N750 Exam 2 wo MSK PDF

Describe normal anatomy and functions of the pulmonary system. - Normal anatomy: - Thorax (chest): structure of bone, cartilage and muscle capable of movement as lungs expand. It consists anteriorly of the sternum, manubrium, xiphoid process, and costal cartilages. - Primary muscles...

Describe normal anatomy and functions of the pulmonary system. - Normal anatomy: - Thorax (chest): structure of bone, cartilage and muscle capable of movement as lungs expand. It consists anteriorly of the sternum, manubrium, xiphoid process, and costal cartilages. - Primary muscles of respiration: diaphragm and intercostal muscles - Diaphragm: dominant muscle, contracts and moves downward during inspiration, lowering the abdominal contents to increase intrathoracic space - External intercostal muscles: Increase the AP chest diameter during inspiration - Internal intercostal muscles: Decrease the lateral diameter during forceful expiration - Accessory Muscles: sternocleidomastoid and trapezius - - Interior Chest: 3 components - - - Lungs: - - - - - Tracheobronchial tree: - - - Main bronchi: - - - Bronchial arteries: - - Bronchial vein - - Perform an age-appropriate history and physical examination for a patient with a respiratory concern. From Class Slides: Chest & Lungs HPI: COUGH - - - - - - HPI: SHORTNESS OF BREATH (SOB) - - - - - HPI: WHEEZING - **Onset: When did the wheezing start, and is it a new or chronic issue?**​ - **Pattern: Is the wheezing constant, or does it come and go? Is it worse during certain times of the day or with physical activity?**​ - **Triggers: Is the wheezing triggered by specific factors (e.g., exercise, allergens, cold air)?**​ - **Associated Symptoms: Any cough, shortness of breath, or chest tightness?** REVIEW OF SYSTEMS (ROS) ENVIRONMENTAL & EXPOSURE HISTORY - **Exposure: Have you been exposed to any dust, chemicals, or pollutants at work or home?**​ - **Travel: Have you traveled to areas where lung infections are common, such as TB or fungal infections?**​ - **Tobacco Use: Do you or anyone in your household smoke? How many years have you smoked or been exposed to secondhand smoke?** PHYSICAL EXAM FOR RESP CONCERN **Purpose:** To detect abnormalities such as fluid, air, consolidation, or masses.​ **Goal:** Systematic assessment helps in diagnosing respiratory conditions early and guiding appropriate interventions.​ **Key Steps:**​ Inspection, Palpation, Percussion, Auscultation - INSPECTION  - Breathing Patterns - Tachypnea - Bradypnea - Hyperpnea - Cheyne-Strokes - Air trapping - Paradoxical breathing Notes: AP Diameter: width of chest straight on and then on their side/lateral portion of chest; anterior should be 2x the lateral side ; AP usually 2:1; COPD will have barrel chest 1:1 ratio ​ Pectus excavatum: \"scooping out\" or hollowness of chest; \"bowl on chest wall\"​ Pectus carinatum: \"poking out\" have hump on the chest (pigeon chest)​ Respiratory distress: e.g. sternaclomastoid muscles being used accessory muscle use; if see these symptoms STOP & INTERVENE immediately before proceeding with rest of exam ​ ​Hyperpnea: abnormal e.g. metabolic acidosis; deeper breaths -- can occur w/ or wo inc. In RR​ Cheyne Strokes: cycle of increasing and decreasing breathing leading to temporary pause in breathing (apnea)​ Paradoxical breathing: chest wall moves inward w/ inhalation and outward w/ exhalation \[opposite of normal breathing\] - PALPATION: Assess thoracic expansion, tactile fremitus, abnormalities: tenderness, masses, crepitus - Compare vibratory sensation bilaterally; in normal conditions it will feel equal on both sides; if there's a difference, then concern for consolidation, disease, inflammation, etc. - PERCUSSION: Resonance is expected sound over air-filled lung tissue; percuss at intercostal spaces - Hyperresonance: suspect pneumothorax or emphysema - Dullness: suspect pleural effusion or consolidation from pneumonia (PNA) - AUSCULTATION - Use diaphragm of stethoscope - Listen systematically from apex to base of lungs \-- compare sides; ensure pt takes deep breath through an open mouth - Pay special attention to lung bases, where pulm pathologies often occur - Special Auscultation Techniques - Egophony - Steps: place stethoscope over intercostal space, pt say "E" then move to opposite side in lateral pattern comparing sides - Patient saying "E", examiner hears "A" - Any changes can indicate consolidation - Bronchophony - Same as egophony but ask patient to say "ninety-nine" - Whispered Pectoriloquy - Pt whispering comparing sounds laterally; consider consolidation where whisper is louder Diaphragmatic Excursion - Involves measuring the movement of diaphragm during respiration; normally moves 3-5 cm during deep breathing; this measurement is higher on R side dt liver's position beneath the diaphragm - Steps: Take deep breath in, percuss resonant area to fullness and mark, intercostal space as holding in, then breath all air out and hold breath, percuss resonant area from fullness to dull and mark there​; Difference should be between 3-5 cm Remainder of Slides was Case Studies 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 state of underlying lung parenchyma in pleural space; air is a poor conductor of low sound frequencies whereas a solid or dense medium inc. Transmission of low sound frequencies. Vocal fremitus may be DECREASED in conditions affecting lung parenchyma, pleura, or chest wall. ​ Example: [Bronchial asthma, emphysema/COPD, or bronchial obstruction dt air trapping & dec. Density of lung parenchyma] ​ \--Pleural effusion & pneumothorax: air fluid accumulates in space between chest wall & lung parenchyma -\> dec. Transmission of lower frequency sound vibrations ​ \--Obesity: dec. Vocal fremitus ​ \--[Inflammation and consolidation create dense medium -\> INCREASED Vocal fremitus] w/ inc. Transmission of lower frequency sounds ​ -Vocal resonance is auscultatory counterpart of vocal fremitus; example changes in resonance: ​ \--Bronchophony: LOUDER sound over area of CONSOLIDATION ​ \--Whispering Pectoriloquy: While auscultate over lung fields, ask pt to whisper \"one, two, three\" \-- whispered words are HEARD CLEARLY in presence of CONSOLIDATION ​ \--Egophony or an \"E to A\" change: qualitative change in voice resembles \"bleating of a goat.\" Sound frequencies pass through consolidation tend to distort sound of vowel: \"E\" perceived by examiner as \"A\" or \"AAAH\" ​ -Rhonchal fremitus: palpable rhonchi ​ -Pleural fremitus: palpable pleural rub ​ **Examination for Tactile Fremitus:** ​ -Ask pt to fold arms across the chest wall to displace scapulae -- ask to repeat \"ninety-nine\" or \"one, two, three\" in constant tone while practitioner palpates chest wall on both sides using ulnar border of hand or palmar base. Palpation begins w lung apex and moves to same location on opposite side of chest wall ​ -Compare vibrations on both sides while moving hands from apex to base of the lung ​ -Repeat maneuver on anterior and lateral chest walls ​ ***Pneumothorax*** ​ Inspection: Diminished chest movements on the affected side. ​ Palpation: Diminished chest movements on palpation. Decreased vocal fremitus on the affected side. ​ Percussion: [Tympanic note] on percussion of the affected side. ​ Auscultation: Diminished breath sounds and vocal resonance on the affected side. ​ ​***Pleural effusion*** ​ Inspection: [Fullness of intercostal spaces] and diminished chest movements on the affected side. The apical impulse may not be visualized. ​ Palpation: Diminished chest movements on palpation of the affected side. Decreased vocal fremitus on the affected side. Trachea may be shifted to the opposite. The apical impulse may not be palpable. ​ Percussion: [Stony dullness] on percussion of the affected side. ​ Auscultation: Diminished breath sounds and vocal resonance on the affected side. Egophony may be present on the upper border of the effusion. ​ ***Consolidation*** ​ Inspection: Diminished chest movements on the affected side. ​ Palpation: [Diminished chest movements] on palpation of the affected side. Increased vocal fremitus on the affected side. ​ Percussion: Dullness on percussion of the affected side. ​ Auscultation: [Bronchial breathing sounds may be present.] [Increased vocal resonance] on the affected side may be associated with [bronchophony and whispering pectoriloquy. ​] ​[**Causes of increased vocal fremitus**: pneumonia, lung abscess, inflammation & consolidation] ​ ​[**Causes of decreased vocal fremitus**: pleural effusion, pneumothorax, emphysema/COPD, bronchial obstruction, bronchial asthma] ​ **Patient w/ Shortness of Breath Video**​ ​Scenario: Progressive SOB when walking reported by 65 year old Caucasian man approx 3 wks ago. Pt concerned about new onset of s/s. \"Im having difficulty breathing\"​ - - Patient reporting needing to stop halfway with stairs to catch their breath, no palpitations, chest tightness, syncope; no stents, bit of dry nonprod cough during night and day started 3 weeks as well; breathless at night laying In bed -- wake up \[paroxysmal nocturnal dyspnea\] needing to catch breath, put 2 pillows under head to raise it helps slightly; fullness in abdomen 3 weeks ago; swollen ankles (as day goes on) (new finding)​ Pertinent Positives: breathlessness at night, dry cough, dyspnea on exertion, peripheral edema​ - - - - - - - Physical Exam should include: General, Skin, HEENT, Resp, Cardiac, Peripheral vasc, GI​ ​HF s/s: S3 gallop, S3, JVD, Hepatomegaly, splenomegaly, Crackles (rales), wheezing peripheral edema, positive hepatojugular reflex​ - **Describe essential components of a comprehensive respiratory exam.** - Physical Respiratory Examination Components (From textbook) 1. - Size and shape (anteroposterior diameter compared with the lateral diameter) - Symmetry - Color - Superficial venous patterns - Prominence of ribs 2. - Rate - Rhythm 3. 4. 5. - Thoracic expansion - Sensations such as crepitus, grating vibrations - Tactile fremitus 6. - Diaphragmatic excursion - Percussion tone intensity, pitch, duration, and quality 7. - Intensity, pitch, duration, and quality of breath sounds - Unexpected breathe sounds (crackles, rhonchi, wheezes, friction rubs) - Vocal resonance - - - - - - - - - - - - - - - - - - - - - - - - - - - - - identify the relationship of respiratory, CV, metabolic syndrome, and obesity with environment and health behaviors METABOLIC SYNDROME \-- Co-occurrence of metabolic risk factors for both T2DM & CVD: Abdominal obesity, hyperglycemia, dyslipidemia, and HTN DIABESITY: Diabetes & Obesity - Discuss recommendations for nutrition, physical activity, and daily health behaviors for primary prevention - Primary prevention - Blood pressure should be measured at every routine clinical visit. Patients found to have elevated blood pressure (140/ 90 mmHg) should have blood pressure confirmed using multiple readings, including measurements on a separate day, to diagnose hypertension - All hypertensive patients with diabetes should monitor their blood pressure at home - For patients with blood pressure \>120/80 mmHg, lifestyle intervention consists of weight loss when indicated, a Dietary Approaches to Stop Hypertension (DASH)-style eating pattern including reducing sodium and increasing potassium intake, moderation of alcohol intake, and increased physical activity - For patients with diabetes aged 40--75 years without atherosclerotic cardiovascular disease, use moderate-intensity statin therapy in addition to lifestyle therapy. - For patients with diabetes aged 20--39 years with additional atherosclerotic cardiovascular disease risk factors, it may be reasonable to initiate statin therapy in addition to lifestyle therapy - In patients with diabetes at higher risk, especially those with multiple atherosclerotic cardiovascular disease risk factors or aged 50--70 years, it is reasonable to use high-intensity statin therapy - In adults with diabetes and 10-year atherosclerotic cardiovascular disease risk of 20% or higher, it may be reasonable to add ezetimibe to maximally tolerated statin therapy to reduce LDL cholesterol levels by 50% or more. - Secondary prevention - For patients of all ages with diabetes and atherosclerotic cardiovascular disease, high intensity statin therapy should be added to lifestyle therapy. - For patients with diabetes and atherosclerotic cardiovascular disease considered very high risk using specific criteria, if LDL cholesterol is at or above 70 mg/dL on maximally tolerated statin dose, consider adding additional LDL-lowering therapy (such as ezetimibe or PCSK9 inhibitor). A Ezetimibe may be preferred due to lower cost. - For patients who do not tolerate the intended intensity, the maximally tolerated statin dose should be used - In adults with diabetes aged \>75 years already on statin therapy, it is reasonable to continue statin treatment - In adults with diabetes aged \>75 years, it may be reasonable to initiate statin therapy after discussion of potential benefits and risks. - Statin therapy is contraindicated in pregnancy - In asymptomatic patients, routine screening for coronary artery disease is not recommended as it does not improve outcomes as long as atherosclerotic cardiovascular disease risk factors are treated. - Consider investigations for coronary artery disease in the presence of any of the following: atypical cardiac symptoms (e.g., unexplained dyspnea, chest discomfort); signs or symptoms of associated vascular disease including carotid bruits, transient ischemic attack, stroke, claudication, or peripheral arterial disease; or electrocardiogram abnormalities (e.g., Q waves). - Children and adolescents who present with obesity and/or findings associated with MetS should receive extra attention toward reducing long-term risks for future chronic disease \--DASH Diet Eating Plan \--Physical Activity Recommendations 4-9mmHg SBP Reduction with Aerobic Physical Activity​ for 30 minutes Most Days of the Week​ - - - - Resistance training three days per week​ - Screen for age and risk-appropriate recommendations following the [[U.S. Preventive Services Task Force]](https://www.uspreventiveservicestaskforce.org/uspstf/) Guidelines \--Type 2 Diabetes (T2DM) Screening  ASCVD Risk Calculator: [[https://tools.acc.org/ASCVD-Risk-Estimator-Plus/\#!/calculate/estimate/]](https://tools.acc.org/ASCVD-Risk-Estimator-Plus/%23!/calculate/estimate/)​ - Low: \\>\> lifestyle changes alone, reassess risk every 4-6 years​ - Borderline 5 to \\>\>lifestyle changes; shared decision making for medication intervention; reassess risk every 4-6 years​ - Intermediate [\>]7.5% to \\>\> moderate intensity statin to decrease LDL by at least 30% + healthy lifestyle ,reassess risk more frequently​ - High: [\>]20%\>\>\> high intensity statin to decrease cholesterol by at least 50% + healthy lifestyle USPSTF Statin Use Recommendations  - Know the available Self Management Support tools for asthma, HTN, obesity, and DM. - Million Hearts  - Practice motivational interviewing and engaging patients to set SMART goals to promote healthy living and decrease preventable diseases.  - Person-Centered / Culturally Effective Care \-- Respectful communication & building trust - - - - - - - - - OARS - OPEN-ENDED QUESTIONS: client/family to express thoughts, experiences, values, barriers to change - AFFIRMATIONS of what the client/family says: affirm ability to change and how this is congruent with their values & goals - REFLECTIVE LISTENING: clarify & restate, help move towards behavioral change - SUMMARIES of the convo & decisions made: summarize goals set by client/family and reinforce plan for change w/ small, achievable goals SDOH w/ Screening   LAB ARTICLES \-- WEEK 6 [CARDIOVASCULAR DISEASE AND RISK MANAGEMENT: STANDARDS OF MEDICAL CARE IN DIABETES---2021 \[Purple Highlighted Area Recommendations, Screening Recommendations & Primary/Secondary Prevention\]] - - - - - - - - - - - - - - - - - - - - - - - - - - - - ASSESSING AND MANAGING THE METABOLIC SYNDROME IN CHILDREN AND ADULTS - - - - - - - - - - - - - - - The 5 *A*s framework for obesity management: Do we need a more intricate model?. *Canadian family physician Medecin de famille canadien* - - - Week 7  - Identify pertinent components of a history for common cardiac concerns through demonstrated knowledge of normal cardiac and vascular function and signs/symptoms of dysfunction HISTORY \[PPT\] - Change in s/s overtime - Last week v month v year (understanding how long s/s have been present, any changes) - Alterations in daily activities to accommodate symptoms - OLDCARTS - [Onset:] acute or gradual​ - [Location:] Site of pain​ - [Duration:]​ - [Characteristic:] sharp, dull, aching, radiating; positional; reproducible on palpation - [Aggravating:] worse with exertion, improves/ resolves with rest​ - [Associated symptoms:] numbness, tingling, weakness, nausea, vomiting, fever, neck pain; shortness of breath​ - [Alleviating:]​ Pharmacological: NTG,​ antacids​; Rest​ - [Radiating] - [Relieving ] - [Timing] - [Severity] - HPI - \*Shortness of breath/ dyspnea on exertion​ - orthopnea, paroxysmal nocturnal dyspnea​ - \*Chest pain/ discomfort​ - \*Fatigue​ - \*Lower Extremity edema​ - Cough: dry, timing?, persistent​ - Dizziness​ - Palpitations​ - Syncope​ - Weight gain​ - Nocturia​ - Surgical history:​ - Prior heart surgery​ - Family History​ - Congenital heart disease​ - CV Diseases​ - Early onset​ - Sudden death​ - Cardiomyopathy​ - Hyperlipidemia​ - Depression​ - Diabetes​ - Aneurysms​ - Social History \-- target: prevention & lifestyle changes - Tobacco use​ - Alcohol​ - Drugs​ - Stress​ - Diet- Nutrition​ - Lifestyle​ - Exercise​ - Environment​ - Employment​ - ROS - - - - - - - - - - - ### Discuss the assessment of a patient for risk factors of cardiovascular disease - Risk Factors for CVD - Preventable - Smoking \-- Tobacco 5 A's 1-800-QUIT-NOW - Ask, Assess, Advise, Assist, Arrange - Diet \-- malnutrition / Food insecurity - Physical inactivity / Sitting / Sedentary - High blood pressure (HTN, High BP) - Obesity - Stress? - Alcohol & Substance misuse - Non-preventable - Age - Socioeconomic status - Family Hx - Gender - Race  ASCVD RISK CALCULATOR PLUS LINK: [[https://tools.acc.org/ASCVD-Risk-Estimator-Plus/\#!/calculate/estimate/]](https://tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/estimate/) \\ HEART SCORE for Major Cardiac Events (Use in patients ≥21 years old presenting with symptoms suggestive of ACS. Do not use if new ST-segment elevation ≥1 mm or other new EKG changes, hypotension, life expectancy less than 1 year, or noncardiac medical/surgical/psychiatric illness determined by the provider to require admission.) [[https://www.mdcalc.com/calc/1752/heart-score-major-cardiac-events]](https://www.mdcalc.com/calc/1752/heart-score-major-cardiac-events) Risk Factors CVD \[PPT\] - Modifiable:​ - Tobacco Use​ - Sedentary lifestyle​ - Diet​ - Hyperlipidemia​ - HTN​ - Obesity​ - Stress​ - Diabetes​ - Depression​ - Non-modifiable:​ - Male gender​ - Increasing age​ - Family h/o CVD​ - Race​ - h/o COVID 19 infection​ - CHD Risk Equivalents​ - Peripheral arterial disease (PAD)​ - Abdominal aortic aneurysm (AAA)​ - Carotid artery stenosis (TIA , CVA, or \> 50%​ - Diabetes mellitus​ - **Risk Enhancers**​ - Family history of early ASCVD (men \ - ### Demonstrate knowledge of essential components of cardiac physical exam - Physical Examination Components: Heart (From textbook) The following steps are performed with the patient sitting, supine, and in the left lateral recumbent positions; these positions are all used to compare findings or enhance the assessment. Having the patient lean forward while in the seated position can bring the heart closer to the chest wall and accentuate findings. 1\. Inspect the precordium for: - Apical impulse - Pulsations - Heaves or lifts 2\. Palpate the precordium to detect: - Apical impulse - Thrills, heaves, or lifts 3\. Percuss to estimate the heart size (optional): 4\. Systematically auscultate in each of the five areas while the patient is breathing regularly and holding breath for: - Rate - Rhythm - S1 - S2 - Splitting - S3 and/or S4 - Extra heart sounds (snaps, clicks, friction rubs, or murmurs) 5\. Assess the characteristics of murmurs: - Timing and duration - Pitch - Intensity - Pattern - Quality - Location - Radiation - Variation with respiratory phase - **Discuss pertinent physical exam findings concerning for cardiac abnormalities** - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - **Common Chest Pain Presentations** (from PPT) -- -- -- -- -- -- [Cardiac Physical Exam from Slides \[PPT\]: ] - - E.g. displaced to left can be sign of enlarged ventricle - - - - - - - JVD = can be sign of fluid vol overload (e.g. RHF) - - - - - - - - - E.g. patient can have stable weight dt fluid overload but have loss of muscle mass - late sign of heart failure - Heart Failure Functional Status Assessment  - Helpful as repeatedly seeing patient in clinic​ - NYHA Class Heart failure functional status assessment ​ - Can be used for preserved ejection heart failure as well as those w/ low EF ​ Common presenting s/s of CV disease \[PPT\] - SOB / DOE - Angina equivalent/ CAD​ - AS/ HOCM due to decreased cardiac​ output​ - - - - - - - Edema / Peripheral Edema - HF​ - Venous insufficiency​ - Thrombophlebitis​ - Renal disease​ - Hepatic disease​ - Trauma​ - Tumor​ - Inflammation​ - Chest pain / discomfort - E.g. Pleuritic Chest pain (more specific to lung itself) - varies with respirations; worse with​ deep inspiration​ - - \*\*Example: "What do you mean by chest pain?" "Where it's coming from and when it is worse/better or with different positions; describing the pain - E.g. leaning forward relieving pressure on heart \-- sign of pericarditis; something always there may be MSK; infection thinking of fever/cough/etc. - Syncope - Non-cardiac: bleeding, dehydration, stress​ - - - - - - - - Fatigue - Palpitations: irregular/ fluttering, rapid/ racing heart rate; skipped beats; may be with stress or exertion​ - Ischemia, valvular disease, cardiomyopathy​ - Atrial ectopy: COPD, rheumatic heart disease, valve dysfunction​ - Ventricular ectopy: consider cardiac pathology​ - Associated symptoms​ [Changes w/ Aging] - Heart dec. in size - Atherosclerosis -\ HTN, CAD, valvular dysfunction - Widening pulse pressure - Dec. in pacemaker cells -\ arrhythmias - Effects of meds - ### Discuss the most common diagnostic tests used in the evaluation of chest pain in the primary care setting. AHA Guideline Recommendations (From week 7 articles) for Setting Considerations-\ - Unless a noncardiac cause is evident, an **ECG** should be performed for patients seen in the of fice setting with stable chest pain; if an ECG is unavailable the patient should be referred to the ED so one can be obtained - For patients with acute chest pain and suspected ACS initially evaluated in the office setting, delayed transfer to the ED for cTn or other diagnostic testing should be avoided - In all patients who present with acute chest pain regardless of the setting, an ECG should be acquired and reviewed for ST-segment elevation myocardial infarction (STEMI) within 10 minutes of arrival - In patients with chest pain in which an initial ECG is nondiagnostic, serial ECGs to detect potential ischemic changes should be performed, especially when clinical suspicion of ACS is high, symptoms are persistent, or the clinical condition deteriorates Presenting with Acute Chest pain: - Chest x-ray: useful to evaluate for other potential cardiac, pulmonary, and thoracic causes of symptoms - cTn I or T levels: useful to identify abnormal values and a rising or falling pattern indicative of acute myocardial injury - High-sensitivity cTn: Preferred biomarker because it enables more rapid detection or exclusion of myocardial injury and increases diagnostic accuracy 1. Electrocardiogram (ECG or EKG): - Often the first test performed - Detects heart rhythm abnormalities and signs of current or past heart attacks - Quick, non-invasive, and widely available 2. Blood tests: - Cardiac enzymes/biomarkers (e.g., troponin, CK-MB) - Detect heart muscle damage - Also include tests for anemia, infection, or other conditions 3. Chest X-ray: - Visualizes heart, lungs, and major blood vessels - Can identify pneumonia, lung masses, or aortic problems 4. Exercise stress test: - Evaluates heart function during physical exertion - Can reveal coronary artery disease not apparent at rest 5. Echocardiogram: can be used in primary care - Ultrasound imaging of the heart - Assesses heart structure and function - Detects changes in heart size: normal vs dilated - LV and RV wall thickness - - Ejection Fraction- left ventricle - Preserved 55-77% - Reduced= less than 50% - Right Ventricle - - - - - - - - 6. CT coronary angiography: - Non-invasive imaging of coronary arteries - Can detect blockages or narrowing 7. D-dimer test: - Blood test to help rule out pulmonary embolism → Stress Testing Key Principles: - Considered "gold standard" noninvasive test to induce ischemia and diagnosis ischemic heart disease - "Normal" stress test can't rule out the chance that a plaque will later rupture and block an artery. - Indications for stress test: - Diagnosis and Risk Stratify: Suspected CAD and Known CAD with change in status - Assess: location and degree of ischemia - Determine effectiveness: of current medical therapy and need for revascularization in patients with CAD   Differential Dx of Noncardiac Chest Pain - ### Identify life-threatening causes of chest pain and appropriate need for referral - Assessment of chest pain \[PPT\] - Benign conditions -\> life threatening - Assess life-threatening causes - Triage appropriately - Consider lower risk conditions - Risk stratification is KEY - HISTORY is everything - Physical Exam offers clues - EKG = vital sign - **LIFE-THREATENING CAUSES of Chest Pain** - Dissecting thoracic aneurysm​ - "Feels like they;re going to die" \-- splitting chest pain from front to back - Acute Myocardial Infarction​ (MI) - Get EKG but also triaging to ER - Pulmonary Embolism​ - Maybe hypotensive, tachycardia, low O2/hypoxemic, etc. - Pneumothorax​ - Can be spontaneous; lacing breath sounds on one side - Esophageal Rupture​ - Consider: GI illness, N/V - Heart failure​ (HF) - \*\*Ensure to educate patient when triaging to ER (CALL AN AMBULANCE / 911), financial concerns but reassure patient on importance that ER can perform interventions if anything happens on route to the hospital!  Major adverse cardiac events (MACE)​ 0-3 points - low risk (6%) of event​ 7-10 points - moderate risk (50%) of an event ​ ST elevations and depressions -- call 911 [Patient w/ Acute Chest Pain Diagram - Workup ] **Week 7 Articles** Acute chest pain in adults -  - - One systematic review found that the validated Marburg Heart Score is better than clinical judgment alone for predicting whether chest pain is cardiac in origin - presents the probability of CAD as the cause of chest pain for pretest probabilities of 2%, 10%, and 20% -  - can predict the presence or absence of CAD in patients who present with chest pain in the primary care setting - Patients with a score of less than 2 have only a 2% chance of having CAD, whereas 43% of patients with a score of 2 or more have CAD, making the test useful for ruling out CAD as a cause of the patient's chest pain - **[ACUTE CHEST PAIN ARTICLE ]** Here are the key points from this article on evaluating acute chest pain in adults in an outpatient setting: - Only 2-4% of patients presenting with chest pain in primary care will have unstable angina or acute myocardial infarction. More common causes include chest wall pain, reflux esophagitis, and costochondritis \[inflammation of cartilage that connects the ribs to sternum known as costosternal joint\]. - ACS is a clinical diagnosis that includes unstable angina, ST segment elevation myocardial infarction, and non--ST segment elevation myocardial infarction. - Initial evaluation should focus on determining if the patient needs immediate referral to the emergency department to rule out acute coronary syndrome (ACS). - Age, sex, and type of chest pain can help predict the likelihood of coronary artery disease (CAD). Clinical decision rules like the Marburg Heart Score and INTERCHEST rule can help estimate ACS risk. - 12-lead ECG should be performed on all patients with suspected cardiac ischemia. Patients with concerning ECG changes or suspicion of acute coronary syndrome should be immediately referred to the emergency department. - the role of previous chest pain in diagnosing ACS concluded that chest pain that is pleuritic, positional, or reproducible with palpation and not related to exertion is low risk for ACS. - Pain that is described as pressure (similar to that of prior myocardial infarction), worse than prior anginal pain, associated with exertion, accompanied by nausea or diaphoresis, and/or radiates to one or both arms/shoulders is higher risk for ACS - For low to intermediate risk patients not requiring immediate referral, options for further evaluation include exercise stress testing, coronary CT angiography, or cardiac MRI. - Cost is a barrier to the use of CCTA and cardiac magnetic resonance imaging. - Consideration should also be given to the harms of radiation and contrast exposure from CCTA - Other important diagnoses to consider include: - Chest wall pain/costochondritis - Gastroesophageal reflux disease (GERD) - Panic disorder/anxiety - Pericarditis - manifests as a clinical triad of pleuritic chest pain, a pericardial friction rub, and diffuse ECG ST--T-wave changes often preceded by a viral illness - should be considered in patients presenting with new-onset chest pain that increases with inspiration or when reclining and is lessened by leaning forward.36 ECG - usually demonstrates diffuse ST segment elevation and PR interval depression. - Pneumonia - fever, chills,productive cough, and pleuritic chest pain - Egophony (LR+ = 8.6) - dullness to percussion of the posterior thorax (LR+ = 4.3) - respiratory rate greater than 20 breaths per minute (LR+ = 3.5) - Heart failure - dyspnea on exertion, although some will present with chest pain - acute dyspnea and one or more of the MICE criteria (Male sex, history of myocardial Infarction, basal lung Crepitations, and ankle Edema) likely have heart failure and should be evaluated with echocardiography - Pulmonary embolism - presentation is highly variable, Although dyspnea, tachycardia, and/or chest pain are present in 97% - no single clinical feature effectively supports or rules out its diagnosis - PERC Score - Wells criteria - - Patients at moderate or higher risk should undergo additional testing with a d-dimer assay, ventilation-perfusion scan, or helical computed tomography of the pulmonary arteries - Pulmonary Embolism Rule-out Criteria were developed to specifically rule out PE in the primary care setting - meeting all eight criteria (50 years or younger, heart rate less than 100 beats per minute, oxygen saturation greater than 94%, no unilateral leg swelling, no hemoptysis, no surgery or trauma within four weeks, no previous deep venous thrombosis or PE, no oral hormone use) have a less than 1% likelihood of PE and thus do not need d-dimer testing or imaging - Acute thoracic aortic dissection - may present with chest or back pain and a pulse differential in the upper extremities modestly increases the likelihood of an acute thoracic aortic dissection (LR+ = 5.3).49 - Clinical suspicion for thoracic dissection warrants immediate referral to the emergency department **[HEART FAILURE ARTICLE ]** The role of the clinical exam in the patient with HF The article \"The Role of the Clinical Examination in Patients with Heart Failure\" discusses the continued importance of the clinical examination (history and physical exam) in managing heart failure (HF), despite advances in biomarkers and technology. It emphasizes that clinical examinations allow noninvasive assessments of a patient's hemodynamic status, particularly focusing on ventricular filling pressures and cardiac output. This information is crucial for prognosis and guiding treatment decisions. Key points include:  - Volume Status Assessment: Clinicians can assess volume status (e.g., jugular venous distention, hepatojugular reflux) to estimate filling pressures. Jugular venous pressure (JVP) is a critical indicator, with higher values correlating with worse outcomes. - Wet is estimated pulmonary capillary wedge pressure (PCWP) is at or above 22 mm Hg and anything lower is dry - Wet findings include jugular venous distention (JVD), hepatojugular reflux (HJR), orthopnea, bendopnea, and a square-wave response in blood pressure (BP) during the Valsalva maneuver - JVD is found to be the most useful H&P finding for assessing ventricular filling pressures - assessment of the JVP can be used to estimate right atrial pressure (RAP) and guide therapy - Hepatojuglar reflex - the presence of HJR indicates worse prognosis in patients with HF - HJR is an increase inJVP by \>3 cm sustained during 10 s of continuous pressure on the abdomen, with an abrupt fall after the pressure is released - Orthopnea, or dyspnea when supine, was associated with elevated PCWP in ESCAPE - Valsalva maneuver: patients with elevated left-sided filling pressure, a square-wave pattern of response is seen. - The BP rises with strain and remains stably elevated throughout the strain, returning to baseline only when the strain is released - Note that there is no decrease in BP during the strain despite decreased pulmonary venous return, as occurs in healthy individuals - Bendopnea: - symptom of dyspnea that is elucidated by bending forward at the waist - bendopnea was associated with elevated filling pressures and low cardiac index in patients with HF, it is not diagnostic of HF and may also occur in other disease processes - Perfusion Status: The clinical exam is less reliable for assessing low cardiac output, though signs like cool extremities and narrow pulse pressure may suggest inadequate perfusion. - Physical Exam Findings: Some common physical findings, such as rales (lung sounds) and peripheral edema, are not always reliable indicators of HF, particularly in advanced stages. - Hemodynamic Profiles: The Stevenson classification system categorizes patients into profiles based on their volume and perfusion status, helping guide treatment (e.g., diuretics, vasodilators, or inotropes). - - Stevenson profile can be used to guide therapy and guide decision-making as to whether vasodilators or inotropes should be added to intravenous diuretics in patients admitted with decompensated HF - Occasionally, a patient is admitted to the hospital with a presumed diagnosis of decompensated HF, yet the clinical examination suggests that the patient is compensated (profile A, warm and dry) - In such cases, alternative causes of the patient's symptoms need to be considered (e.g., in the appropriate setting, amiodarone lung toxicity or pneumonia). - if a patient is profile B, we administer diuretics, reasoning that there is no role for inotropic therapy when perfusion is adequate - In contrast, if the patient is profile C, we add either a vasodilator or inotrope to the diuretics - Emerging Classifications: A newer classification system is discussed that focuses on whether filling pressures are elevated on the right, left, or both sides of the heart. - with regard to the patient's hemodynamic state, the clinical examination is more accurate in the assessment of elevated ventricular filling pressures than in the detection of a low CI. The article concludes that clinical exams are valuable, especially for assessing elevated ventricular filling pressures, though determining cardiac output remains challenging. Integrating biomarkers like natriuretic peptides with clinical exams can improve the diagnosis and treatment of HF. Heart Murmurs in children the article \"Heart Murmurs in Children: Evaluation and Management\" from *American Family Physician* (March 2022) focuses on the commonality of heart murmurs in children, highlighting the high lifetime incidence, with up to 80% of children experiencing them. The majority of these murmurs are innocent and not associated with heart disease, but distinguishing between innocent and pathologic murmurs remains a challenge for clinicians. Pediatric cardiologist referrals are common because of this difficulty. - Murmur intensity increases with increasing cardiac output and decreases in the presence of pericardial effusions, decreased cardiac output, or increases in subcutaneous tissue (e.g., obesity). - Innocent murmurs are commonly referred to as flow murmurs, physiologic murmurs, or functional murmurs. - In contrast, pathologic murmurs are associated with congenital or acquired structural heart disease and often require medical or procedural interventions - In older children, the probability of a murmur being the first sign of congenital heart disease is low. - Any abnormalities in infant pulse should prompt a referral to cardiologist - cardiac auscultation in infants should be performed with the infant in the supine position in a location with minimal ambient noise and during periods of inactivity when pulse is lower - The most common innocent murmurs in infants are attributed to peripheral pulmonic stenosis or closure of a patent ductus arteriosus (PDA) - the murmur typically resolves after three to six months - For older children, palpation also includes noting the point of maximal impulse (PMI) on the anterior chest wall in the midclavicular line with note of any shift from this position. - shift in position suggests malpositioning of the heart (e.g., dextrocardia if palpable on the right side of the chest) or cardiac enlargement (if palpable towards the axilla) - Common innocent murmurs in childhood include Still's murmur, pulmonary flow murmurs, and venous hum - useful mnemonic for identifying [innocent murmurs is the seven S's]: soft, systolic, small area of involvement on precordium, short duration (typically early systolic or midsystolic sounds), single (without clicks or snaps), sweet (not harsh), and sensitive (to standing and respiratory variations). All infants should be screened for critical congenital heart disease using pulse oximetry, ideally 24 hours after birth. Key elements of evaluation include: - Thorough history and physical exam - Assessing murmur characteristics (timing, location, intensity, etc.) - Dynamic maneuvers to alter the murmur - Looking for other signs/symptoms of heart disease Referral to pediatric cardiology is indicated for: - Any murmur in a neonate that persists - Signs/symptoms of heart disease - Abnormal pulse oximetry screening - Syndromic features or family history of congenital heart disease - Characteristics concerning for a pathologic murmur Echocardiography is not routinely needed for evaluation of innocent-sounding murmurs without other concerns. Routine use of ECG, chest x-ray, etc. is not cost-effective for evaluating murmurs without other signs of heart disease. Emerging technologies like phonocardiography and AI algorithms may aid in murmur evaluation in the future. Key points include: - **Incidence**: Innocent murmurs are prevalent in 20-80% of children, but only about 1% of murmurs in children are linked to structural heart disease requiring intervention. - **Evaluation**: For infants with murmurs, a thorough review of obstetric and family history is essential. All infants should be screened for critical congenital heart disease using pulse oximetry. In older children, findings such as diastolic murmurs, loud or radiating murmurs, and signs of cardiac disease warrant specialist referrals. - **Diagnostic Methods**: Routine use of tests like electrocardiography and chest radiography is discouraged due to their low cost-effectiveness and potential for misclassification. Instead, referral to a pediatric cardiologist is emphasized for suspected pathologic murmurs. - **Technological Advances**: Emerging technologies, such as phonocardiography and artificial intelligence, show promise in helping differentiate between innocent and pathologic murmurs. Overall, the article underscores the importance of clinical history, physical examination, and judicious use of technology in managing heart murmurs in children.   \*\*\*implications of pathological murmurs in children (table 6 in article has more information related to exam)