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Approach To The Cardiac Patient

Approach To The Cardiac Patient. Howard Sacher, D.O. Long Island Cardiology and Internal Medicine. Signs and Symptoms. Most Common are non-specific Dyspnea Chest Pain Palpations Presyncope/ Syncope Fatigue. Dyspnea. More often than not is a results of either:

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Approach To The Cardiac Patient

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  1. Approach To The Cardiac Patient Howard Sacher, D.O. Long Island Cardiology and Internal Medicine

  2. Signs and Symptoms • Most Common are non-specific • Dyspnea • Chest Pain • Palpations • Presyncope/ Syncope • Fatigue

  3. Dyspnea More often than not is a results of either: • Elevated left atrial pressure • LV dysfunction • valvular obstruction • Elevated pulmonic venous pressures • Pulmonary Edema secondary to acute LA HTN • Hypoxemia • Pulmonary Edema • Intracardiac shunting

  4. Paroxysmal Nocturnal Dyspnea • Most specific for cardiac disease • Occurs acutely with 30min to 2hrs of going to bed • Relieved by sitting or standing up

  5. Chest Pain • Most commonly associated with anginia • Not always associated with AMI • Patients usually c/o not of pain but rather • Pressure • Tightness • Squeezing • Gassy/ bloated feeling

  6. Ischemic Chest Pain • Usually subsides within 30min (depends) • Precipitated by • Cold • Exertion • Post prandial • Stress

  7. Usually pain > 30min is indicative of an AMI • Usually associated with • Anxiety and uneasiness • SSCP that may radiate

  8. Other causes of cardiac pain • Ventricular hypertrophy • Valvular disease • Myocarditis • Endocarditis • Pericarditis • Cardiomyopathies • Ao Dissection

  9. Palpitation • The awareness of a heart beat • Usually normal • Pathologies include: • Cardiac abnormalities that increase SV • Regurgitant diseases • Bradycardia • Ventricular or Atrial Premature beats • SVT • VT

  10. These pathologies can cause a significant decline in CO leading to impaired cerebral blood flow causing • Dizziness • Blurring of vision • syncope

  11. Most commonly a result of Sinus node arrest Exit block AV block VT V-fib Other significant causes: Ao valve disease IHSS Hyperstimulation of the Vagus Cardiogenic Syncope

  12. Edema • Right heart failure most commonly presents with dependant edema • Also • Pericardial diseases • Tricuspid and Pulmonic Valve diseases • Cor Pulmonale Must look for a nutmeg liver as well

  13. 4 Functional Classification of Heart Disease • Class I • No limitation of phyical activity • Ordinary activity does not induce symptomology

  14. Class II • Slight limitation on physical activity in which the patient becomes symptomatic • Class III • Marked limitation on physical activity, comfortable only at rest. With ordinary activities the patient becomes symptomatic • Class IV • Pt is symptomatic at rest and is unable to engage in any limited activities without discomfort and pain

  15. Look at your patient: • Appearance: • Diaphoretic? – Think hypotensive, tamponade, tachyarrhythmias, or an MI • Cachectic? – Think CHF, low cardiac output states • Cyanotic? – Ask is it central or peripheral? • Central – arterial desaturation states • Peripheral – impaired tissue delivery • Vital Signs: • HR • BP – bilaterally as well as sitting and standing • RR • Temp

  16. Pulses • Peripheral • Central • Carotid for delayed upstroke and/ or bisferiens • Pulsus Paradoxus – decrease in blood pressure > 10 mmHg with inspiration • Pulsus Alternans – amplitude of the the pulse alternates with each beat during NSR, most commonly seen with Pericardial effussions • Jugular venous pulsations – evaluating right atrial pressure • Cannon A waves – 3rd degree heart block

  17. Pulmonary Exam • Rales – CHF • Wheezing – COPD (COLD) • Rhonchi – COPD (COLD) • Pleural effusion on CXR – CHF most commonly • Precordial Pulsations • Parasternal lift – RVH, LAH, PHTN • Displaced or Exaggerated PMI - LVH

  18. Heart Sounds • S1 – First heart sound – closing of the MV and TV; occurs during isovolumetric systole • Ej– Second heart sound as the contraction begins to take place and the blood is ejected • S2 – Third heart sound as diastole begins with isovolumetric relaxation forcing the AoV and PV closed (on inspiration S2 has a normal physiologic splitting)

  19. OS - The fourth heart sound during the tailend of isovolumetric relaxation – a point in which the ventricular pressure falls below atrial pressure and one can hear the opening snap of the MV/TV (this usually silent but accentuated with MVS) • S3– normal in young adults, peds and pregnancy. A Sound made by the deceleration of the blood as it hits the ventricular wall. Pathologic in all other patients – sign of a stiff ventricle • S4 – abnormal in all patients if heard, this last heart sound of the cardiac cycle is indicative of an atrium that is trying to pump blood into a very stiff ventricle Please review heart sounds in textbook

  20. Murmurs • Innocent murmurs – vary with inspiration most commonly in adolescence and diminishes in the upright position – located along the lower left sternal border • Most murmurs are diagnostic for valvular disease • Systolic Murmurs • Holosystolic – starts with S1 ending with S2 • Ejection – starts with S1 and end before S2 • Diastolic Murmurs • Associated with a palpable vibration - Thrills

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