[05.01c] Review on the History and PE of the CVS V2.pdf

75%

What percentage of the diagnosis comes from the history?

History

What step in the diagnosis process confirms the clinician's suspicions?

Adequate history and physical examination

What two components are essential for diagnosis?

Multiple differential diagnoses

What can a comprehensive history alone lead to?

Pediatric patient

What type of patient should prompt consideration of congenital heart disease?

Female, around 20 years old, with suspected valvular pathologies

What patient profile should prompt consideration of rheumatic heart disease?

60 years old and above, with audible murmur

What patient profile should prompt consideration of atherosclerosis or age-related heart disease?

Rheumatic heart disease

What cardiovascular condition should be considered in a 26-year-old female patient within reproductive age?

Dyspnea

What was the Chief Complaint in Case #1?

Cardiac, pulmonary, or nephrologic

Dyspnea without descriptors may be of what three origins?

Difficulty in breathing on exertion

What is Exertional Dyspnea?

Chest pain on effort, relieved by rest

What is the typical presentation of angina?

Non-anginal problems or severe chest pain that progressed from chest pain on exertion

What two things can chest pain at rest connote?

Bipedal edema, enlarging abdomen, exertional dyspnea, orthopnea, easy fatigability

What were the five main symptoms listed in the HPI 1 year prior to consult in Case #1?

Warfarin, empagliflozin, digoxin, carvedilol, spironolactone

What five medications was the patient in Case #1 given?

Productive cough, fever, dyspnea

What three symptoms occurred 4 days prior to consult in Case #1?

The evolution of the disease process

What should the History of Present Illness show?

Gradual

What was the evolution of the disease in Case #1?

Exertional dyspnea and easy fatigability

What two symptoms indicated Left-sided Heart Failure (LHF) in the suggested sequence for Case #1?

Orthopnea

What symptom followed exertional dyspnea and easy fatigability in the suggested sequence for Case #1?

Enlarging abdomen and bipedal edema

What two symptoms indicated Right-sided Heart Failure (RHF) in the suggested sequence for Case #1?

RHF

What condition is bipedal edema usually seen in?

LHF

What condition is RHF usually preceded and caused by?

Waking up with shortness of breath 2 hours after lying down

How do patients with Paroxysmal Nocturnal Dyspnea (PND) usually wake up?

The earlier the patient wakes up after lying down

What indicates more severe PND?

Having to use multiple pillows when sleeping

What patient behavior implies PND?

Orthopnea

Between PND and orthopnea, which is considered a more severe symptom of combined LHF and RHF?

A pulmonary condition and not heart failure

If a patient experiences orthopnea without PND, what might be the cause?

Emphysema

PND is usually not present in patients with what pulmonary condition?

Constrictive pericarditis

If the sequence of symptom onset is RHF leading to LHF (bipedal edema and enlarging abdomen first, then orthopnea and PND later), what condition may be the case?

Acute

Cardiac tamponade is ruled out in Case #1 because it has a more onset?

LHF leading to eventual RHF

Given the lack of specified symptom onset in the example HPI, what sequence should be considered first?

LHF

What is the most common cause of RHF?

Cor pulmonale and primary pulmonary hypertension

What two conditions are examples of primary RHF?

Engorged neck veins, right ventricle dilation, enlarged abdomen, hepatosplenomegaly

What four symptoms are associated with primary RHF?

Diagnosed with an unrecalled cardiac disease

What was the key entry in the Past Medical History (PMH) for Case #1?

When they were diagnosed

What information should be asked regarding an unrecalled cardiac disease to infer whether it was acquired or congenital?

Pediatric cases

In what type of patients is asking about congenital diseases especially important?

Hypertension and Cardiac illness

What two conditions were listed in the Family History of Case #1?

Who specifically in the family has such conditions

Besides the condition itself, what detail should the Family History indicate?

Premature coronary artery disease (CAD) or death

What is a significant risk factor related to the age family members acquired a condition?

Male <55 years old or female <65 years old

What defines premature CAD?

During menstruating years until about 15 years after menopause

During what period are women naturally protected from CAD?

Non-smoker, Non-alcoholic beverage drinker, Unemployed

What three details were listed in the Personal History for Case #1?

(Number of packs) x (number of years)

What is the traditional way of counting smoking history?

10 pack years

If a patient smokes 10 sticks a day (1/2 pack) for 20 years, what is their pack-years history?

Those not covered in the history of present illness

What are Review of Systems?

Sore throat

What positive finding was reported in the Review of Systems (ROS) for Head and Neck in Case #1?

History of exposure or recurrent upper respiratory tract infection

What history is relevant when considering Rheumatic Fever?

Streptococcal infection

History of exposure or recurrent upper respiratory tract infection implies the presence of what kind of infection?

Lesions, Fever and cough before admission, Lymphadenopathy

What three specific findings related to Streptococcal infection are associated with Rheumatic Fever?

Mitral Stenosis (MS)

What condition leads to the left atrium being enlarged?

The left recurrent laryngeal nerve (RLN)

What nerve is impinged upon when the left atrium is enlarged in MS?

The left bronchus

What structure is the roof of the left atrium, around which the left RLN loops?

Hoarseness of voice

What symptom manifests due to the left vocal cord being paralyzed or paretic from RLN palsy?

Ortner’s syndrome

What is the term for hoarseness of voice from RLN palsy due to underlying cardiac disease, such as MS?

Hemoptysis or pulmonary edema (pinkish and frothy sputum)

Increased pulmonary vascular congestion in MS manifests as what?

Osler Nodes

What type of lesion in Infective Endocarditis is painful?

Janeway Lesions

What type of lesion in Infective Endocarditis is non-tender and located on the palm and soles?

Start with family history

If a patient comes for a general checkup without a chief complaint, what is suggested as a starting point?

Lifestyle of the patient

What information is very important to probe in the personal and social history?

2 sticks/week or 3 sticks/day

If a patient smokes occasionally, what kind of specific detail should be input into the history?

False

Is the HPI should focus primarily on documenting past medical history rather than the current disease process?

False

Does Physical Examination comprise 75% of the diagnosis?

False

Do patients with mitral stenosis not have hemoptysis manifestations due to vascular compensation of the lungs?

Landmarks

What aspect is "really important to remember" in the Physical Examination?

Sternocleidomastoid muscle (SCM)

What is a key landmark when getting the JVP?

External jugular vein (EJV)

Which jugular vein is the most visible?

Internal jugular vein (IJV)

Which jugular vein is concerned with JVP measurement?

Inferior to the SCM

Where is the IJV located relative to the SCM?

Only the JVP will disappear

When palpating, how is JVP distinguished from the carotid pulse upon compression?

Inspect the anterior chest wall

What is the target area for inspection regarding heaves or thrills?

The ball of the hand

What tool is used to palpate for heaves or lifts?

Fingertips or the base of the fingers

What tool is used to palpate for thrills?

5^th ICS, left MCL

Where is the Point of Maximal Impulse (PMI) located?

Lateral and downward displacement of the apex

What characteristic indicates LV Heave/LV enlargement?

Lateral and upward displacement of the apex

What characteristic indicates RV Heave/RV enlargement?

Right, 2^nd ICS at the parasternal border

Where is the Aortic Valve area located?

Left, 2^nd ICS at the parasternal border

Where is the Pulmonic Valve area located?

Left, 4^th ICS at the parasternal border

Where is the Tricuspid Valve area located?

Left, 5^th ICS at the midclavicular line

Where is the Mitral Valve/Apex area located?

LVH

What condition may cause the Mitral Valve area to go further laterally to the 6^th ICS?

Diaphragm

What part of the standard stethoscope catches high-pitch sounds like S1 and S2?

Bell

What part of the standard stethoscope catches low-pitch sounds like S3 and S4?

If pressure is applied against the chest wall

When does a floating diaphragm stethoscope function as a diaphragm?

If the chest piece barely touches the skin

When does a floating diaphragm stethoscope function as a bell?

Phonocardiograph

What is the simulation of heart sounds or vibrations recorded by a 1st Generation Digital Stethoscope called?

Record a long-lead ECG

What specialized feature does the 2nd Generation Digital Stethoscope have?

Faces the side opposite to you

How should the patient be positioned when examining JVP and carotid arterial pulse?

EJV

What vein crosses the IJV and is the most visible?

Parallel and under the SCM

Where does the IJV run?

a (atrial filling) and v (atrial venous filling)

Which two JVP waves are usually seen in practice?

Before ventricular contraction

When does the a-wave of the JVP occur?

Simultaneously feel the upstroke of the carotid pulse or use a stethoscope to auscultate for S1

How is the a-wave identified in relation to other events?

Systole

What time period corresponds to the carotid upstroke and S1?

45^\circ

At what minimum angle should the patient be positioned to start observing JVP?

Compress on the lower part of the neck

What maneuver can be done to confirm the presence of JVP if it is not visible?

Right side of the heart

What part of the heart's pressure does the Jugular pulse reflect?

180^\circ

At what angle is the jugular pulse hardest to see due to gravity?

Tricuspid regurgitation and third degree heart blocks

What two conditions are listed where a "very deceased patient" might exhibit visible JVP abnormalities?