Transcript CVS Talk
THE CARDIOVASCULAR SYSTEM University of TEESSIDE Nurse Practitioner Course Dr. Phil Jennings. James Cook University Hospital Introduction • History Taking – Features of common symptoms – Presentation of common problems • Examination Routine – What do to – Important physical signs • Investigations – A quick look at X rays and ECGs Symptoms: Chest Pain • Important points to establish – – – – Site Radiation Character Exacerbating and Relieving factors – Duration – Associated symptoms Symptoms: Chest Pain NON ORGANIC CARDIAC Anxiety Angina PULMONARY Pleurisy Myocardial Infarct Pericarditis Aortic dissection Pulmonary Embolus Pneumothorax MUSCULOSKELETAL Chostochondritis Trauma GASTRO Ulcer or Reflux Gallstones Pancreatitis Chest Pain: Angina Angina pains are typically central crushing chest pains. Patients describe angina as feeling like a heavy weight in the middle of the chest Angina can present in unusual positions Chest Pain: Angina Angina pains commonly radiate to the arms, neck and jaw Typically angina lasts for several minutes Chest Pain: Angina Angina pains normally occur during periods of physical exertion. This is the single most important factor to consider when deciding if a patient has angina or not The term ‘unstable angina’ is used to describe pains which occur at rest and signifies severe coronary disease Chest Pain: MI • Features suggesting MI – The pains are usually more severe – There are more associated symptoms such as sweating, nausea or vomiting – Duration is > 30 minutes – Usual relieving factors such as rest or GTN spray do not help Chest Pain: Pericarditis • Pericarditis – – – – – Similar distribution to angina / MI Often sharper or stabbing Helped by sitting forward Typically has a long duration Often seen in otherwise well, young patients without coronary disease – May be a history of a viral illness of fever Chest Pain: Dissection • Features of Dissection – Pains are described as tearing and can be excruciating – Often radiates through to the back Symptoms: Palpitations Important points to establish Onset Rate Rhythm Duration Termination Associated symptoms Symptoms: Palpitations Supraventricular Atrial Fibrillation Atrial Flutter Atrial Tachycardia Reentrant Tachycardia Ventricular Ventricular Ectopics Ventricular Tachycardia Symptoms: Palpitations • Features of Atrial Fibrillation – Common. Especially elderly or IHD – Pulse is irregularly irregular in other words unpredictable from one beat to the next – Can be an incidental finding or presents with palpitations, fatigue, chest pain or breathlessness – The mainstay of treatment is rate control and anticoagulation – Electrical cardioversion may be used in some patients Symptoms: Breathlessness • Breathlessness or dyspnoea can have a number of causes – – – – Heart Failure Valve disease Myocardial Ischaemia Pericardial disease There are also non cardiac causes of dyspnoea - Pulmonary disease - Anaemia, Obesity or being unfit Symptoms: Breathlessness • Important points to establish – Occurrence of symptoms: • All the time • Woken from sleep • During exertion – Assess normal exercise tolerance – Associated symptoms • Chest pain, palpitations • Cough, wheeze, sputum, haemoptysis • Ankle oedema Symptoms: The End Any Questions So Far ??? Examination • Suggested CVS Exam routine – – – – – General Inspection Hands Pulse BP Head & Neck • JVP, Carotids, Anaeimia, Cyanosis – Praecordium – Auscultation – Extras Examination What is the most important start to any exam ?? Introduce yourself to the patient and let them know what you are about to do … Exam: General Inspection • If the patient is not exposed then ask if you may expose them • The patient should be reclined at a 45º angle • Look for obvious – – – – – Breathlessness Pallor Sweating Scars Props: Oxygen pipes, Inhalers, GTN spray • Make some comments Exam: Hands • Start with the nails and look for clubbing – Increased Curvature – Loss of nail bed angle – Fluctuant nail Beds • Examine BOTH hands at eye level Exam: Hands • Cardiovascular causes of clubbing can be – Congenital Cyanotic Heart Disease – Atrial Myxoma – Endocarditis Exam: Hands • Next look for Splinter Haemorrhages – A sign of systemic vasculitis which may indicate Infective Endocarditis. – They can also be caused by trauma so remember to bear in mind the patient’s occupation Exam: Hands • Other points to note – – – – – Temperature Perfusion Pallor Nicotine staining Extensor tendon swellings (xanthomas) Exam: Pulse • Start by palpating the radial pulse • At this site asses – Rate – Rhythm • You should not asses volume at the radial artery Exam: Pulse • Next move to the brachial artery to assess – Volume – Character Exam: Blood Pressure • You may now want to measure the blood pressure • A single measurement is acceptable unless the history suggests dissection Exam: Head & Neck: FACE Jaundice Exam: Head & Neck: FACE Anaemia Exam: Head & Neck: FACE Xanthelasma Arcus Exam: Head & Neck: FACE Cyanosis Exam: Head & Neck: JVP The JVP is best examined by looking across the neck. A double waveform should be seen for each cardiac cycle Exam: Head & Neck: JVP Top of venous pulsation Sternal Angle Height Of JVP Top of venous pulsation Sternal Angle In cms Exam: Head & Neck: JVP • Carotid Pulsation – 1 per cardiac cycle – Palpable – Position independent – Does not enhance with hepatojugualr – reflex • JVP Pulsation – 2 per cardiac cycle – Not palpable – Varies depending on position – Enhances with hepatojugular reflex Exam: Praecordium Look For Obvious Deformity Pigeon Chest Funnel Chest Exam: Praecordium Look For Obvious Scars Median Sternotomy CABG, Valve, Tx Lateral Thoracotomy Coarct Repair Exam: Praecordium Locate Apex Examine for heave Exam: Praecordium 1 23 2nd 3rd 4th 5th Intercostal Spaces 1. Mid Clavicular Line 2. Anterior Axillary Line 3. Mid Axillary Line Exam: Auscultation Bell Low pitched murmurs eg. Mitral Stenosis Press hard enough only to make a seal with the skin The ‘hole’ must be rotated to the bell in order for it to work Exam: Auscultation Diaphragm Normal / High pitched murmurs. Use for general purpose auscultation Exam: Auscultation Earpiece Angled to provide a better fit into the auditory cannal. During use point forward unless you have an abnormal shaped head ! Exam: auscultation 1. Apex: Mitral Valve 2. Sternal Edge: Tricuspid Valve BELL & DIAPHRAGM 3. L 2nd Space: Pulmonary Valve 4. R 2nd Space: Aortic Valve Exam: auscultation Heart Sounds: Lub Dub First Second Mitral Valve Aortic Valve Tricuspid Valve Pulmonary Valve Exam: auscultation Heart Murmurs: Systolic Mitral Regurgitation Tricuspid Regurgitation First Second Pan Systolic Murmur Exam: auscultation Heart Murmurs: Systolic Aortic Stenosis Pulmonary Stenosis VSD First Second Ejection Systolic Murmur Exam: auscultation Heart Murmurs: Diastolic Aortic Regurgitation First Second Early Diastolic Murmur Exam: auscultation Heart Murmurs: Diastolic Mitral Stenosis First Second Mid Diastolic Murmur Exam: auscultation Heart Murmurs: Extras Mitral Murmurs Mitral Area Patient in Left Lateral Radiate to Axilla Exam: auscultation Heart Murmurs: Extras Aortic Murmurs Aortic Area Sit Patient Forward Breath Held in Expiration Radiates to Carotids Exam: Extras • Is there anything else you wish to do ? – – – – – – Examine the peripheral pulses Check for radio – radial or radio – femoral delay Listen at the lung bases Check for sacral oedema Check for peripheral oedema Measure the BP if not already done Investigations: CXR Name Projection Marker Investigations: CXR Cardiac Lung Silhouette Fields Investigations: CXR Trachea Aortic Knuckle Left Atrial Appendage Right Hilum Right Hemidiaphragm Left Ventricle Left Hemidiaphragm Investigations: CXR Cardiac Thoracic Normal Cardio – Thoracic Ratio (CTR) is up to 0.5 Investigations: ECG Investigations: ECG Calculating the Heart Rate Divide 300 by the number of large squares inbetween R waves 300 / 2 = 150 bpm 300 / 6 = 60 bpm Investigations: ECG Rhythm In sinus Rhythm 1 P wave for each QRS complex Rate lies between 60 – 100 beats per minute Investigations: ECG Normal ECG Thankyou for your attention