Medex Objectives Fall 2002
MEDEX Northwest Physician Assistant Objectives Home: http://faculty.washington.edu/alexbert/MEDEX/
Last updated 7 Dec 2003
Cardiovascular History Taking Objectives
Goal: After reading the prescribed information and listening to the appropriate lecture(s) the student should be able to take a complete and appropriate history from a patient with a cardiovascular complaint.
1. Be able to define the following terms and state their general significance in cardiovascular disease patterns:
Chest pain Murmurs
Orthopnea Cyanosis
Paroxysmal nocturnal dyspnea Claudication
Edema Hypertension
Palpitations
Anonymous
Chest pain – AKA angina pectoris, which results from a temporary difference between the supply and the demand of oxygen to the heart muscle. Angina can be the result of low oxygen levels in the blood, restricted blood flow to the heart or an increase in the work of the heart beyond normal levels.
Murmurs – extra heart sounds heard between normal beats. They have a longer duration than heart sounds and are attributed to turbulent blood flow. They are usually caused by a valvular defect or disease that disrupts the smooth flow of blood in the heart. Systolic murmurs are classified as ejection murmurs (aortic and pulmonic stenosis) or regurgitant (mitral and tricuspid insufficiency). Diastolic murmurs are due to aortic or pulmonic regurgitation or mitral stenosis. Murmurs may indicate serious heart disease.
Orthopnea – dyspnea that occurs when the pt is lying down and improves upon sitting up. Classicly quantified by # of pillows pt uses to sleep on. Suggests Lt ventricular failure, mitral stenosis or obstructive lung disease.
Cyanosis – Bluish skin caused by an increased concentration of deoxyhemoglobin in cutaneous blood vessels. It is a sign of CHF or septal defects.
Paroxysmal nocturnal dyspnea – episodes of sudden dyspnea and orthopnea that waken a pt from sleep, usually 1-2 hrs after going to bed. Wheezing and coughing can be associated. May recur the same time on subsequent nights. Can occur because of COPD, asthma that is worse at night, or interstitial pulmonary edema secondary to left ventricular failure.
Claudication – Aching, cramping and possibly numbness or severe fatigue in feet and legs that appears with walking and disappears promptly with rest. Can be an indicator of atherosclerosis in vascular beds.
Edema – Kraytman p. 56-57 accumulation of excessive fluid in the interstitial spaces, appears as swelling. When generalized edema is associated with cardiomegaly, gallop, basilar crackles, distended jugular veins or hepatomegaly, CHF is possible. In CHF, edema is caused when increased venous pressure produces an elevated capillary hydrostatic pressure. Localized edema of head, neck, and upper extremities signifies a possible superior vena cava obstruction – bronchogenic carcinoma, mediastinal lymphoma or aneurysm of the aorta. Localized edema in the lower extremities can also be cardiac in nature.
Hypertension – consistent elevation of systemic arterial blood pressure that is caused by increases in cardiac output, total peripheral resistance or both. Cardiac output is increased by any condition that increases heart rate or stroke volume, whereas peripheral resistance is increased by any factor that increases blood viscosity or reduces vessel diameter, particularly arteriolar diameter.
Palpitations – unpleasant awareness of the heartbeat such as skipping, racing, fluttering or pounding of the heart. Palpitations may result from irregular heartbeat, rapid acceleration or slowing of heart or from increased forcefulness of cardiac contraction. They do not necessarily mean heart disease.
Anonymous
Chest Pain: Pain or discomfort in the chest resulting from decreased oxygen levels in blood, restricted blood flow to the heart or an increase in the work of the heart beyond normal levels. Causes: Cardiac would include Angina and Myocardial Infarct. Other sources of pain may be from muscularskeletal sources, GI tract, or respiratory sources.
Orthopnea: SOB when lying flat. Usually occurs within 1-2 minutes of assuming recumbency and develops when patient is awake. Due to redistribution of fluid from abdomen and lower body into chest. Sign of left sided heart failure. Source: Noble pg 175 and 584.
Paraxysmal nocturnal dyspnea: Form of
orthopnea and may occur with further progression of
Edema: A complex physical sign, first determine if edema is localized or generalized. Localized causes of edema in a limb usually are due to obstruction of the venous or lymphatic drainage. The 3 most common causes of generalized edema are cardiac failure, liver failure and renal failure. Source: Ballweg PA book.
Palpatations: Uncomfortable sensations in the chest related to cardiac arrhythmias described as “skipping”, “fluttering”, “pounding” or “racing”. May be an emotional reaction or caused by a heart arrthymia.
Murmurs: Abnormal heart sound heard between normal beats, usually caused by vavular defect (including stenotic valvular orifice). Disrupts the smooth flow of blood in the heart. Also heard in cases of interseptal defect. Source: Bates pg283 and Lang.of Med pg 393.
Cyanosis: Caused by deficient oxygen in the blood; hemoglobin in RBC is deoxygenated. Cyanosis indicates hypoxemia from abnormal respiratory function or low cardiac output. Source: Lang of Med pg 432 and Noble pg 163-164. Cyanotic congenital heart disease and arteriovenous shunts are the most common in children. CHF is the most common cardiac cause of cyanosis in adults. Ballweg PA book.
Claudication: pain, tension and weakness in a leg after walking has begun, but absence of pain at rest. Source: Noble pg 397. Also described as angina occurring in the legs. Causes include atherosclerosis of the arteries of the legs. Source: Ballweg PA book.
Hypertension: High BP. In adults a BP greater then 140/90 is considered high. Essential hypertension in idiopathic Secondary hypertension is always associated with some lesion in the kidneys or disease of the adrenal glands that are responsible for elevated BP. Lang of Medicine pg 395.
Tim PA a Guide to Clinical Practice 1st
a.) Chest pain: Pain in the thorax that can be related to pathology from the cardiovascular, respiratory and gastrointestinal system or may involve the chest wall. The main cardiovascular cause is coronary artery disease (CAD), which usually presents as angina pectoris from exertion (stair climbs, uphill walking).
b.) Murmurs: Cardiovascular sound created by turbulence produced by damaged valves, septal defects, narrowed arteries or atriovenous communications. Can also be normal in hyperactive circulation such as for children.
c.) Orthopnea: Breathlessness usually due to classic left sided CHF that manifests when the patient lies in the recumbent position and experiences wheezing and dyspnea. Severity measured by how many pillows are needed to prop the patient up to a position comfortable enough to sleep without episodes.
d.) Cyanosis: Bluish discoloration of the skin and mucous membranes resulting from an inadequate supply of oxygen in the blood. Causes include CHF and pulmonary problems in adults, AV shunts and congenital heart defects in kids.
e.) Paroxysmal nocturnal dyspnea: The sudden onset of shortness of breath occurring at night during sleep. Associated with CHF and pulmonary edema. Patients may wheeze and cough, very similar to orthopnea.
f.) Claudication: Angina occurring in the legs (usually lower leg) that is brought on by exertion and relieved by rest. Cause is atherosclerosis of the legs.
g.) Edema: Excessive accumulation of fluid in the body tissues, can be general or local and is caused by many different factors such as HTN and obstruction.
h.) Hypertension: High blood pressure that is caused by different factors such as narrowing of the arteries, renal disease and others. Increases the workload on the heart.
i.) Palpitations: Uncomfortable sensations in the chest associated with a range of arrhythmias. May be described as fluttering, pounding or irregular.
DeAnna
Chest pain-physical complaint that requires immediate diagnisis and evaluation. It may be symptomatic of cardiac disease such as angina pectoris, myiocardia infarction or pericarditis. Mosby’s dictionary
Orthopnea-dyspnea that occurs when the patient is lying down and umproves when sitting up. It suggests left ventricular failure or mitral stenosis. Bates pg52 or Swartz 323
Paroxysmal nocturnal dyspnea-sudden onset of shortness of breath occurring at night during sleep. Patient wakes suddenly and usually goes to the window to get “air”. It suggests left ventricular failure or mitral stenosis. Bates pg 52 and Swartz 323
Edema-accumulation of excessive fluid in the interstitial spaces and appears as swelling. If edema is present in the lower body parts it maybe related to congestive heart failure. Bates 52 and 480 Swartz 361
Palpitations-uncomfortable sensations in the chest associated with a range of arrhythmias. They don’t necessarily mean heart disease but can be ventricular tachycardia. Bates 51 and Swartz 356-357
Murmurs-gentle blowing or fluttering sound. Diastolic murmurs are usually indicative of valvular heart disease. Systolic murmurs may indicate valvular disease but the heart is entirely normal. Bates 313 and Mosby’s Dictionary
Cyanosis-subtle bluish discoloration from inadequate gas exchange due to low cardiac output. Swartz pg324
Claudication-a specific pattern of pain when walking such as aching, cramping and possibly numbness that is relieved with rest. It results from impairment of arterial flow by atherosclerosis. Bates 67and 97
Hypertension-elevated blood pressure that persistently exceeds 140/90. Risk is increased by obesity, a high serum sodium level, hypercholesterolemia and family history. Mosby’s dictionary
2. Identify the known cardiac risk factors. (E-res)
Anonymous
According to Table 13-2 (Goldman’s Cardiac Risk Index) cardiac risks include the following factors: Coronary artery disease, MI’s, unstable angina within 6 months, alveolar pulmonary edema, suspected critical aortic stenosis, dysrhythmias, poor general medical status (check table for specific lab result abnormalities), aged persons, emergency surgery. There is a quote that says, “Factors that do not increase risk in the Goldman analysis include stable HTN, stable angina, diabetes, elevated cholesterol and cigarette smoking.” HOWEVER, on pg. 547 it is stated that the Framingham Heart Study identified 4 major potentially modifiable risk factors: hyperlipidemia, HTN, cigarette smoking and diabetes mellitus. The AMA also added obesity. Nonmodifiable risk factors include advanced age, male sex, family hx of coronary disease. Other unproven risk factors include a sedentary lifestyle and stressful emotional states.
Anonymous
Source: Noble pg 163 and Emerg. Medicine pg 342.
Personal history of Coronary Artery Disease (CAD)
Truncal obesity
Gender (Males greater risk) and post menopausal females.
HTN
Diabetes
High LDL or total cholesterol or low HDL.
Family history of premature CAD (Male under age 55 or female under 65).
Smoking
Substance Abuse (Cocaine especially).
Sedentary lifestyle
High sodium Intake.
Tim E-res, CV related readings
a.) Atherosclerosis is responsible for almost all cases of CHD. This insidious process begins with fatty streaks which are first seen in adolescence; these lesions progress into plaques in early adulthood, and culminate in thrombotic occlusions and coronary events in middle age and later life.
b.) Sex and Age; The older the greater the risk and men are at greater risk.
c.) Family history is a significant independent risk factor for coronary heart disease, particularly among younger individuals with a family history of premature disease.
d.) Lipids; The serum total cholesterol concentration is a clear risk factor for coronary heart disease.
e.) Hypertension and left ventricular hypertrophy are well-established risk factors for adverse cardiovascular outcomes, including CHD, CHD mortality, stroke, congestive heart failure, and sudden death.
f.) Pulse pressure; The principal components of blood pressure consist of both a steady component (mean arterial pressure) and a pulsatile component (pulse pressure), which is the difference between the systolic and diastolic blood pressures and is determined primarily by large artery stiffness.
g.) Glucose intolerance and diabetes mellitus; Insulin resistance, hyperinsulinemia, and glucose intolerance appear to promote atherosclerosis.
h.) Estrogen deficiency; The incidence of CHD increases in women after menopause, an effect that is thought to be secondary to hypoestrogenemia.
i.) C reactive protein; Among apparently healthy men and women, the baseline level of inflammation, as assessed by the plasma concentration of C-reactive protein (CRP) predicts the long-term risk of a first myocardial infarction, ischemic stroke, or peripheral vascular disease.
j.) Lifestyle factors; A diet rich in calories, saturated fat, and cholesterol contributes to other risk factors that predispose to coronary heart disease.
k.) Exercise of even moderate degree has a protective effect against coronary heart disease and all-cause mortality.
DeAnna
Most important risk factors
• Advanced age
• Male sex (males are more prone than females until age 50)
Other risk factors
• Cigarette smoking
• High blood cholesterol levels
• Hypertension
• DM
Controversial risk factors
• Sedentary lifestyle or lack of regular exercise
• Marked obesity
• Type A personality
3. Identify the general anatomic sources of chest pain (organ systems, not individual diseases) that are most commonly responsible for the symptom.
Anonymous
Common chest pain etiology – Cardiovascular, Respiratory, GI, and Musculoskeletal systems (chest wall). In some instances, neurological disorders or psychogenic problems contribute.
Anonymous
(Source: Noble pg 164).
a) Muscularskeletal: costochondritis, muscle strain/sprain, arthritis, myositis.
b) Respiratory: Pleuritis, pleural effusion, pneumonia, tracheobronchitis.
c) Gastrointestinal: GERD, gastritis, ulcer, hiatal hernia, esophageal spasm.
d) Cardiovascular: Angina, MI, Pericarditis.
e) Here’s an extra one too: Dermatologic: Zoster, cellulites.
Tim PA a Guide to Clinical Practice,
The anatomic sources for chest pain are cardiovascular (CAD with angina), respiratory (PE), gastrointestinal (reflux) and the chest wall (Pleurisy, rib fx)
DeAnna
Cardiovascular
Respiratory
Gastrointestinal
Chest wall
Neural
Emotional
4. Be able to describe in detail the specific, systematic questions you would ask in taking a history of present illness from a patient with episodic chest pain.
Anonymous
First consider the outline categories: chief complaint, onset duration, description of pain & location of pain, aggravating and relieving factors, associated symptoms/ROS (general ROS & CV ROS), Medications/Tx/Evaluation, other medications, drug allergies, PMH, FH of this complaint, LMP (if female), birth control, habits, effect on life. Use the following breakdown as depicted in Kraytman. For meds, drug allergies, LMP & birth control just ask the specific question.
Pages 11-18 of Kraytman detail an entire hx for chest pain. In short, questions include: Location and radiation of pain/discomfort (where do you have pain, is it localized, superficial or deep, does it radiate); mode of onset and evolution of pain (how long have you had the pain, duration of episodes, frequency); intensity of pain (mild, moderate, severe); character of pain (squeezing, constricting, dull, throbbing); aggravating factors (pain appears at rest, with activity, when eating, when anxious, when exhausted, induced by walking, with inspiration or swallowing); relieving factors (remaining immobile, belching, with food, with exertion, holding breath, with nitroglycerin); accompanying symptoms (pain accompanied by sweating, SOB, palpitations, coughing, fever, blood, pain, edema or pain in legs, dizziness, depression, difficulty swallowing); personal/social (smoking, occupation, physical activity, emotional tensions, alcohol, personality type); personal antecedents (past ECG or chest xray, recent surgeries, HTN, cardiac disease, emphysema, high cholesterol); and family hx (anyone in family w/ DM, HTN, high cholesterol, premature death).
Anonymous
Source: Emergency Medicine pg 342 and very complete listing in Ballweg PA book pg 179-182).
Questions should determine quality, location, radiation, frequency, intensity, associated symptoms. For any patient complaining of Chest Pain you must obtain a detailed history but particular emphasis on (1) the description of typical episodes and (2) aggravating and relieving factors.
Onset: When chest pain began, what the pt was doing, time of day, relation to meals, emotional state. Duration: Typical length of episodes (seconds, minutes or hours). How frequently?
Description: sharp, dull, heavy, stabbing, pressure or burning? Severity on a scale 1-10. Any radiation of pain? Aggravating factors: This is often key to diagnosis!!! (pain appears at rest, with activity, when eating, coughing, moving, with inspiration, swallowing, bending over, when anxious, exhausted or emotionally upset). Relieving factors: Ask about rest, position changes, eating, belching, use of nitro or other medications. Review of Systems or associated symptoms:
You must ask all the Cardiac and Respiratory ROS questions and you should ask most of the GI ROS questions. Any breathing difficulties, sweating, nausea, syncopy, dizziness, palpitations, vomiting, fever, cough. Ask about cardiac risk factors. Medications: Inquire aout the effect of any medication the patient is taking or has obtained. (ex: Nitro, Antacids, inhalers, NSAIDS).
Past Medical History: ask about similar episodes as well as any history of Cardiovascular disease. Ask aout EKG’s, C-Xray, treadmill tests. Ask about previous respiratory, chest wall or GI disorders. Family History: inquire about any FH of heart disease, HTN, premature death, DM. Habits: smoking, occupation, physical activity, alcohol usage, emotional stress. Effect on patients life: Inquire not only about physical effects but also about psychological ones.
Tim PA a Guide to Clinical Practice,
Questions should emphasize description of episodes, aggravating and relieving factors such as;
a.) Onset- When did the pains first start?, what were you doing?, time of day?, relation to meals?
b.) Duration- How long do episodes last?, how frequently do they occur?, has there been an increase in frequency, duration or severity lately?
c.) Description- How would patient describe the pain; burring (usually GI), stabbing (typical of chest wall), heavy or squeezing (CAD).
d.) Location- Try to get the patient to point with one finger to precise area.
e.) Radiation- Chest pain that radiates down the left arm and to the shoulder and or jaw can be indicative of ischemic heart disease.
f.) Aggravating or relieving factors- this info is often the key to the diagnosis, chest pain that is brought on with exertion and relieved by rest is classic for angina pectoris resulting from CAD. Pain with coughing or breathing suggests chest wall. Pain with lying down or bending over (GI).
g.) All ROS questions from the cardiac and respiratory systems must be asked as well as pertinent GI questions depending on symptoms. Also PMH, Meds and effect on life.
Howie
BATES 8th ed 261, BALLWEG 180, SWARTZ 355, Handout from Carmen on CV Hx
Four sources of chest pain are CV,Resp,GI, and chest wall.
The aggravating and relieving factors will often be the key to Dx.
HPI
ONSET:
DURATION: (If CV, less than 20 mins probably angina)
DESCRIPTION:
PAIN:
LOCATION:
RADIATION:
SEVERITY:
TYPE:
AGGRAVATING FACTORS:
RELIEVING FACTORS:
ROS: General, Pulmonary, CV, GI,
MEDS/Tx/EVALS:
OTHER MEDS:
ALLERGIES/REACTION:
PMH:
FH:
SH:
LMP/BC:
EFFECTS ON LIFE:
ANYTHING ELSE? Add Cardiovascular Risk Factors: Old man, smoke cigarettes, high cholesterol, HTN, DM, FH, sedentary, obese, Type A
SUMMARY:
5. Describe Levine's sign and its diagnostic significance.
Zen Seeker
Anonymous
Sometimes, while describing angina, a patient raises a clenched fist to the sternum (Levine sign) as if to indicate the constrictive sensation by that tight grip.
Anonymous
Sometimes, while describing angina, a patient raises a clenched fist to the sternum (Levine sign) as if to indicate the constrictive sensation by that tight grip. Noble, p547
Tim Schwartz,
Howie BALLWEG, 180
A patient describing pain by placing a clenched fist over the sternum. This is a pathognomonic sign of angina.
6. State the relative importance of aggravating and relieving factors in a history of chest pain. Which ones are most suggestive of a) CAD? b) pleuritic chest pain? c) GI causes? d) chest wall disorders?
Anonymous
Aggravating factors are those that make the chest pain worse while relieving factors improve it.
CAD – aggravating: on exertion, at rest (coronary artery spasm)
relieving: leaning forward
Pleuritic chest pain – aggravating: at rest, while bending over, on inspiration, with coughing
relieving: holding breath in deep expiration
GI causes – aggravating: a heavy meal, after protracted vomiting, while eating, at night when lying down or
when swallowing (esophageal pain)
relieving: belching, passing gas, sitting up, food, antacids
Chest wall – aggravating: unusual activity or physical strain, trauma
relieving: at rest, analgesics
Anonymous
a) Aggravating factors associated with CAD include walking uphill, walking against a cold wind, eating a heavy meal, stressful dreaming, and emotional upset.
b) Pain associated with coughing or deep breathing suggests a pleuritic or chest wall cause.
c) Pain aggravated by lying down or bending over suggests a GI cause, like hiatal hernia.
d) Pain reproducible by pressing on the chest wall is diagnostic of a chest wall disorder.
Relieving factors to ask about are rest, position change, eating, and medication.
Stephen.
What brings on the chest pain and what relieves it will lead the examiner down a path of relatively specific to classic symptoms common with different cardiac diseases. For instance, coronary artery disease has the classic symptom of SOB with exertion, which is relieved by rest or nitroglycerin tabs under the tongue. Shwartz. Pg 355, Table 13-1 lists examples of Angina vs. not Angina.
Pain associated with pleurisy will be during respirations .
GI causes are a long list of diseases, i.e., ulcer, hiatal hernia, pancreatitis and cholecystitis, with symptoms of heart burn, radiating pain to or from the flank, etc.
Chest wall disorders, i.e., bone tumor, muscular spasms, inflammation of the intercoastal spaces or arthritis can cause chest pain that may not be relieved by rest.
Janelisa Ballweg 180
The aggravating and relieving factors are often the key to the diagnosis.
a) Aggravating factors for CAD are walking uphill or against a cold wind, eating a heavy meal, stressful dreaming, and emotional upset.
b) Pain associated with coughing or deep breathing suggests a pleural or chest wall cause.
c) Pain aggravated by bending over or lying down suggests a GI cause like hiatal hernia.
d) Pain reproducible by pressing on the chest wall is diagnostic of a chest wall disorder.
Relieving factors to ask for all these are rest, position change, eating, and medications.
Howie
BALLWEG, 180
Aggravating and relieving factors are often the key to Dx.
Most suggestive of:
CAD—walking uphill, walking against a cold wind, eating a heavy meal, stressful dreaming, emotional upset.
pleuritic chest pain—coughing, deep breathing
GI—lying down, bending over like hiatal hernia
chest wall disorders—press on chest wall
7. State the classic symptom description of angina pectoris.
Anonymous
Most often described as tightness, squeezing, heaviness, pressure, burning, indigestion or aching sensation. Rarely described as a pain. It is never sharp, stabbing, prickly, spasmodic or pleuritic but is usually a steady discomfort that lasts a few minutes.
Anonymous Noble, p.547
Most often angina is described as a tightness, squeezing, heaviness, pressure, burning, indigestion, or aching sensation. Other symptoms that frequently accompany angina include dyspnea, diaphoresis, and nausea.
Stephen. Shwartz. Pg. 335
Levines sign. Pt. clinches fist over heart to describe the chest pain sensation.
Pain usually relieved by rest or nitro vasodilation of coronary arteries.
Janelisa Ballweg 180 Chest pain brought on by exertion and relieved by rest is the classic, and still most reliable, indicator of angina pectoris.
Howie SWARTZ, 355t
Characteristics of chest pain
Location—retrosternal, diffuse
Radiation—left arm, jaw, back
Description—aching, dull, pressing, squeezing, vise-like
Intensity—mild to severe
Duration—minutes
Precipitated by—effort, emotion, eating, cold
Relieved by—rest, nitroglycerin
Chest pain brought on by exertion, relieved by rest. BALLWEG, 180
Exertional chest pain with radiation to the left side of the neck and down the left arm. BATES 8th ed, 261
8. Identify which ROS questions must be asked when taking a history of chest pain.
Anonymous
All CV questions including: pain, palpitations, murmurs, DOE, orthopnea, PND, edema, cyanosis, HTN, claudication, past EKG’s/heart tests/CXR. In general ROS, ask about fatigue, weakness and sweating. Respiratory questions should be asked including wheezing and breath sounds, dyspnea, chest pain, hemoptysis. GI questions including dysphagia, indigestion, pain, reflux. It’s also important to assess for edema, cyanosis/clubbing of nails, cyanosis of lips, ulcerations, varicosities as well as pt’s general emotional state including anxiety and emotional well-being. Pages 11-18 of Kraytman detail an entire hx for chest pain, or you can see question #4 above for further CV info.
Anonymous
You must ask all the cardiac and respiratory ROS questions. You should ask most of the GI R”OS questions as well, especially those that go with the upper GI tract (indigestion, dysphagia, abdominal pain, etc.) Ask the bowel movement questions if there is any possibility of a GI cause-ulcers, for example, can cause GI bleeding and melena. Then ask about the cardiac risk factors. (Ruth’s book, p.180)
Stephen
Questions would include, HTN Hx, claudation, last EKG, indigestion or constipation,
ABD surgeries, hernias, diabetes, edema, muscle pain, fractures, arthritis,
Pneumonia,…(just to name a few)
Janelisa Swartz 355
Where is the pain?
How long have you had the pain?
Do you have recurrent episodes of pain?
What is the duration of the pain?
How often do you get the pain?
What do you do to make it better?
What makes the pain worse? Breathing, lying flat, moving your arms or neck?
How would you describe the pain? Burning, pressing, crushing, dull, aching, throbbing, knife-like, sharp, constricting, sticking?
Does the pain occur at rest? With exertion, after eating, when moving your arms, with emotional strain, while sleeping, during sexual intercourse?
Is the pain associated with shortness of breath? Palpitations, nausea or vomiting, coughing, fever, coughing up blood, leg pain?
Howie BALLWEG 180
CV, Pulmonary, most GI, plus cardiac risk factors.
9. Identify the specific cardiac disease associated with orthopnea and paroxysmal nocturnal dyspnea.
Anonymous
Orthopnea suggests left ventricular failure or mitral stenosis, but may also accompany obstructive lung disease.
Paroxysmal nocturnal dyspnea suggests left ventricular failure or mitral stenosis and may be mimicked by nocturnal asthmatic attacks.
Stephen. Shwartz. Pg. 323
Orthopnea suggests CHF and mitral valve disease.
PND also suggests CHF and the strain put on the heart to deal with an increase in the intrathoracic blood volume. Shwartz. Pg 358
Janelisa Ballweg 180
Congestive heart failure is associated with both these symptoms.
Orthopnea is classic for left-sided CHF.
PND is also known as “cardiac asthma” because patients may experience more wheezing or coughing than dyspnea. Associated symptoms are sweating, palpitations, and substernal tightness.
If either orthopnea or PND have a recent onset or increasing frequency, prompt evaluation is need for the precipitating cause.
Howie
Orthopnea CHF, mitral valve disease but may also accompany obstructive lung disease.
Paroxysmal nocturnal dyspnea suggests left ventricular failure or mitral stenosis and may be mimicked by nocturnal asthmatic attacks.
10. Distinguish between localized and generalized causes in a patient with edema.
Anonymous Bates pp. 480
Localized causes for edema: venous stasis, lymphatic stasis, and prolonged dependency.
Generalized causes for edema: congestive heart failure, hypoalbuminemia, and excessive renal retention of salt and water.
Increased capillary permeability may be either local or general in distribution.
Anonymous
Localized edema – movement of plasma fluid into interstitium caused by localized increase in capillary permeability (due to chemical, bacterial, thermal or mechanical agents) or by any localized increase in the capillary pressure (due to local obstruction in venous and lymphatic drainage). Examples include around the eyes or face, in one upper or lower extremity, in both arms, or both legs.
Generalized edema – systemic changes that cause edematous conditions. For example, changes in venous pressure can increase capillary hydrostatic pressure causing edema. This is common in CHF. Hypoproteinemia causes a shift of plasma water into interstitial spaces causing generalized edema. In cirrhosis, blood volume is diminished and an increase in portal venous pressure causes ascites.
Stephen.
Localized edema may be caused by trauma or infections that have triggered the inflammatory response. Eres CV Edema ETIOLOGY ? The most common causes of generalized edema seen by the clinician include:
Congestive heart failure
Cirrhosis
Nephrotic syndrome and other forms of renal disease
Premenstrual edema and pregnancy
Drug-induced edema ? Certain drugs can induce edema by enhancing sodium reabsorption
Some patients have localized edema. This can be caused by a variety of conditions including venous obstruction, as occurs with deep vein thrombosis or venous stasis, acute left ventricular failure (which is a form of venous obstruction), and allergic reactions (such as laryngeal
edema).
Stephen.
Generalized edema or systemic edema may be caused by an allergic reaction or malnutrition by generally is a sign of a weakened heart. Decreased cardiac out-put has the secondary response of decreased renal perfusion which should not be underestimated and has a long laundry
Janelisa Ballweg 181
Localized causes of edema in a limb are usually due to obstruction of the venous or lymphatic drainage (varicose veins, postmastectomy, thrombophlebitis). The 3 most common causes of generalized edema are cardiac failure/CHF, liver failure/cirrhosis, and renal failure (nephrotic syndrome, acute glomerulonephritis). Other causes are PMS, severe hypothyroidism, and severe protein deficiency.
Howie martini p989
localized edema-can result from damage to capillary walls, as in bruising, constriction of regional venous circulation or blockage of lymphatic drainage
generalized edema- can result from a decrease in blood colloid osmotic pressure as in advanced starvation, when plasma protein concentrations decline.
11. Name the three most common organ failures that cause generalized edema.
Anonymous
Heart, Renal and Liver.
Anonymous Kraytman, 52
Congestive heart failure, increased venous pressure produces an elevated capillary hydrostatic pressure, promoting edema.
Decreased glomerular filtration rate. Impaired sodium excretion.
Hypoproteinemia causes a shift of plasma water into interstitial spaces.
Deb B Ballweg,pg.181
cardiac, liver, and renal failure
Greg R. Ballweg p. 181
he three most common causes of generalized edema are cardiac failure (e.g., CHF), liver failure (e.g., cirrhosis), and renal failure (e.g., nephrotic syndrome, acute glomerulonephritis).
Howie Kraytman, 52
Heart, Renal and Liver.
Congestive heart failure, increased venous pressure produces an elevated capillary hydrostatic pressure, promoting edema.
Decreased glomerular filtration rate. Impaired sodium excretion.
Hypoproteinemia causes a shift of plasma water into interstitial spaces.
12. List a number of specific questions you would ask in taking a history of present illness in someone with palpitations. Describe the frequent emotional component of this complaint versus its usual significance.
Anonymous Kraytman, 83-89
Duration
a. How long have you had palpitations?
b. How frequently do these episodes occur?
c. How long do they last?
Character
a. Do you feel: heart fluttering? Beating rapidly? Skipped beats? Flopping sensation? Isolated jumps? Pounding? Thudding? Slow beats
b. Are onset and cessation of the attacks: abrupt? Instantaneous? Gradual?
c. Is the rapid heart action: regular? Irregular? Chaotic? Repetitive and fleeting?
Aggravating Factors
a. Do you have palpitations: during or after strenuous physical activity? During mild exertions? With effort? Excitement? On standing? At rest? Lying? On feet? Nights? After meals?
Relieving Factors
a. Are your palpitations relieved or less marked by: lying down? Belching? Medications? Which ones?
Accompanying Symptoms
a. Are your palpitations accompanied or followed by syncope? Faintness? Anxiety? A lump in your throat? Blurring of vision? Buzzing in ears? Chest pain? Fever? Intolerance to heat?
Palpitation is a normal sensation when the force of the heartbeat and its rate are considerably elevated, as in strenuous physical effort or emotional stress. In anxious patients the threshold of consciousness of the heart’s beating may be so lowered that palpitation may occur with normal rhythm and rate.
Deb B./Ballweg,pg.181
Do palp. Occur as isolated “jumps” or “skips”?
Are they assoc. with exercise or excitement?
Do they occur upon standing?
(if middle aged woman) Do pallp. Occur in conjunction with flushes and sweats?
Do they begin abruptly?
Emotional comp.=people with life threatening arrhythmias have little or no sensation of heartbeat, and some people react strongly to any perceived palpitation
Greg R. Ballweg p. 181
Specific questions in HPI for someone with palpitations include:
Do the palpitations occur as isolated “jumps” or “skips” (extrasystoles/premature ventricular contractions)?
Are “attacks” of palpitation known to begin abruptly, with a very rapid heart rate (120/min. or greater), with either regular or irregular rhythm (paroxysmal arterial or ventricular tachycardia)?
Does the patient deny an association of palpitations with exercise or excitement (atrial fibrillation, atrial flutter, fever, anemia, thyrotoxicosis, anxiety state, hypoglycemia)?
Can the patient draw an association between the palpitations and use of drugs or stimulants (coffee, tea, tobacco, alcohol, epinephrine, ephedrine, aminophylline, atropine)?
Do the palpitations occur upon standing (postural hypotension)?
Is the patient a middle-aged woman and do her palpitations occur in conjunction with flushes and sweats (menopausal syndrome)?
Do palpitations occur when the heart rate is known to be normal and the rhythm is regular (anxiety state)?
Howie swartz pr 356,357
how long have you had palpitations?
recurrent attacks? if so how frequently do they occur?
onset,how long did it last? what did it feel like?
what maneuvers or positions stop it? did it stop quickly?
what brings them on? after strenuous exercise? on exertions? lying down
on left side?
after a meal? when tired?
any episodes of fainting while having palpitations? chest pain? flush?
headache?
sweating?
are yoy intolerant of heat or cold?
present meds for thyroid, lungs, ever diagnosed with thyroid disease?
daily comsumption of tea, coffe, chocolate cola?
do you smoke? if yes, what do you smoke? drink alcohol?
after palpitations do you have to urinate?
Pts. may describe palpitations as fluttering, skipped beats, pounding,
jumping, stopping,irregularity. Palpitations are common and do not
necessarily indicate serious heart disease.
13. List a number of specific questions you might ask of someone who states that they have a known heart murmur.
Anonymous Kraytman, 59-63
Mode of onset and evolution
a. How long have you known that you have a heart murmur? When was the murmur first heard?
b. How was it detected
c. How long have you known that you have a hear murmur without having any complaint?
Accompanying Symptoms
a. Do you have shortness of breath: sudden? At rest? On exertion? At night?
b. How long have you had shortness of breath on exertion?
c. Do you have: chest discomfort? Pain?
d. Do you feel tired?
Personal and social profile questions.
Deb B Ballweg,pg. 181
How long have you had your murmur?
Who told you about it?
Were any diagnostic tests ever done for the murmur?
Did you ever have rheumatic fever?
Has the murmur ever caused you any problems in life (DOE, being kept out of the military, etc.)?
Greg R Ballweg p. 181
Ask the following questions of the patient who knows that they have a murmur:
How long have you had your murmur? Who told you about it?
Were any diagnostic tests ever done for the murmur (e.g., echocardiogram, cardiac catheterization)? Was a name or diagnosis ever given to it? Did you ever have rheumatic fever?
Has the murmur ever caused you any problems in life (for example, DOE, inability to keep up with the other kids in youth, being kept out of athletics, deferment from military service)?
Do you take, or were you advised to take, prophylactic antibiotics (prevention against bacterial endocarditis), or were you advised to have surgery or follow-up tests?
Howie Kraytman, 59-63
Mode of onset and evolution
How long have you known that you have a heart murmur?
When was the murmur first heard?
How was it detected
How long have you known that you have a hear murmur without having any complaint?
Accompanying Symptoms
Do you have shortness of breath: sudden? At rest? On exertion? At night?
How long have you had shortness of breath on exertion?
Do you have: chest discomfort? Pain?
Do you feel tired?
Personal and social profile questions.
14. State how you would attempt to quantify the symptoms of someone who complained of claudication.
Anonymous Kraytman, 78,248,366,390
A good start is to ask about pain in the calves when walking. Occlusion of popliteal artery or higher. Or occlusion of common femoral artery iliac arteries. Be careful, Pseudoclaudication syndrome: spinal stenosis due to spondylosis or congenital narrowing.
Anonymous Ballweg, page 182
In most patients, a fairly fixed, reproducible walking distance brings on the pain. Beware of one trap: the patient who can walk any distance “at my own pace.” Be sure to cover all the cardiac risk factors, especially smoking.
Deb B./Ballweg,pg. 182
In most pts, a fairly fixed, reproducible walking distance brings on the pain. Beware of one trap---the pt who can walk ANY distance “at my own pace”.
Greg R. Ballweg p. 182
Try to quantitate the claudication. In most patients, a fairly fixed, reproducible walking distance brings on the pain. Watch out for a trap: the patient who can walk any distance “at my own pace.” Be sure to cover all the cardiac risk factors, especially smoking.
Norm
Does the pain come on with walking?
How much walking?
Does it go away with rest?
15. List a number of specific questions you would ask of someone who states that they have had high blood pressure before.
Anonymous Merck Manual pg. 652; 17th ed.
In patients with chronic bronchitis, increased intensity and intractability of a preexisting cough suggest a neoplasm.
Mode of Onset and Evolution
At what time was high blood pressure first observed?
- before age 35?
- between the ages of 35 and 55?
- after age 55?
How was your high blood pressure detected?
Is your pressure variable? or constantly elevated?
What was the highest level of your elevated blood pressure?
Has your blood pressure recently increased over previous high levels?
Precipitation or Aggravating Factors
What is your daily salt intake?
For female patients:
Are you pregnant?
Do you take contraceptive pills?
Has your weight recently increased?
Accompanying Symptoms
Do you have:
Headaches?
Severe headaches?
Vomiting?
Visual disturbances?
Transient weakness?
Lightheadedness? Vertigo? Tinnitus?
Syncope upon standing?
Episodes of weakness? Dizziness?
Shortness of breath?
Chest pain on exertion?
Etc., etc., etc.
Personal and Social Profile
Do you smoke?
What is your alcohol consumption?
What is your fat intake?
Do you exercise regularly? Do you engage in sports?
Are you under emotional stress at work? at home?
Personal Antecedents Pertaining to the Hypertension
Have your ever had a CXR, ECG, urinalysis, IV pyelogram, an eye examination? When? What were the results?
Have you ever been treated for your high blood pressure? Names of drugs? Dosage? Duration of therapy? Results and side effects?
Do you have any of the following conditions:
A heart disease?
A heart murmur?
A kidney disease?
Repeated urinary infections?
An episode of acute flank pain?
A previous stroke?
Transient ischemic attacks?
Diabetes?
Lipid abnormalities?
Family Medial History Pertaining to the Hypertension
Are there any members of your family who have:
Hypertension?
A myocardial infarction?
Cerebrovascular disease?
Diabetes?
Anonymous Kraytman, 79
1. Evolution
a. At what time was high blood pressure first observed? (age)
b. How was your hbp detected?
c. Is your blood pressure: variable or constant?
d. What was the highest level of BP record?
2. Aggravating Factors
a. What is your daily salt intake?
b. Female: are you pregnant
c. Do you take B/C pills
d. Has your weight recently increased?
3. Accompanying symptoms
a. Do you have: headaches? Syncope up standing? Episodes of weakness? Dizziness?
b. Do you have spells of HA? Sweating? Palpitations? Nervousness?
4. Personal and social profile questions
a. Do you smoke?
b. What is your alcohol consumption? What is your fat intake?
c. Do you exercise regularly? Do you engage in sports?
d. Are you under emotional stress at work? At home?
Anonymous Ballweg, page 182
To make sure a pt. is receiving adequate treatment, ask the following questions:
*Have you ever been told that your blood pressure was high? When? By whom?
*(If yes) Were any tests done? Was a diagnosis made? Were you ever given treatment, for instance, water pills, other blood pressure pills, or a salt-restricted diet?
*(If yes) Are you still taking your medications? (If yes) What are they? Are you having any problems with them?
*(If no) Was there a reason why you stopped taking them?
Deb B Ballweg,pg. 182
Were any tests done?
Was a diagnosis made?
Were you ever given tx, for example, pills?
Are you still taking your med?
Are you having any problems with your med?
Greg R. Ballweg p. 182
Have you ever been told that your blood pressure was high? When? By whom?
(If yes) Were there any tests done? Was a diagnosis made? Were you ever given treatment, for instance, water pills, other blood pressure pills, or a salt-restricted diet?
(If yes) Are you still taking your medications? (If yes) What are they? Are you having any problems with them?
(If no) Was there a reason why you stopped taking them?
Norm
When was it first noticed?
How was it detected?
What was the highest it was?
How much salt do you eat?
Do you take BCP’s?
Are you pregnant?
Has your weight increased lately?
Do you take meds?
Any problems with the meds?
16. Be able to obtain and communicate a pertinent, cardiovascular history given a patient with a complaint that could relate to the cardiovascular system.
EChing, Ruth B, P179-182
A patient with complaint related to the cardiovascular system, the following points must be covered when asking cardiovascular history:
1) Chest pain:
Onset, Duration, Description, Location, Radiation, Severity, Aggravating & Relieving factors, ROS & Associated symptoms, Medication & Treatment, PMH for this complaint, FH for this complaint, Effect on patient’s life.
2) Orthopnea
3) Paroxysmal Nocturnal Dyspnea (PND)
4) Palpitations
5) Murmurs
6) Cyanosis
7) Claudication
8) History of hypertension.
A T This in word for word from Ballweg in the Medical history Taking for PA’s chapter. I tried to leave room for noted.
1. Risk factors
2. Symptoms- chest pain, respiratory, GI, pleuritic.
Onset
Duration
Description
Location
Radiation
Severity
Aggravating symptoms
Relieving symptoms
Meds and treatment
PMH for problem
FH of problem
Effect on life
Orthopnea
PND
Edema- cardiac failure, liver failure, renal failure
Palpitations
Murmurs
Cyanosis
Claudication
Hx of HTN