteninemia
- 50-69 if hx: smoking or diabetes
- Over 70: all
- leg symptoms with exertion or ischemia pain at rest
- abnormal lower extremity pulses
- known atherosclerotic coronary, carotid or renal artery disease
83
What are PVD warning signs?
1. fatigue, aching, numbness, pain when walking (erectile dysfunction)
2. Poorly healing or non-healing wound on legs/feet
3. Abdominal pain after meals asso. with food fear and weight loss
4. Any first degree relative with any AAA
84
Raynaud's Phenomena
- turning white and/or blue when cold
- painful when they warm up again (re-vascular)
- occurs from cold temp or stress
- symmetrical episodic attack
85
Intermittent Claudication
- arterial disorder
- episodic muscular ischemic induced by exertion
- due to arteriosclerosis of large or medium arteries
- location depends on level of obstruction. common: calfs, butt, thighs, hips
- resolves with rest in 10 minutes
86
Rest Pain
- arterial disorder
- episodic muscular ischemic pain, even at rest
- distal pain
- persistent, worse at night
- aggravated with elevated feet
- better sitting legs dependent
87
What are the 5 P's of acute arterial occlusion?
```
Pain
Pulseless
Pallor
Parasthesia
Paralysis
```
88
Acute arterial occlusion
- arterial disorder
- embolism or thrombosis
- distal pain, usually foot and leg
- sudden onset
- coldness, numbness, weakness, absent distal pulses
89
Chronic renal insufficiency
- intermittent claudication, progressing to pain at rest
- Decreased or absent pulses
- pale when elevation, red on dependent
- cool temperature
- mild edema
- trophic skin changes: shiny, thin, loss of hair, thickened toe nails
- Ulcers on toes or feet
- gangrene may develop
90
Superficial thrombophlebitis
- venous disorder
- pain, tenderness, induration and erythema along the superficial vein
- from inflammation and/or thrombosis of superficial vein
- benign and self-limiting
- increased risk for DVT or PE
91
DVT Risk factors
- hx: immobilization or prolonged hospitalization/bed rest or flying
- recent surgery
- obesity
- prior DVT
- lower extremity trauma
- malignancy
- Use of oral contraception or hormone replacement therapy, especially with smoking
- pregnancy or post partum status
- stroke
92
DVT physical findings
- swelling pain and edema of lower extremity
- difference in calf diameter
- order an ultrasound
93
Chronic Venous Insufficiency
- Pain: none to aching on dependency
- Pulses: normal. but may be hard to find
- Color: normal or cyanotic on dependency. With chronic CVI: petechiae, then brown
- leg may narrow as scarring develops
- edema present
- no gangrene
94
Thromboangitis Obliterans/ Buergers Disease
- inflammation and thrombotic occlusion of small arteries and veins
- occurs in smokers
- intermittent claudication in arch of the foot
- Pain at rest in fingers and toes, brief and recurrent
- aggravated by exercise and relived with rest
- distal coldness, sweating, numbness and cyanosis
- maybe gangrene or ulceration in toes
95
What is the normal Ankle Brachial Index?
Mild PAD?
Moderate PAD?
Severe PAD?
Normal PAD = 0.9 +
Mild PAD = 0.6 - 0.9
Moderate PAD = 0.4 - 0.6
Severe PAD = less than 0.4
96
What is ABI?
BP leg / BP arm
97
Who should have ABI testing/
- Ppl. over 70 years
- abnormal/absent pulses
- 50-69 years with smoking hx or diabetes
