Chest Pain and Heart Failure Overview
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Chest Pain and Heart Failure Overview

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Questions and Answers

What is not a characteristic of the complex deformity known as clubfoot?

  • Adduction of the forefoot
  • Varus of the knee (correct)
  • Equinus (foot in plantar flexion)
  • Cavus (a high arch)

    • Which of the following treatments is the recommended method for managing clubfoot?

  • Static splinting with a walker
  • Physical therapy alone
  • Ponseti method of serial casting (correct)
  • Surgical intervention immediately after birth

    • After casting for clubfoot, how long should patients wear a foot abduction orthosis full-time?

  • 6 months
  • 1 month
  • 1 year
  • 3 months (correct)

    • What is the most common cause of chest pain in primary care visits?

    <p>Costochondritis</p> Signup and view all the answers

    Which evaluation method is most appropriate for a patient suspected of having cardiac ischemia?

    <p>12-lead ECG</p> Signup and view all the answers

    Which condition is associated with elevated filling pressures in heart failure patients?

    <p>Bendopnea</p> Signup and view all the answers

    What is the primary challenge in assessing cardiac index/perfusion?

    <p>Lack of clinical findings</p> Signup and view all the answers

    What tool would you use to stratify the risk for coronary artery disease?

    <p>Marburg Heart Score</p> Signup and view all the answers

    Which of the following symptoms is often reproducible by palpation in chest wall pain?

    <p>Chest tenderness</p> Signup and view all the answers

    Which factor has been shown to complement but not improve outcomes in guiding therapy for heart failure?

    <p>Natriuretic peptides</p> Signup and view all the answers

    When screening infants for critical congenital heart disease, what is the ideal time for pulse oximetry screening?

    <p>24 hours after birth</p> Signup and view all the answers

    Which of the following represents a key finding in assessing pulmonary embolism risk?

    <p>Hepatojugular reflux (HJR)</p> Signup and view all the answers

    For what reason is routine ECG and chest x-ray not cost-effective for evaluating murmurs?

    <p>Insufficient clinical relevance</p> Signup and view all the answers

    What classification system is emerging to categorize congestion in heart failure?

    <p>Left-sided vs right-sided filling pressures</p> Signup and view all the answers

    Which heart murmur aspect is most common in children and generally indicates no underlying heart disease?

    <p>Systolic murmurs</p> Signup and view all the answers

    What is the main focus of a neurological examination?

    <p>Localizing lesions and guiding management</p> Signup and view all the answers

    Which condition is likely to result in decreased vocal fremitus due to poor conduction of low sound frequencies?

    <p>Pleural effusion</p> Signup and view all the answers

    In paradoxical breathing, how does the movement of the chest wall differ from normal breathing?

    <p>Chest wall moves inward with inhalation and outward with exhalation</p> Signup and view all the answers

    What is the primary cause of decreased vocal fremitus during conditions like bronchial asthma or emphysema?

    <p>Air trapping and decreased density of lung parenchyma</p> Signup and view all the answers

    What immediate action should be taken when accessory muscles are clearly being used during a breathing examination?

    <p>Stop and intervene before proceeding</p> Signup and view all the answers

    What is a significant risk factor for Slipped Capital Femoral Epiphysis (SCFE)?

    <p>Obesity during adolescence</p> Signup and view all the answers

    What is the primary imaging technique used for diagnosing Scoliosis?

    <p>X-ray</p> Signup and view all the answers

    Which physical exam tests are crucial for screening Developmental Dysplasia of the Hip (DDH) in infants?

    <p>Ortolani and Barlow tests</p> Signup and view all the answers

    At what degree of curvature is surgical fusion usually required for Scoliosis?

    <blockquote> <p>50°</p> </blockquote> Signup and view all the answers

    Which complication can arise from Slipped Capital Femoral Epiphysis (SCFE)?

    <p>Avascular necrosis</p> Signup and view all the answers

    What is the recommended action when SCFE is suspected?

    <p>Urgent referral to orthopedics or emergency department</p> Signup and view all the answers

    Which curve degree typically requires monitoring without treatment for Scoliosis?

    <p>10-25°</p> Signup and view all the answers

    What is the primary goal of treatment for Developmental Dysplasia of the Hip (DDH)?

    <p>Prevent further dislocation and allow normal development</p> Signup and view all the answers

    When should MRI be employed in the evaluation of Scoliosis?

    <p>For atypical curves or early-onset scoliosis</p> Signup and view all the answers

    What screening method is recommended for high-risk infants suspected of having DDH?

    <p>Ultrasound at 4-6 weeks</p> Signup and view all the answers

    What is the role of the PCP regarding echocardiograms and stress tests?

    <p>PCPs can order echo and stress tests as part of routine evaluations.</p> Signup and view all the answers

    Which of the following findings is consistent with increased tactile fremitus?

    <p>Lung consolidation</p> Signup and view all the answers

    Which abnormal finding may exhibit increased resonance on percussion?

    <p>Pneumothorax</p> Signup and view all the answers

    What is the significance of using chest pain algorithms in patient assessment?

    <p>They guide the urgency of referral to emergency care.</p> Signup and view all the answers

    Which element is crucial for evaluating cough in patients?

    <p>Moisture, frequency, regularity, pitch, and loudness</p> Signup and view all the answers

    What does increased percussion dullness typically indicate?

    <p>Pleural effusion or consolidation</p> Signup and view all the answers

    Which headache disorder is the most prevalent and affects 12% of the population?

    <p>Migraine</p> Signup and view all the answers

    What type of headache requires evaluation for possible urgent conditions like cerebrovascular events?

    <p>Secondary headache</p> Signup and view all the answers

    Which of the following preventive treatments is NOT commonly used for migraines?

    <p>Over-the-counter analgesics</p> Signup and view all the answers

    In the diagnostic approach to headaches, which method is recommended for high-risk cases?

    <p>Lumbar puncture</p> Signup and view all the answers

    What is a newer treatment option for acute migraine management?

    <p>Gepants</p> Signup and view all the answers

    Which validated tool is utilized to stratify the risk of coronary artery disease?

    <p>Marburg Heart Score</p> Signup and view all the answers

    Which of the following conditions is characterized by often reproducible pain upon palpation?

    <p>Costochondritis</p> Signup and view all the answers

    What is considered a diagnostic trial for Gastroesophageal reflux disease (GERD)?

    <p>Trial of proton pump inhibitor</p> Signup and view all the answers

    In heart failure evaluation, which finding indicates elevated filling pressures?

    <p>Jugular venous distention</p> Signup and view all the answers

    When evaluating low-intermediate risk patients for cardiac issues, which test might be considered?

    <p>Cardiac MRI</p> Signup and view all the answers

    Which symptom is associated with panic disorder and can be screened with validated questions?

    <p>Chest pain</p> Signup and view all the answers

    What method is used to assess the risk of pulmonary embolism?

    <p>Wells Criteria</p> Signup and view all the answers

    Which of the following conditions is likely to result in decreased vocal fremitus due to the presence of air in the pleural space?

    <p>Pneumothorax</p> Signup and view all the answers

    Which physical exam finding is most indicative of heart failure in patients?

    <p>S3 gallop</p> Signup and view all the answers

    Which of the following is a likely cause of decreased vocal fremitus in a patient?

    <p>Pleural effusion</p> Signup and view all the answers

    What finding on auscultation may indicate the presence of lung consolidation?

    <p>Increased breath sounds</p> Signup and view all the answers

    What additional symptom is consistent with congestive heart failure, particularly noted in the evening?

    <p>Swelling of the ankles</p> Signup and view all the answers

    What is a common cardiovascular finding associated with heart failure in a physical examination?

    <p>Hepatomegaly</p> Signup and view all the answers

    Study Notes

    Chest Pain

    • Approximately 1% of primary care visits are for chest pain.
    • Only 2-4% of these cases are due to unstable angina or acute myocardial infarction.
    • The most common causes of chest pain are chest wall pain, reflux esophagitis, and costochondritis.
    • Initial evaluation should focus on determining if immediate referral to the ER is needed.
    • The likelihood of coronary artery disease should be considered based on age, sex, and type of chest pain.
    • Validated tools like the Marburg Heart Score or INTERCHEST rule can be used to assess risk.
    • A 12-lead ECG is recommended for all patients with suspected cardiac ischemia.
    • Exercise stress testing, coronary CT angiography, or cardiac MRI may be considered for low-intermediate risk patients.

    Heart Failure

    • The clinical exam (history and physical) is crucial for managing heart failure.
    • The Stevenson classification categorizes patients based on volume status (wet/dry) and perfusion (warm/cold).
    • Key findings for assessing elevated filling pressures include jugular venous distention (JVD), hepatojugular reflux (HJR), orthopnea, square wave blood pressure response to Valsalva maneuver, and bendopnea.
    • Natriuretic peptides can complement the clinical exam but have not been shown to improve outcomes when used to guide therapy.

    Heart Murmurs in Children

    • Heart murmurs are prevalent in children, occurring in up to 80%.
    • Most murmurs are innocent, but some indicate underlying heart disease.
    • In infants, 37% of murmurs are associated with congenital heart disease.
    • Beyond infancy, only about 1% of murmurs are associated with structural heart disease.
    • Pulse oximetry should be used to screen all infants for critical congenital heart disease, ideally 24 hours after birth.

    Neurological Exam

    • The neurological exam focuses on localizing lesions, identifying signs of normal and abnormal neurological function, and guiding treatment and diagnosis.

    Clubfoot

    • Clubfoot is a complex deformity characterized by cavus, adduction of the forefoot, varus of the hindfoot, and equinus.
    • The incidence of clubfoot is around 1-2 per 1000 live births.
    • Treatment involves the Ponseti method of serial casting and possible Achilles tenotomy.
    • Recurrence is common and may require additional casting or surgery.

    Calcaneovalgus Foot

    • Characterized by excessive dorsiflexion of the foot.

    Vertical Talus

    • A rare foot deformity characterized by a rigid, rocker-bottom foot.

    Cavus Foot Anomaly (High-Arched Foot)

    • Presents with a high arch, plantar flexion, and limited dorsiflexion.

    Flatfeet

    • Characterized by a collapsed arch.

    Kyphosis

    • Kyphosis is an abnormal outward curvature of the spine, primarily in the thoracic region.

    Slipped Capital Femoral Epiphysis (SCFE)

    • SCFE is a disorder where the capital femoral epiphysis slips over the neck of the femur.
    • It typically occurs in adolescents, often obese.
    • Treatment involves urgent surgical fixation.

    Scoliosis

    • Scoliosis is a lateral curvature of the spine.
    • The most common type is adolescent idiopathic scoliosis.
    • Curves > 20-25° require referral to orthopedics.

    Limb Length Discrepancy

    • Limb length discrepancy occurs when one leg is longer than the other.

    Developmental Dysplasia of the Hip (DDH)

    • DDH is a spectrum of conditions affecting the hip joint, ranging from mild acetabular dysplasia to complete hip dislocation.
    • Risk factors include breech presentation and family history.
    • Abnormal physical exam or imaging requires referral to orthopedics.

    Low Back Pain

    • Mechanical Low Back Pain is pain caused by problems with the muscles, ligaments, bones, or discs of the spine.
    • General Risk Factors include poor posture, lack of exercise, smoking, and obesity.

    Red Flags in Clinical History

    • Age-Specific Concerns: Symptoms present in individuals under 20 or over 50 years old, suggesting underlying conditions.
    • Use of Anticoagulants: Indicates potentially serious conditions like spinal epidural abscess or vertebral compression fracture.
    • Constitutional Symptoms: Fever, unexplained weight loss, or night sweats are red flags.

    Key Physical Examination Findings

    • Neurological Evaluations: Abnormal reflexes, sensory deficits, or weakness are potential signs of serious conditions.
    • Genitourinary Symptoms such as urinary incontinence suggest possible cauda equina syndrome.

    Specific Conditions Associated with Red Flags

    • Spinal Epidural Abscess: Characterized by fever, back pain, and neurological deficits.
    • Cauda Equina Syndrome: Presents with severe back pain, saddle anesthesia, bowel and bladder dysfunction.
    • Vertebral Compression Fractures: May occur due to trauma, osteoporosis, or malignancy.
    • Malignancies and Metastatic Disease: Require careful evaluation and investigation.

    Musculoskeletal Exam

    • A detailed musculoskeletal exam is crucial for diagnosing conditions affecting the shoulder, spine, and upper extremities.
    • Accessory muscle use during respiration can indicate respiratory distress, requiring immediate intervention.
    • Diaphragmatic excursion evaluation assesses diaphragm function.

    Vocal Fremitus

    • Vocal fremitus is palpation of chest wall to detect changes in vibration intensity caused by spoken words.
    • Decreased vocal fremitus might indicate conditions affecting lung parenchyma, pleura, or chest wall (e.g., asthma, emphysema, pleural effusion).
    • Increased vocal fremitus suggests conditions with increased density (e.g., pneumonia).

    Cardiovascular Disease and Risk Management

    • Standards of Medical Care in Diabetes --- 2021
      • Purple Highlighted Area Recommendations
      • Screening Recommendations
      • Primary/Secondary Prevention

    Assessing and Managing Metabolic Syndrome in Children and Adults

    The 5 A's Framework for Obesity Management

    Lab Objectives, Week 6:

    • Pulmonary Function Tests (PFTs)
    • EKG - vital signs
    • Chest pain algorithm
    • Troponin - if suspecting acute coronary syndrome, send to ED and call EMS
    • PCP can order echocardiogram, stress test

    Lab Objectives, Week 7 Cardiovascular and Peripheral Vascular

    • Ankle-brachial index (ABI)
    • Doppler ultrasound of the legs
    • Carotid ultrasound
    • Cardiac catheterization
    • Coronary artery bypass graft (CABG)
    • Percutaneous coronary intervention (PCI)
    • Pacemaker implantation
    • Defibrillator implantation
    • Valve replacement

    EKG (Vital Sign)

    • Chest pain algorithm
    • If suspecting acute coronary syndrome, send to ED and call EMS
    • Primary Care Provider (PCP) can order echocardiogram and stress test

    Algorithm for Stable Chest Pain

    • History and physical exam to risk-stratify
    • Determine if immediate referral to ED for possible acute coronary syndrome (ACS) is needed
    • Perform 12-lead EKG on all patients with suspected cardiac ischemia

    Cardiac and Peripheral Vascular System

    • Palpate carotid, brachial, radial, femoral, popliteal, posterior tibial, dorsalis pedis pulses
    • Auscultate heart sounds for murmurs, gallops, rubs
    • Assess for jugular venous distention (JVD)
    • Check for peripheral edema

    Respiratory System

    • Inspect respiratory rate, rhythm, effort, and pattern of breathing
    • Auscultate lung sounds for wheezes, rales, rhonchi, and diminished breath sounds
    • Palpate for tactile fremitus
    • Percuss for resonance, hyperresonance, dullness

    Patterns of Respiration:

    • Eupnea: Normal breathing
    • Tachypnea: Rapid breathing
    • Bradypnea: Slow breathing
    • Hyperpnea: Abnormal breathing, often caused by metabolic acidosis. Deeper breaths may occur with or without increased respiratory rate.
    • Cheyne-Stokes: Cycle of increasing and decreasing breathing leads to temporary pause in breathing (apnea)
    • Paradoxical breathing: Chest wall moves inward with inhalation and outward with exhalation – opposite of normal breathing

    Common Respiratory Findings:

    • Wheezes: High-pitched whistling sound that occurs during expiration, particularly in asthma and bronchospasm.
    • Rales: Clicking or crackling sound that can occur during inspiration or expiration, often associated with fluid in the alveoli.
    • Rhonchi: Low-pitched, rumbling sound that occurs during expiration, often associated with mucus in the larger airways.
    • Diminished breath sounds: This can occur when air flow is obstructed or reduced in the lungs.

    Abnormal Respiratory Findings:

    • Bronchophony: A sound that is clearly heard and is louder than normal, often present in pneumonia.
    • Pectorililoquy: A whisper that is heard more clearly than normal, often in pneumonia.
    • Egophony: The sound of the letter E is heard as an A, often present in pneumonia or other lung consolidation.

    Cough

    • Describe according to moisture, frequency, regularity, pitch, and loudness, quality and circumstances.
    • Moist cough: Cough that brings up mucus (sputum).
    • Non-productive cough: Dry cough.
    • Hacking cough: Short, repetitive cough.
    • Barking cough: Loud, harsh cough

    Tactile Fremitus:

    • Increased with lung consolidation (pneumonia (PNA), mass, thick secretions), decreased or absent with hyperinflation (emphysema, asthma, pneumothorax, effusion).
    • Causes of Increased Tactile Fremitus: Pneumonia, lung abscess, inflammation, and consolidation.
    • Causes of Decreased Tactile Fremitus: Pleural effusion, pneumothorax, emphysema/COPD, bronchial obstruction, and bronchial asthma

    Percussion

    • Resonant: Normal percussion sound.
    • Hyperresonant: Indicates hyperinflation, such as emphysema, pneumothorax, or asthma.
    • Dull: Suggests lung consolidation (pneumonia, effusion), atelectasis, and also asthma.

    Acute Chest Pain Article

    • Prevalence and Causes:
      • About 1% of primary care visits are for chest pain
      • Only 2-4% of these cases are due to unstable angina or acute myocardial infarction
      • Most common causes: chest wall pain (20-50%), reflux esophagitis (10-20%), costochondritis (13%)
    • Initial Evaluation:
      • Focus on determining if immediate referral to ER is needed for possible acute coronary syndrome (ACS)
      • Consider age, sex, and type of chest pain to estimate likelihood of coronary artery disease
      • Use validated tools like Marburg Heart Score or INTERCHEST rule to stratify risk
      • Perform 12-lead EKG on all patients with suspected cardiac ischemia
    • Further Evaluation:
      • For low-intermediate risk patients: Consider exercise stress testing, coronary CT angiography, or cardiac MRI
      • Cost Considerations: Exercise stress test (171)vs.CTangiography(171) vs. CT angiography (171)vs.CTangiography(667) vs. cardiac MRI ($1,075)
    • Other Important Diagnoses to Consider:
      • Chest wall pain/costochondritis
      • Gastroesophageal reflux disease (GERD)
      • Panic disorder/anxiety
      • Pericarditis
      • Pneumonia
      • Heart failure
      • Pulmonary embolism
      • Acute thoracic aortic dissection
    • Key Points for Specific Conditions:
      • Chest wall pain: Often reproducible by palpation
      • GERD: Trial of proton pump inhibitor can be diagnostic
      • Panic disorder: Validated screening question available
      • Pulmonary embolism: Use Wells criteria or Pulmonary Embolism Rule-out Criteria (PERC)

    Heart Failure Article Summary

    • The clinical examination (history and physical) remains fundamental in managing heart failure patients to assess hemodynamic state.
    • Patients can be categorized based on volume status (wet/dry) and perfusion (warm/cold) using the Stevenson classification.
    • Key findings for assessing elevated filling pressures include:
      • Jugular venous distention (JVD) - image of JVD provided
      • Hepatojugular reflux (HJR)
      • Orthopnea
      • Square wave blood pressure response to Valsalva maneuver
      • Bendopnea (shortness of breath when bending forward)

    Primary Headache Disorders

    • Migraines, tension-type headaches (TTH), trigeminal autonomic cephalalgias (TACs), and other less common types.

    Secondary Headaches

    • Attributed to underlying medical conditions like vascular, infectious, or neoplastic causes.

    Primary Headaches:

    • Migraine is the most disabling and prevalent primary headache disorder, affecting 12% of people.
    • Migraine treatment: NSAIDs, triptans, gepants, and the newer 5-HT1F agonist lasmiditan.
    • Tension-type headache (TTH) affects 38% of the population.
    • Tension-type headache treatment: Simple analgesics like acetaminophen and NSAIDs.
    • Trigeminal autonomic cephalalgias (TACs), including cluster headaches, are rarer and present with unilateral pain and autonomic symptoms.

    Secondary Headaches:

    • Secondary headaches are due to underlying issues and must be evaluated for possible urgent conditions such as cerebrovascular events or infections.

    Headache Management

    • Acute treatment options include over-the-counter analgesics, triptans, and newer agents like gepants.
    • Preventive treatments for migraines include antihypertensives, antidepressants, antiepileptics, botulinum toxin, and monoclonal antibodies targeting the calcitonin gene--related peptide (CGRP).

    Headache Diagnostic Approach

    • Diagnosing headaches involves a thorough history and examination, focusing on distinguishing between primary and secondary causes.
    • Diagnostic imaging or lumbar puncture is recommended in certain high-risk cases.

    Emerging Headache Treatments

    • Neuromodulation devices and behavioral therapies are becoming increasingly recommended, particularly for patients with contraindications or who prefer nonpharmacological treatments.

    Accessory Muscle Use

    • Sternocleidomastoid muscles being used as accessory muscles during breathing.
    • If see these symptoms STOP & INTERVENE immediately before proceeding with rest of exam.

    Hyperpnea

    • Abnormal breathing, e.g., metabolic acidosis; deeper breaths - can occur with or without increased respiratory rate

    Cheyne-Stokes

    • Cycle of increasing and decreasing breathing leading to temporary pause in breathing (apnea)

    Paradoxical Breathing

    • Chest wall moves inward with inhalation and outward with exhalation – opposite of normal breathing.

    Diaphragmatic Excursion

    • Assess the movement of the diaphragm.

    Patient with Shortness of Breath Video

    • Scenario: Progressive shortness of breath (SOB) when walking reported by a 65-year-old Caucasian male, approximately 3 weeks ago.
    • Patient concerned about new onset of symptoms, states "I’m having difficulty breathing."
    • Patient reports needing to stop halfway up stairs to catch their breath. No palpitations, chest tightness, or syncope.
    • Reports no stents, but has a bit of dry, nonproductive cough during the night and day, started 3 weeks ago as well.
    • Has breathlessness at night while lying in bed, waking up (paroxysmal nocturnal dyspnea) needing to catch breath.
    • Putting 2 pillows under head to raise it helps slightly.
    • Fullness in abdomen 3 weeks ago.
    • Swollen ankles (as the day goes on) (new finding).

    Pertinent Positives from Patient History:

    • Breathlessness at night (paroxysmal nocturnal dyspnea)
    • Dry cough
    • Dyspnea on exertion
    • Peripheral edema

    Physical Exam Elements

    • Physical exam should include: General, Skin, HEENT, Respiratory, Cardiac, Peripheral vascular, GI
    • Heart Failure Symptoms:
      • S3 gallop
      • S3 heart sound
      • Jugular venous distention (JVD)
      • Hepatomegaly
      • Splenomegaly
      • Crackles (rales)
      • Wheezing
      • Peripheral edema
      • Positive hepatojugular reflex

    Vocal Fremitus Article Notes:

    • Tactile fremitus is palpation of chest wall to detect changes in the intensity of vibrations created with certain spoken words in a constant tone & voice indicating underlying lung pathology
    • Pathophysiology: Transmission of spoken tones depends on the state of the underlying lung parenchyma in the pleural space- Air is a poor conductor of low sound frequencies whereas a solid or dense medium increases transmission of low sound frequencies
    • Vocal fremitus may be decreased in conditions affecting lung parenchyma, pleura, or chest wall.

    Causes of Decreased Vocal Fremitus:

    • Bronchial asthma
    • Emphysema/COPD
    • Bronchial obstruction.
    • Air trapping and decreased density of lung parenchyma.
    • Pleural effusion and pneumothorax (air/fluid accumulates between the chest wall and lung parenchyma, decreasing transmission of lower frequency sound vibrations)
    • Obesity

    Causes of Increased Vocal Fremitus:

    • Pneumonia
    • Lung abscess
    • Inflammation and consolidation (create a dense medium)

    Percussion in Relation to Vocal Fremitus:

    • Dullness on percussion of the affected side.

    Auscultation in Relation to Vocal Fremitus:

    • Bronchial breathing sounds may be present.
    • Increased vocal resonance on the affected side may be associated with bronchophony and whispering pectoriloquy.

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    Description

    This quiz provides an overview of chest pain and heart failure management. It covers common causes of chest pain, evaluation strategies, and the importance of clinical exams in heart failure. Participants will learn about assessment tools and classification systems crucial for diagnosis and treatment.

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