Wednesday October The Cardiovascular System

							Wednesday, October 01, 1997:
The Cardiovascular System:
  Past/Family History:
      Cardiac surgery
      Acute rheumatic fever:
      Hypertension: 20% of the population. Kidneys, brain and eyes are primary systems involved.
      Bleeding disorders:
      Hyperlipidemia:
      Diabetes:
      Coronary artery disease:
      Congenital heart defect:

     Symptoms:
      Chest Pain          Fatigue
      Palpitations        Dependent Edema: at the lowest point (bilateral swelling of ankles in day)
      Dyspnea             Hemoptysis
      Syncope             Cyanosis

Get Handout From The Library:
CARDIAC DISABILITY:
       Gender (men are more at risk than women; women’s risk is increased in the post-menopausal
         years and with oral contraceptive use)
       Hyperlipidemia*
       Hypertension (treated or untreated)*
       Smoking*
       Family history of cardiovascular disease, diabetes, hyperlipidemia, hypertension, or sudden
         death in young adults
       Diabetes Mellitus
       Obesity; dietary habits and an excessively fatty diet
       Sedentary life-style without exercise
       Personality type

Watch Video About Heart Exam:

Wednesday, October 01, 1997:
Second Hour:
   Most common reason for going to ER for chest pain is esophageal spasm. Mimics heart problems.
   Myocardial disease is the second leading reason for going to the ER.
   Colisystitis is also confused with heart pain
   Most common cause is congenital defects (pulmonic valve is the most common)
   Cardiac problems may be seen in infants who develop cyanosis while crying.
   Knee chest position
   Get Shortness of Breath (SOB) while eating.
   Develop leg pain on activity and tire very easily and get tired with eating, failure to thrive, takes
     many naps. Headaches, nosebleeds, THESE COULD ALL BE INDICATIVE OF CARDIAC
     PROBLEM.

     Pregnant women
       Edema of face, hands, legs Is indicative that heart is having a hard time keeping up with the
          body
       Fainting and light headedness upon standing
       Severe or progressive dyspnea, (DNP)

     Elderly patients
       Problems with confusion, dizziness, palpitations, SOB, chest pain.
       Claudicatoin and orthostatic hypotension.


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     When there is chest pain we need to perform a thorough history but we also need to check other
      systems.

TABLE 2-3
Chest Pain:
  Systems Differential:
       Cardiac
       Pulmonary
       Musculoskeletal
       Gastrointestinal
       Skin/Neural
       Psychogenic: anxiety and depression

     Questions:
       Exact location
       Onset
       Constant/Recurrent
       Palliative/Provocative
       Episodes/Duration
       Quality
       Radiation

Levine’s Sign: Patient takes closed fist and puts it over sternum or to the left of the sternum because of
pain: THIS COULD BE A NATIONAL BOARDS EXAM QUESTION.

Watch Video on Chest Pain:

Thursday, October 02, 1997:
Exam I First Hour
Second Hour:
Still looking at table 2-3:
   Chest pain is considered hallmark of cardiac conditions.
   Temporary ischemia leads to a spasm and it is very painful. It feels like squeezing.
   Vasodilators are released when there is problem with the myocardium. This allows blood to get
        there and take care of the situation.
   Unstable Angina: Angina pain that occurs at rest. There is no pattern associated with this.
   Pericarditis: pt may sit up and lean forward “fowlers position” provides minimal relief.

Palpitations:
   Uncomfortable sensations in the chest associated with various arrhythmias
   Could be associated with fluttering, jumping, pounding, irregular, stopping and then pounding.
   It is important to find out how long

Questions:
  Onset
  Duration
  Recurrent: Number of episodes
  Familial tendencies, younger people notice palpitations and get them checked out more often.
  Quality: Fluttering, jumping, pounding, skipped beats, irregular
  Associated Factors: Exercise, chest pain, headache, sweating, dizziness, heat/cold intolerance,
               alcohol, caffeine, certain medications, smoking.




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Other conditions associated with palpitations:
  Thyroid problems:
         Notorious for causing palpitations b/c they increase protein synthesis & T3 and T4 influence
            message of messenger RNA. Thyroid hormone increase leads to increase in O2 consumption
            which has affect of Na pump mechanism that affects the heart. (will not ask this amount of
            detail
  Hypoglycemia
  Anemia
  Stress or anxiety
  Certain medications
  Wolff-Parkinson-White syndrome:
         Has never asked this question but has seen it on boards
         Associated with shortened PR interval. Leads to severe palpitations

TABLE 2-4:
  Left ventricular failure
  Mitral valve stenosis
  Aortic valve stenosis

Dyspnea:
Subjective symptoms of SOB
MISSED THE REST OF THE OVERHEAD.

Syncope:
   Fainting or transient loss of consciousness due to inadequate cerebral profusion

      Systems Differential
       Cardiac
       Pulmonary
       Psychogenic
       Metabolic disease
       Neurologic
       Medications

Questions:
  Patient may state they blacked-out, or fainted, felt dizzy – need to know exactly what they mean
  Did you actually lose consciousness?
  What were you doing just before you fainted?
  What position were you in?
  Any preceded symptoms or warning?
  Is this the first time or has it happened before? If so how often?

TABLE 2-17:
  Vasodepressor Syncope (the common faint)
  Postural (Orthostatic) Hypotension
  Cough Syncope: important thing is decreased venous return
  Micturation Syncope: could be in early stages of decompliance of peripheral vessels. Decreased
    return of blood to the heart
  Cardiovascular disorders
  Medications such as strong diuretics may change electrolyte balance and upset sodium potassium
    ATPase mechanism




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Fatigue:
   Common symptom of decreased cardiac output – non specific

        Systems Differential
         Cardiac
         Anxiety
         Depression
         Anemia
         Chronic illness
         Medications

M/C cardiac disease:
  CHF
  Mitral valve disease

Dependent Edema:
  Accumulation of excessive fluid in the interstitial spaces appears in lowest body parts

        Systems Differential
         Cardiac
         Kidney
         Liver

Questions:
  Onset
  Unilateral/Bilateral
  Timing
  Palliative/Provocative
  Shift depending upon the position. (ankles while standing, sacrum while lying down)

Associated Sx:
  Missed it

Cyanosis:
Location? Onset? Pall/Prov.?
Assoc. Sx.: SOB, cough, bleeding

Diff. Central Vs Peripheral Cyanosis
LOOK AT LAST NOTES

TABLE 2-5:
Cough/hemoptysis
  Left ventricle failure, pulmonary emboli, and other associated symptoms

We went through most of these conditions in the past, now we must look at them again with the
cardiac system in perspective.




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Wednesday, October 08, 1997:
Arrive to class at 8:50 am.

Pulse contour:
   Best evaluated at the corotid or brachial pulse
   N wave form is smooth and rounded
   Ascending limb – peak – descending limb

Amplitude:
  Increased or decreased
  Described on a scale of 0 – 4
     4 = bounding
     3 = full, increased
     2 = normal
     1 = diminished, barely palpable
     0 = absent, not palpable.


DeMusset’s Sign: associated with a large bounding pulse that has a very wide interval between pulsations.
The head may bob with the contraction of the heart. THIS IS GOING TO BE A TEST QUESTION.

TABLE from book on pulses
Bisferiens Pulse:
Pulsus alternans: see alternating pulse, can see with some heart blocking situations
Bigeminal Pulse: definitely associated with heart block
Paradoxical Pulse: Associated with COPD, constrictive pericarditis or pericardial tampanon or when the
right side of the heart is failing. THIS IS WHAT SHE WOULD LIKE US TO KNOW FOR HER
TEST AND OTHER TESTS ABOUT PARADOXICAL PULSE!

Condition of Vessels:
  Press proximal finger to occlude flow, roll artery over bone with distal finger
  Check radial artery for atherosclerotic plaquing
  If Normal – vessel wall not felt
  If Atherosclerosis - feels like cord

Blood Pressure:
Systolic pressure: stroke volume and the compliance of the blood vessels to accept the blood
Diastolic Pressure: peripheral resistance, drain peripheral filling.

Systolic – diastolic pressure = pulse pressure

Normal adult systolic: 100 – 140 mm Hg
             Diastolic: 60 – 90 mm Hg

Repeat in other arm. Normal difference is within 10 mm Hg > possible arterial obstruction on lower limb.

Viscosity of blood, volume of blood, compliance of vessels, peripheral resistance all correlate to blood
pressure.

Pulse contours: a lot of it depends on the stage, she will ask many conditions on each condition. She will
not ask us questions that depend on stages.




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TABLE in text (know these values and not the action notes values)
BLOOD PRESSURE CLASSIFICATION (Adults)
Category                          Systolic (mm Hg)                Diastolic (mm Hg)
Hypertension
   Very severe                         > 210                             > 120
   Severe                            180 – 209                         110 – 119
   Moderate                          160 – 179                         100 – 109
   Mild                              140 – 159                          90 – 99
High Normal                          130 – 139                          85 – 89
Normal                                < 130                               > 85

Second hour:

Pulse: Neck Evaluation
   Carotid artery pulse
   Jugular venous pressure (JVP)

Carotid Pulse
  Assessment of the contour and amplitude of pulse, waveform is described as; Normal, diminished,
      increased; speed of up slope, down slope, wave duration and peak.

Jugular venous pulse Reflects status of the Right heart, the level at which the pulse is visible gives
indication of Right atrial pressure. HMM VERY IMPORTANT.

Which vessel is best to evaluate JVP? The optimal vessel is the internal jugular vein (other tests)
Manello says the external is better.

THESE ARE THE TYPES OF THINGS WE COULD BE ASKED ABOUT JUGULAR VENOUS
PRESSURE
An incline level of 45o angle: Normal (JVP) = 2 cm
Normal range is 1-3 cm

Hepatojugular reflux: (THIS IS A VERY FAIR CONCEPT TO TEST ON written and skills)
  Test for venous congestion – firm pressure applied over liver for 20-30 seconds. Observe increase
     distention of venous blood in neck. Normal response < 1 cm inc. RHF > 1 cm.
  Patient should be supine breathing with mouth open.
  With RHF it goes greater than 1 cm and stays there.

Jugular venus pulses.
   A,C,V are the upstrokes
   X,Y are downstrokes
   A wave is the largest and first impulse that is noted. A result of brief back flow of blood into viena
      cava during right atrial contraction
   C wave is nothing more than wave transmitted impulse from the corotid artery. Associated with
      first heart sound.
   V wave associated with increasing volume and increased pressure in right atrium. Ass with right
      atrial filling during ventricular systole
   X wave: associated with atrial relaxation
   Y wave: atrial emptying with the tricusp id valve opening.




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Abnormal findings:
Absent a wave – atrial fibrillation
More prominent a wave – inc. JVP
  Tricuspid valve stenosis
  Pulmonic valve stenosis
  Pulmonary hypertension
  Reduced R ventricular compliance

Possible Test Question: Pt presents and demonstrates an increase with jugular venous pressure
                        These symptoms would not be associated with systemic hypertension.

TABLE in book comparing JUGULAR and COROTID pulses.
  Jugular has three positive waveforms on inspection
  Corotid only has one positive venous

CHEST WALL
  Shape of chest
  Apical impulse
  Pulsations
  Abnormal bulges

Apical Impulse: (PMI: point of maximal impulse)
  Considered point of maximal impulse
  Caused by contraction of L. ventricle at the 5th ICS (Inter Costal Space) in the mid-clavicular line.
  Absence could mean contractility of left ventricle is diminished.

Abnormal Bulges:
  Distention vessels: superior vena cava obstruction
  Tumors
  Aortic dilation with aortic regurgitation.

Abnormal pulsations:
  Epigastric: abnormal aortic enlargement
  Sternoclavicular: aortic arch aneurysms
  Right sternal border:
       Aneurysms of aorta
       Ascending portion
       Right ventricular enlarged
  Sternal notch: carotid artery transmitted.

Palpation:
   Confirm inspection findings
   Locate and define tender areas
   Location of apical impulse
   Palpable thrill and abnormal pulsations

TEST QUESTION If you are palpating in _____ space, what valve are you appreciating?
This is the same sequence as auscultation.

Sequence:
   Apical Impulse
     




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Missed class from October 9, 1997 to October 17,1997:

Wednesday, October 22, 1997:
15 minutes late to class:
Taking shitty notes today:

Diastolic murmur that can be obliterated by pressure on the jugular vein. (Look this statement up in book
Page 312 or something.) TEST QUESTION.

Lesions that can led to a mummer
Any valve that does not close completely leads to a continuous heart sound.
Will not ask lists on differences between murmurs and such.

Know general heart sounds

Systolic Murmurs:
Mitral valve regurgitation:
   Causes:
        One of the top three causes of valvular conditions in every condition except pulmonic valve
           stenosis.
        There is damage done to hypersensitivity to type I beta hemolytic strep.
        Mitral valve stenosis is heard best over the apex (mitral valve area)

Click Murmur syndrome

     Mitral valve prolapse is usually an incidental finding and is not limiting to a person. Usually
      considered a small problem with no therapy provided.
     You may want to encourage a lifestyle to reduce stress to the heart. Recommend exercise and diet.
     May be more prone to suffer from fatigue.
     Subgroup three is not a good thing. There are symptoms and signs of mitral valve prolapse present,
      including chest pain, palpatations, or transient Ischemic episodes.
     Grade 4 is significant mitral valve regurgitaiton. Antibiotics prophylaxis against infective
      endocarditis mandatory
     Pt should be under chiropractic care to boost immune system.

Know what mitral valve regurgitation is and the symptamatoligy associated with it.

Triscuspid Regurgitation
Retrograde bloood flow from the right ventricle into the right atrium.

Causes:
Pulmonayr hypertention – left ventricular failure is the most common cause.

Aortic valve stenosis
  Narrowing of the aortic outflow tract at the valvular, supravalvular or subvalvular levels obstruction
       blood flwo from the l. vent. Into the ascending aorta causeing inc pumpoing pressure
  Respiration will not affect this murmur.

Pulmonic Stenosis:
Causes: Congenital. Gets progressive in nature with aging.




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Diastolic murmurs
Aortic regurgitation murmur:
   DeMusset’s: patient nods head with every heart beat. Seen in late stages. By this time they have
       severe weakness.
   Austin-Flint murmur: low pitch rumbling murmur at apex. This is fairly common finding. This is
       due to increased turbulence coming from two directions going into the ventricle. KNOW THIS FOR
       BOARDS NOT FOR MANELLO’S EXAM.

Pulmonic valve regurgitation:
   Pulmonary valve not closing completely with retrograde blood flow into Right ventricle
   Hear it best at second left intercostal space or also appreciated at the third.

Mitral stenosis:
  Causes are rheumatic fever and cardiac infection.

Pulmonic Valve stenosis is most congenital in small infants and toddlers.
   Major signs and symptoms are failure to thrive.
   Assume positions to diminish pressure on the heart.

Second hour watch video to listen to heart sounds.
Listen to murmurs.

KNOW
  Reasons for performing an exam: symptamatology and risk factors
  Normal and abnormal finding associatged with insepection, palpation, percussion and ascultation
  What creates Heart sounds, what increases and decreases
  Know splits. Normal vs abnormal and where you hear them
  Physiological splits, when pahtological
  Ejection clicks are due to stenosis of the valve that is supposed to open but becaues of decreased
    compliance they do not open passively
  Opening snap diastolic is due to mitral or tricuspid
  S3, S4 sound associated with children or young adults (look up)
  Know how to listen to them in the left lateral position and supine and sitting positions and when to
    listen to each and in what position.
  S3 can also be pahtological. S3 is more pahtological than an S4 in the general population.
  S3 is usually due to ventricualr heart failure, CHF, and is a remanant of Myocardial Ischemia due to
    an MI.
  If S4 suddenly appears and pt is cyanoic it is probably due to an active MI. this is the only time S4
    has poor prognosis.
  Know which heart sounds are affected by respiration: Right heart sounds
  Murmurs may develop:
  Only ones in systaly is mitral or tricuspid or aortic or pulmonic stenotic murmur which is crescendo
    or decrescendo
  Diastolic murmurs are considered pathologic until proven otherwise.
  Hear a LUB DUB situation the first thing you want to know is which cycle it is in. determine by
    upstroke of corotid impulse. Now you want to know where you are listening. Should listen at left
    second intercostal space peristernally (pulmonic area). This heart sound in the middle is pulmonic
    regurgitation murmur. In general this murmur is all the way through diastole. Once this happens it
    is no longer termend an opeing snap It is either a tricuspid or mitral murmur
  S2 spilt over the pulmonic area. This is a physiologic split or a normal split. She drew what the
    diagram for sound would look like.

  Wednesday, October 29, 1997:
  Missed Both Hours Of Class.

  Thursday, October 29, 1997: Exam II


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