Western+Diagnosis+-+Cardiovascular

Atherosclerosis Hypertension Coronary Artery Disease Myocardial Infarction (MI) Heart Failure Cor Pulmonale Cardiomyopathy Arrhythmias Valvular Disease Endocarditis Aortic Aneurism Peripheral AS Disease> Buerger's Disease Raynaud's Disease and Phenomenon Venous Thrombosis Varicose Veins Orthostatic Hypotension

Anemia Blood Loss Edema Hypercholesterolemia Pericarditis Poor Circulation Rheumatic Heart Disease Tachycardia/Bradycardia

surface projections
1. R border - 1 cm lateral to R sternal margin, 3rd to 6th costal cartilage2. inferior border - xiphisternal jct to L midclavicular line, 5th ICS3. L border - midclavicular line 5th ICS to 1 cm lateral to L sternal border at 2nd ICS

cardiac circulation, chambers, valves
1. IVC & SVC to R atrium2. tricuspid valve3. R ventricle4. pulmonic valve5. pulmonary trunk to pulmonary arteries to lung6. pulmonary veins to L atrium7. mitral valve8. L ventricle9. aortic valve10. aorta

cardiac cycle
1. systole2. rise in ventricular pressure followed by ventricular contraction3. aortic and pulmonic valves open, mitral and tricuspid (AV) valves close4. blood ejected5. diastole6. ventricle relaxes and pressure decreases7. aortic and pulmonic valves close, mitral and tricuspid valves open8. atrial pressure exceeds ventricular and blood flows into ventricles9. ventricle contracts, pressure exceeds atrial pressure, mitral and tricuspid valves close10. valve closure causes S 1: R sided events slightly after L but mitral and tricuspid closure at roughly same time11. ventricular pressure continues to rise, exceeding aortic and pulmonic pressure12. aortic and pulmonic valves open13. as ventricular pressure falls below aortic and pulmonic pressure, aortic and pulmonic valves close14. valve closure causes S 2: sometimes N splitting of S 2 due to increased blood flow into R side during inspiration and R ventricular ejection is prolonged15. atrial pressure now greater than ventricular again and AV valves open

reflection of heart sounds
1. aortic - R 2nd ICS close to sternum2. pulmonic - L 2nd ICS close to sternum3. tricuspid - L 5th ICS close to sternum4. mitral - L 5th ICS midclavicular line

muscular contraction stimulated and coordinated by electrical conduction system
1. normal impulse initiated by sinus node in R atriuma. cardiac pacemakerb. 60-100 impulses/minute2. through both atria via internodal fibers to AV node in lower atrial septum3. slight delay then into transitional fibers and down AV (Bundle of His): now Purkinje fibers instead of internodal fibers4. L and R bundle branches to ventricular myocardium

History
A. family: MI, high BP, ASB. tobacco, alcohol, rec drug useC. physical activityD. stressE. inc BPF. Ht disease: rheumatic fever, Ht murmursG. chest pain--OPQRST--pressure, squeezing--clenched fist in center of sternum--worse with exertion, better with rest--radiation commonly to L jaw, neck, shoulder, armH. chest pressure, tightness, heaviness--dyspnea--orthopnea--paroxysmal nocturnal dyspnea--dry cough--leg edemaI. palpitations: perception of Ht actionK. rapid or irregular Ht beatL. lightheadedness, fainting, weakness, fatigueM. circulation--cold hands or feet--leg cramps--phlebitis--varicose veinsN. past EKG

vital signs
1. BPa. 120/80b. CO - systolec. peripheral resistance - diastoled. elastic recoil of aorta and large arteriese. blood volumef. blood viscosity2. HR: 60 – 1003. RR: 12 – 204. T

peripheral pulses
1. rate, symmetry, bruits2. radial, carotid, femoral, popliteal, posterior tibial, dorsalis pedis

jugular venous pressure
1. competency and compliance of R Ht 2. pt. at 45 O 3. see venous column - waves - in internal jugular vein; behind SCMa. N just below clavicles4. briefly elevated by pressure of hand on abdomena. hepatojugular reflux5. should return to N in a few seconds even with continued pressure on abdomen6. if not - cardiomyopathy, Ht failure, R vent problem

inspection
1. pt should lie for remainder of examination2. tangential lighting to detect pulsations

palpation
<span style="display: block; font-family: Times New Roman,serif; text-align: left;">1. orderlya. aortic, pulmonic, tricuspid (R vent), mitral(L vent), epigastric2. thrillsa. loud murmursb. vibrations - use ball of hand3. pulsationsa. pads of fingersb. apical - PMIi. 5th ICS midclavicular linec. epigastrici. aortic width

<span style="display: block; font-family: Times New Roman,serif; text-align: left;">auscultation
<span style="font-family: Times New Roman,serif;">1. possibly the most demanding skill2. lungs first - congestion, rubs3. orderly: aortic, pulmonic, tricuspid, mitral4. 1st sound - S 1: intensity, pitch, duration, timing, splitting5. 2nd sound - S 2: --as above<span style="font-family: Times New Roman,serif;">--breathe through nose--inspiratory splitting6. systole: --extra sounds--timing, intensity, pitch--murmurs7. diastole--extra sounds --<span style="font-family: Times New Roman,serif;">murmurs8. for all murmurs, listen for the following characteristics--duration--timing: early, mid, late--location: interspace; cm from midline--radiation--intensity: grades 1-6--pitch: high, medium, low--quality: blowing, rumbling, harsh, musical9. use diaphragm then bell

<span style="display: block; font-family: Times New Roman,serif; text-align: left;">Laboratory
<span style="display: block; font-family: Times New Roman,serif; text-align: left;">A. lipids--triglycerides[<150]--TC [<200] - ratio of 3.5 or lower is considered by some acceptable, others allow for slightly higher discrepency--cholesterol: HDL [<40], LDL [>160-130], apolipoproteins [A1, B]--homocysteine [Sam-E can elevate levels, caution with use in high homocysteine levels]--CRP: inflammatory marker, very importantB. cardiac enzymes--Creatine kinase, LDH--troponin: elevated with an MI C. specialized testing depending on presumptive diagnosis

<span style="display: block; font-family: Times New Roman,serif; text-align: left;">radiology
<span style="display: block; font-family: Times New Roman,serif; text-align: left;">1. PA, lateral2. size, shape, lung vasculature

<span style="display: block; font-family: Times New Roman,serif; text-align: left;">echocardiography
<span style="display: block; font-family: Times New Roman,serif; text-align: left;">1. ultrasound2. valvular disease3. cardiac chambers4. congenital Ht disease5. coronary artery disease6. cardiomyopathy7. cardiac masses8. pericardial effusion9. aortic disease

<span style="display: block; font-family: Times New Roman,serif; text-align: left;">ultra-fast CT scan
<span style="display: block; font-family: Times New Roman,serif; text-align: left;">1. coronary vessels

<span style="display: block; font-family: Times New Roman,serif; text-align: left;">MRI
<span style="display: block; font-family: Times New Roman,serif; text-align: left;">1. vessels2. masses3. other structures with contrast agents, ECG

<span style="display: block; font-family: Times New Roman,serif; text-align: left;">electrocardiogram
<span style="font-family: Times New Roman,serif;">1. record of Ht electrical activity2. no exam of a cardiac pt is complete without a chest x-ray and an ECG3. standard 12 lead4. exercise ECG (stress test, treadmill test): --stress echocardiogram --<span style="font-family: Times New Roman,serif;">radionuclide imaging: technetium (thallium) scan5. Rapid Interp of EKG’s by Dubin

<span style="display: block; font-family: Times New Roman,serif; text-align: left;">angiocardiography
<span style="display: block; font-family: Times New Roman,serif; text-align: left;">1. visualization of chambers, vessels by x-ray after injection of contrast material

<span style="display: block; font-family: Times New Roman,serif; text-align: left;">venography
<span style="display: block; font-family: Times New Roman,serif; text-align: left;">1. as above

<span style="display: block; font-family: Times New Roman,serif; text-align: left;">cardiac catheterization
<span style="display: block; font-family: Times New Roman,serif; text-align: left;">1. diagnosis and therapy

<span style="display: block; font-family: Times New Roman,serif; text-align: left;">cannulation
<span style="display: block; font-family: Times New Roman,serif; text-align: left;">1. arterial and venous2. monitoring, measurements

<span style="display: block; font-family: Times New Roman,serif; text-align: left;">doppler ultrasonography
<span style="display: block; font-family: Times New Roman,serif; text-align: left;">1. blood flow

<span style="display: block; font-family: Times New Roman,serif; text-align: left;">plethysmography
<span style="display: block; font-family: Times New Roman,serif; text-align: left;">1. peripheral venous blood flow

<span style="display: block; font-family: Times New Roman,serif; text-align: left;">chest pain
<span style="display: block; font-family: Times New Roman,serif; text-align: left;">1. severe with SOB - immediate ER referral2. complex: any acute chest pain needs primary evaluation

<span style="display: block; font-family: Times New Roman,serif; text-align: left;">aneurysm
<span style="display: block; font-family: Times New Roman,serif; text-align: left;">1. dilation of a blood vessel, esp aorta or peripheral a.2. pain3. specific testing - physical, imaging4. immediate ER referral if suspected5. danger is from rupture

<span style="display: block; font-family: Times New Roman,serif; text-align: left;">myocardial infarction (MI)
<span style="display: block; font-family: Times New Roman,serif; text-align: left;">1. ischemic myocardial necrosis from sudden reduction in coronary blood flow2. deep, substernal pain3. restless, anxious, pale4. thready pulse5. die of ventricular fib before reaching hospital6. EKG, cardiac enzymes7. call 911--need rapid dx and tx--50% of deaths from MI occur within 3-4 hours of onset of clinical syndrome

<span style="display: block; font-family: Times New Roman,serif; text-align: left;">deep vein thrombosis (DVT)
<span style="display: block; font-family: Times New Roman,serif; text-align: left;">1. not emergency but needs evaluation and monitoring as soon as possible2. possible pulmonary embolism