Advanced Physical Assessment
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| Step 1 screening for cardiovascular dz | global> family hx, smoking, physical activity, etc- dibetetes htn
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| Step 2 and 3 screening for cardiovascular dz | calculate 10 year and long term and then calculate individual risk factors htn, diabetes, obesity, HBa1c (>6.5)
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| Anatomy of the heart- direction of blood flow | blood from the right side is venous IVC/SVC→ Rt atrium to tricuspid valve rt ventricle → pulmonary artery (only one with deoxygenated blood) → lungs→ p. veins→ l. atrium→ → mitral valve→ l. ventricle
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| Sequence of events in the heart | up then down starts by an impulse started by the SA node
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| SA node | in the right atrium- gives the impulse/start- both atria contract together- gives impulse- to the ventricles- contract after the atria- up then down
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| Most concerning s/s | chest pain (most important), palpitations, swelling edema, SOB (most common), fainting/syncope- relate it with the pts activity always- at rest? Or when you’re walking etc…
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| Ischemic chest pain comes with | excretion- increased activity or emotion
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| Pericardial comes with | position- when they sit up or stand up or lean forward- lie flat- Improves when they sit up
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| Pleuritic pain is with | breathing- disappears when the pt hold their breath
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| Chest wall pain | tenderness- costochondritis
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| GERD pain | tenderness r/t epigastric-MOST COMMON NON CARDIAC SOURCE OF PAIN
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| Typical ischemic chest pain | exertional pressure-like discomfort- retrosternal- may resolve spontaneously in 20 minutes or with nitro (LDL induced- thick)- only hurts when asking for more blood (no nausea or sweating, anxiety)
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| Heart attack/MI | thin fibrous cap- more severe pain and more prolonged (>20 minutes)- unstable, non-stemi or stemi- can occur at rest or with activity- crushing- vise-like pain- nausea, diaphoresis, impending doom, SOB, anxiety- not relieved by nitrates
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| Atypical Presentations of Acute Coronary Syndromes | Women over 65 years, are likely to report atypical symptoms such as upper back, neck, or jaw pain, SOB, PND, N/V, and fatigue
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| Identify angina | retrosternal diffuse, radiates to the left arm, jaw, back, aching, dull, pressing squeezing, vise-like, mild to severe, minutes (most important indicator), precipitated by cold, eating, effort, emotion and relieved by rest and nitro
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| What’s NOT angina | left inframammary, localized, right arm, sharp shooting, cutting, excruciating, seconds, hours, days, brought on by respiration, posture, motion, relief is non-specific
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| Paroxysmal nocturnal dyspnea PND | Episodes of sudden dyspnea and orthopnea that awaken the patient from sleep, usually 1 to 2 hours after going to bed, prompting the patient to sit up, stand up- may be mimicked by nocturnal asthma attacks
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| Angina | classic angina is about 4 minutes- time matters-
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| Palpitations | awareness of heartbeat- get a ECG
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| Edema | when you start to notice edema, it’s 5l of fluid= 10% wt gain so weight the pt
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| Fatigue or syncope | usually arrythmia, 20% of cases
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| Most common risk factor of second MI | hx of MI
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| If a male relative died of MI before age 55 | that’s premature and for females, it’s 65
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| What’s the worst thing in a person’s social hx | tobacco- worst than etoh
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| Differentiate between which 2 pulses | radial and apical- should be exactly the same- apical can be 120 or more with atrial flutter/PVCs/tachy arrythmias- there’s an apical deficit when the radial is different
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| Orthostatic HTN | any HTN that happens within 3 minutes of changing position by 20 or more- dehydration or diabetic pts with poly neuropathy/autonomic neuropathy-lazy with vasoconstriction
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| JVD | 2 prominent bulges (a and v wave)- order echo-prominent a wave in JVD= pulmonary HTN-– absent in atrial fibrillation-right side too much pressure- and prominent v wave= tricuspid regurgitation or ASD- atrial septal defect
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| Findings suggesting coronary artery disease-signs of hyperlipidemia | Xanthelasma-lipid accumulation skin tags- can be around the eyes, cutaneous Xanthomas, tendons Xanthomas (fingers), arcus lipoides- arc around the eye- hyperlipidemia- abdominal obesity
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| Non-coronary heart disease | cyanosis- central} tongue and toes- rt to left cardiac shunt- peripheral cyanosis} fingers and toes only- low cardiac output-clubbing in cyanotic CHD
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| Peripheral s/s endocardidits | oslers nodes- red papules on the fingers and toes, janesways lesions, Roth spot (retina)
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| Carotid pulse and listening to the heart | the sound that corresponds to the pulse is the 1st heart sound- systole- and that’s how you would identify a systolic murmur
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| Volume overload caused by | valve overload- felt- differentiate between pressure and volume overload
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| Concentric vs eccentric hypertrophy | from patho- pressure overload- stronger heave vs volume overload, valvular dz
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| In pt with increased AP diameter, palpate the RV where | in the epigastric area
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| Left ventricular area for Apical Impulse (AI) | Left ventricular hypertrophy or dilation
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| Heart is on the opposite side | Dextrocardia or situs inversus
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| The jugular vein reflects | the right side of the heart
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| The carotid artery reflects | the left side of the heart-the LV pumping →aorta and that has stenosis and blood will resurges back back towards the carotid
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| Pulsus Alternans | weak and strong beats- sign of left ventricular failure
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| Palpation of the anterior chest wall for | heaves, lifts, or thrills- the left ventricle-5th ICS-
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| If you want to feel the aorta | 2nd rt ICS
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| If you want to feel the pulmonary artery | 2nd left ICS
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| Right ventricular area for the hypertrophied RV | Right ventricular pressure overload (pulmonary hypertension or pulmonic valve stenosis) produces an outward impulse just to the left of the sternum that occurs synchronously with the AI.- can feel It in the epigastrium- volume overload
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| What can make the heart bigger | volume and pressure overload
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| Pressure overload for the heart | pulmonary or reg HTN-not much bigger in size but there’s a stronger heave in contraction- so rt ventricle is hypertrophied- concentric is when the cell is wider than longer- hypertrophied-like layers of added-
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| Volume/ valvular dz/ overload in the heart | valvular regurgitation or ischemia- heart dilates- aortic/mitral/tricuspid regurg, chamber is bigger- wider-apical impulse is felt-feel the heart everywhere in the chest- eccentric hypertrophy-cell is more elongated than wide- chamber dilated
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| Pulmonic area- pulmonary artery PA | rare- Prominent pulsation accompanies dilatation or increased flow in PA- Palpable S2 points to pulmonary HTN
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| Aortic area | Prominent pulsation suggests a dilated or aneurysmal aorta Palpable S2 can accompany HTN
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| in patients with an increased AP diameter (as COPD), palpate the RV in the | epigastric area. Hyperinflation of the lungs may prevent palpation of the RV in the left parasternal area. The RV impulse is palpable in the epigastrium where heart sounds are also more audible
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| Epigastric* (subxiphoid) for the dilated RV | Right ventricular volume overload (pulmonic valve regurgitation or tricuspid valve regurgitation) generates a hyperdynamic, high amplitude impulse along the lower left sternal border or at the xiphoid that occurs synchronously with the apical impulse (AI)
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| AI is also known and | PMI- the cardiac impulse that is palpable farthest to the left of the sternum
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| The AI should be evaluated when the patient is | supine and in the left lateral decubitus position.
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| Normal cardio exam of PMI | diameter 2-2.5 cm, confined to single- 5th ICS @ MCL, timing 1st third of systole, synchronizes with S1, and precedes the carotid pulse- Moves laterally by 1-5 cm
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| Concentric ventricular hypertrophy (Pressure overload: e.g. AS, HTN) | diameter is <3cm, One or two ICSs @ medial or MCL, timing 2nd half of systole, and may not retract until after S2, synchronizes w/the carotid pulse (which is also delayed), slightly increased amplitude, Effect of Lt. Lat. Position sustained A1
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| Eccentric ventricular hypertrophy (Volume overload: e.g. AR, M.Regurgitation) | diameter is 4-5cm, confined to 2 or more ICSs, location @ Lateral to MCL, at/below 6th ICS, Begins w/S1 & retracts by 1st half of systole, synchronizes w/carotid, ↑amplitude force(hyperdynamic) that is hard to obliterate with pressure, 4 cm in size or >
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| Left ventricle can normally be felt | in the left ICS can get hypertrophied/pressure overload (HTN) – just bigger/stronger- it’ll stay in the 5th ICS- or dilated/volume overload (regurgitation)- it’ll double in size—it’ll occupy the 7th ICS and you’ll feel it all over the place
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| Most common symptom of valvular heart disease is | SOB/dyspnea- auscultate
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| What should be heard in everyone | S1 and S2- S3 can be heard in infants and young children and innocent murmurs
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| When to use diaphragm | everything BUT s3, s4, mitral stenosis murmur
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| When to use the bell | for s3, s4, mitral stenosis murmur- low pitched sounds
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| When should a pt lie on the left side for a murmur | mitral stenosis murmur- in an immigrant pt- dyspnea-not in US where we have antibiotics for any pharyngitis- rheumatic heart dz- usually a pregnant lady- lies on left side- listen with the bell- diastolic murmur
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| Aortic murmur | best heard when pt sits up and leans forward- diastolic murmur- most common in US
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| Most common cause of valve regurgitation murmurs in US is | HTN and ischemic heart dz
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| 95% of murmurs are | systolic
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