Macleod’s Cardiology Chapter Study Guide.pdf

Learning Objectives: 1. Recognize physical signs of hyperlipidemia and infective endocarditis on the face and hands. 2. Identify common problems in BP measurement and how to respond to them. 3. Identify what Korotkoff sounds represent, the hemodynami...

Learning Objectives: 1. Recognize physical signs of hyperlipidemia and infective endocarditis on the face and hands. 2. Identify common problems in BP measurement and how to respond to them. 3. Identify what Korotkoff sounds represent, the hemodynamic effects of respiration, and physiological and pathological causes of increased pulse volume 4. Identify the optimal sites for cardiac auscultation of each cardiac valve. 5. Identify and describe normal heart sounds as well as abnormalities of S1 and S2 and causes for S3 and S4. 6. Describe murmurs by grading the intensity, common radiation patterns, and causes. 7. Distinguish the common presenting symptoms of peripheral arterial disease and how it is described by patients. 8. Recognize important history questions to ask, physical exam signs to evaluate, and special tests suggesting vascular disease. 9. Know the indications for imaging in peripheral arterial disease. 10. Identify the risk factors for deep venous thrombosis and the signs and symptoms of post-thrombotic syndrome. 11. List the common presenting symptoms of lower limb venous disease. 12. Distinguish the clinical features of and treatment for venous and arterial ulceration. Use Chapter 4 of Macleod’s Clinical Examination, 15th Edition to complete the study guide below. 1. Recognize physical signs of hyperlipidemia and infective endocarditis on the face and hands. A. Identify the peripheral signs that may be present in infective endocarditis on the face and hands o Janeway lesions on the hypothenar eminence o Splinter hemorrhages on nails o Osler’s nodes, typically on the pads of the fingers o Roth’s spot on fundoscopy o Petechial hemorrhages on the conjunctiva B. Identify the physical signs of hyperlipidemia on the face and hands o Xanthelasma o Tendon xanthetoma o Corneal arcus 2. Identify common problems in BP measurement and how to respond to them.  · Different BP in each arm (>10 mmHg): this suggests aortic or subclavian disease. Record the highest pressure and use this to guide management. · Wrong cuff size: The bladder of the cuff should measure 80% of the length and 40% of the width of the upper arm circumference. In obese patients a standard cuff will overestimate the BP so use a large adult or thigh cuff · Auscultatory gap: up to 20% of elderly hypertensive patients have Korotkoff sounds that appear at systolic pressure and disappear for an interval between systolic and diastolic pressure. If the first appearance of the sound is missed, the systolic pressure will be recorded at a falsely low level. Avoid this by palpating the systolic pressure first. · Patient’s arm at the wrong level: The patient’s elbow should be level with the heart. · Postural change: Check the BP after a patient has been standing for 2 minutes o A drop >20 mmHg on standing is postural hypotension · Atrial fibrillation: Reduce cuff pressure slowly and repeat the measurement more than once to allow an acceptable average value. 3. Identify what Korotkoff sounds represent, the hemodynamic effects of respiration, and physiological and pathological causes of increased pulse volume. A. Know the hemodynamic effects of respiration Inspiration Expiration Pulse/heart rate Accelerates Slows Systolic blood pressure Falls (up to 10 mmHg) Rises Jugular venous pressure Falls Rises Second heart sound Splits Fuses B. Know physiological and pathological causes of increased pulse volume o Physiological – exercise, pregnancy, advanced age, increased environmental stimuli o Pathological – hypertension, fever, thyrotoxicosis, anemia, thyrotoxicosis or aortic regurgitation, Paget’s disease of the bone, peripheral atrioventricular shunt C. Know what Korotkoff sounds represent o The sounds produced when the cuff pressure is between systolic and diastolic 5. Identify and describe normal heart sounds as well as abnormalities of S1 and S2 and causes for S3 and S4. A. Identify and describe the heart sounds you should routinely listen for on cardiac auscultation: · First and second heart sounds (S1 and S2) o S1 is caused by closure of the mitral and tricuspid valves and is best heard at the apex o S2 is caused by closure of the pulmonic and aortic valves and is best heard at the left sternal edge § physiological splitting of S2 occurs because the aortic valve closes before the pulmonary valve and increases on inspiration · Extra heart sounds (S3 and S4) o S3 is a low-pitched early diastolic sound best heard with the bell at the apex. o S3 is a normal physiologic finding in children, young adults, febrile patients, and during pregnancy. But it is usually pathologic after age 40. o S4 is soft and low-pitched, best heard with the bell at the apex. · Additional sounds such as clicks and snaps o Opening snap – mitral stenosis – best heard with the diaphragm at the apex o Ejection clicks – high-pitched sounds best heard with the diaphragm – due to congenital pulmonary or aortic stenosis o Mid-systolic clicks – high-pitched and best heard at the apex with the diaphragm – occur in mitral valve prolapse often associated with a late systolic murmur  o Mechanical heart valves have loud closure sounds: high-pitched, with a metallic quality, palpable, may be heard without a stethoscope o Pericardial rub is a course scratching sound, often with systolic and diastolic components – best heard using the diaphragm with the patient holding their breath in expiration. It is highly specific for pericarditis. · Murmurs in systole and/or diastole (timing, duration, character, pitch, intensity, location, and radiation) C. Know abnormalities of the second heart sound. · Wide splitting of S2 with normal respiratory variation occurs in conditions when ventricular emptying is delayed (i.e., right bundle block or pulmonary hypertension) · Wide fixed splitting of S2 with no respiratory variation is usually due to an atrial septal defect. · Reversed splitting of S2 occurs when the left ventricular emptying is delayed (i.e., left bundle branch block and severe aortic stenosis). · Quiet or absent aortic component of S2 can occur with calcific aortic stenosis. · A loud pulmonary component of S2 is a sign of pulmonary hypertension. D. Know common causes for S3. · left ventricular failure · Mitral regurgitation · Heart failure with S3 and tachycardia (gallop) E. Know causes for S4. · Forceful atrial contraction against a non-compliant or stiff ventricle  · left ventricular hypertrophy · Cannot occur during atrial fibrillation. B. Know common radiation patterns for murmurs. · Mitral regurgitation radiates to the left anterior axillary line (axilla) below the third intercostal space · Ventricular septal defect murmurs radiate to the right sternal edge · Aortic stenosis murmurs radiate to the suprasternal notch and the carotid arteries C. Know the causes of systolic, diastolic, and continuous murmurs. Murmur Cause Ejection systolic Increased flow through normal valves murmurs Severe anemia, fever, athletes (bradycardia large stroke volume), pregnancy Atrial septal defect (pulmonary flow murmur) Other causes of flow murmurs (increased stroke volume in aortic regurgitation) Normal or reduced flow through a stenotic valve Aortic flow murmur from inc LV stroke volume: aortic regurgitation Pulmonary flow murmur from inc RV stroke volume: ASD; pulm regurgitation Subvalvular obstruction Hypertrophic obstructive cardiomyopathy Pansystolic murmurs mitral regurgitation tricuspid regurgitation Ventricular septal defect Leaking mitral or tricuspid prosthesis late systolic murmurs MVP Early diastolic murmurs Aortic regurgitation Pulmonary regurgitation (uncommon)  Mid-diastolic murmurs Mitral stenosis Tricuspid stenosis (rare) Austin Flint murmur (regurgitant jet striking the anterior leaflet of the mitral valve and accompanies aortic regurgitation) Continuous murmurs Patent ductus arteriosus D. Describe innocent murmurs. · Occur when stroke volume is increased, as in pregnant women, athletes with resting bradycardia or patients with fever or amnesia 7. Distinguish the common presenting symptoms of peripheral arterial disease and how it is described by patients. A. Know common presenting symptoms of peripheral arterial disease in the legs, abdomen, and digits. o Leg pain: asymptomatic ischemia, intermittent claudication, night pain, rest pain, tissue loss (ulceration and/or gangrene), tissue loss in the diabetic patient, Acute limb ischemia, and compartment syndrome o Abdominal pain: mesenteric ischemia, abdominal aortic aneurysm o Digital ischemia: blue toes, vasospastic symptoms B. Know the most common presenting symptom of PAD and how it is described by patients. o Intermittent claudication is the most common presenting symptom of PAD and patients describe tightness or “cramp like” pain that develops after a relatively constant distance that resolves completely within a few minutes of rest. C. Know the symptoms of Leriche’s syndrome and what it indicates. o buttock claudication and erectile dysfunction indicates bilateral common iliac or internal iliac artery occlusion D. Know the clinical features of arterial, neurogenic, and venous claudication. Arterial Neurogenic Venous Pathology stenosis or occlusion of Lumbar nerve root or Obstruction to the major lower limb arteries cauda equina venous outflow of the compression (spinal leg due to iliofemoral stenosis) venous occlusion Site of Pain Muscles, usually the calf Ill-defined, whole leg, Whole leg, “bursting” in but may involve thigh and may be associated with nature buttocks numbness and tingling Laterality Unilateral or bilateral Often bilateral Nearly always unilateral Onset Gradual after walking the Often immediate on Gradual, from the “claudication distance” walking or standing up moment walking starts  Relieving features On stopping walking, the Bending forwards and Leg elevation pain disappears stopping walking, completely in 1-2 minutes patient may sit down for full relief Color Normal or pale Normal Cyanosed, often visible varicose veins Temperature Normal or cool Normal Normal or increased Edema Absent Absent always present Pulses Reduced or absent Normal Present but may be difficult to feel owing to edema Straight-leg raising Normal May be limited Normal E. Know the signs of acute limb ischemia. o Pallor o Pulselessness o Perishing cold o Parasthesias o Pain o Paralysis F. Describe the difference between the claudication distance and the total walking distance. o Claudication distance – how far patients say they can walk before the pain comes on o Total walking distance – how far patients can walk before the pain is so bad that they have to stop walking 8. Recognize important history questions to ask, physical exam signs to evaluate, and special tests suggesting vascular disease. A. Know important past medical history, family history and social history questions to ask for patients with peripheral arterial disease. o Past medical history - history of peripheral vascular disease? Atherosclerosis? Coronary artery disease? Cerebrovascular disease? Hypertension? Hypercholesterolemia? Diabetes? o Family history of premature coronary or other vascular disease? Abdominal aortic aneurysms? o Social history – smoking history? Occupation? Activities of daily living? How do symptoms impact quality of life or ­employment?  C. Know special tests for peripheral arterial disease and how to interpret the results. o Buerger’s test – positive test if reactive hyperemia on dependency is present o Ankle:brachial pressure index § ABPI >1.0 = healthy § ABPI