HEART FAILURE

• FATIGUE
• SHORTNESS OF BREATH
• DYSPNEA DURING EXERTION OR AT REST – pulmonary congestion
• ORTHOPNEA (DYPNEA DURING RECUMBENT POSITION)-Relieved by sitting upright or
adding pillows (SPECIFIC SYMPTOM)
• NOCTURNAL COUGH
• PND – Acute episode of severe shortness of breath & coughing at NIGHT & AWAKEN the
px. Also manifest as coughing/wheezing
• Other symptoms: ANOREXIA, NAUSEA, EARLY SATIETY W/ ABDOMINAL PAIN. FULLNESS
(Edema of the bowel/ liver congestion)
• CONGESTED LIVER – RUQ pain
• NOCTURIA

PHYSICAL FINDINGS:

• Elevated BP
• Sinus Tachycardia- caused by adrenergic activity
• Cool Extremities, cyanosis of lips and nail beds- peripheral vasoconstriction, excessive
adrenergic activity
• JVP

STEPS FOR ASSESSING THE JUGULAR VENOUS PRESSURE (JVP)

1. Make the patient comfortable

2. Raise the head slightly on a pillow to relax the SCM muscles
3. Raise the head of the bed or examining table to about 30°Turn the patient's head
slightly away from the side you are inspecting
4. Use tangential lighting and examine both sides of the neck
5. Identify the external jugular vein on each side, then find the internal jugular
venous pulsations
6. If necessary, raise or lower the head of the bed until you can see the oscillation
point or meniscus of the internal jugular venous pulsations in the lower half of the
neck
7. Focus on the right internal jugular vein.
8. Look for pulsations in the suprasternal notch, between the attachments of the SCM
on the sternum & clavicle or just posterior to the SCM
9. Identify the highest point of pulsation
10. Extend a long rectangular object or card horizontally from point and a centimeter
ruler vertically from the sternal angle making an exact right angle.
11. Measure the vertical distance in centimeters above the sternal angle where
horizontal object crosses ruler This distance, measured in centimeters above the
sternal angle or the right atrium, is the JVP.

JVP measured at >3 cm above the sternal angle, or >8 cm above the right atrium, is
considered elevated or abnormal.
 • Crackles
• Rales
• Pleural effusion
• Cardiomegaly PMI- below the 5th ICS or lateral to MCL
• S3 palpable at apex- Prodiastolic gallop volume overload who have tachycardia
tachypnea, signifies hemodynamic compromise
• MURMURS (MITRAL TRICUSPID REGURG)

ABDOMEN
• HEPATOMEGALY
• Ascites-late sign increased pressure in hepatic veins and veins draining to the
peritoneum
• Jaundice-late sign; impairment of hepatic function secondary to congestion,
hepatocellular hypoxemia
• Peripheral Edema (symmetric & dependent)
• Weight loss cachexia- severe HF

RIGHT- SIDED LEFT-SIDED

• Hepatomegaly • Tachypnea
• Splenomegaly • Tachycardia
• Ascites • Grunting
• Jaundice • Resp. distress
• Neck vein engorgement • Cardiomegaly
• Periorbital edema • Diaphoresis
• Cold clammy extremities • Gallop rhythm
• Increased urine production • Easy Fatigability
• Decreased urine output

MYOCARDIAL INFARCTION/ISCHEMIC HEART DISEASE/ACUTE CORONARY SYNDROME

HISTORY
• ANGINA (CHEST PAIN)- heaviness, pressure, squeezing, choking, asked to localize
Levine's sign is the finding of a clenched fist held in front of the chest, indicating
ischemic chest pain
• Localization of discomfort with a single fingertip on the chest or reproduction of the
pain with palpation of the chest MAKES IT UNLIKELY THAT THE PAIN IS CAUSED BY
MYOCARDIAL ISCHEMIA
 • ANGINA is usually in Crescendo-Decrescendo last 2-5 mins radiate shoulder, ulnar
surface of arm, radiate to the back
• Radiation to the trapezius muscle is more common of pericarditis
• NOCTURNAL ANGINA – due to episodic tachycardia diminished O2 as the resp system
changes during sleep or expansion of the intrathoracic blood volume that occurs w/
recumbency
• THRESHOLD- Climbing 2 flight of stairs

PRECIPITATION- HEAVY MEAL, EXPOSURE TO COLD Eating and digesting food releases many
hormones into the bloodstream. Those substances increase the heart rate and blood pressure,
and may increase the substances that help form clots. The temporary rise in blood pressure
increases the oxygen requirements and creates an extra burden on the heart
• ANGINA EQUIVALENTS:
• Dsypnea, nausea, fatigue, faintness
• Irregular pulse
• Fatigue and weakness

RISK FACTORS:
• FAMILY HISTORY
• DM
• HYPERLIPIDEMIA
• HYPERTENSION
• SMOKING
• ANEMIA

PHYSICAL EXAMINATION:
If chest pain is ongoing, the patient will usually lie quietly in bed and may appear
anxious, diaphoretic, and pale. Physical findings can vary from normal to any of the
following:
• Hypotension - Indicates ventricular dysfunction due to myocardial ischemia,
infarction, or acute valvular dysfunction
• Hypertension - May precipitate angina or reflect elevated catecholamine
levels due to anxiety or to exogenous sympathomimetic stimulation
• Diaphoresis
• Pulmonary edema and other signs of left heart failure
• Extracardiac vascular disease
• Jugular venous distention
• Cool, clammy skin and diaphoresis in patients with cardiogenic shock

§ Abdominal aortic aneurysm

§ Carotid arterial bruits
§ Diminished arterial pulse lower ex
§ xanthelasma
Xanthelasma is a sharply demarcated yellowish deposit of cholesterol underneath the
skin. It usually occurs on or around the eyelids (xanthelasma palpebrarum,
abbreviated XP)
• Xanthoma- A xanthelasma is a sharply demarcated yellowish collection of cholesterol
underneath the skin, usually on or around the eyelids. Strictly, a xanthelasma is a
distinct condition, being called a xanthoma only when becoming larger and nodular,
assuming tumorous proportions.
§ FUNDOSCOPIC EXAM - increased light reflex, arteriovenous nicking as evidence of
hypertension
§ PALPITATION – reveal cardiac enlargement
§ AUSCULTATION – reveal arterial bruits, S3 S4 sound, systolic murmur due to mitral
regurg
§ Auscultatory signs are best heard in left lateral decubitus position. In addition, a third
heart sound (S3) may be present, and frequently, a fourth heart sound (S4) exists. The
latter is especially prevalent in patients with inferior-wall ischemia and may be heard in
patients with ischemia or systolic murmur secondary to mitral regurgitation
§ A systolic murmur related to dynamic obstruction of the left ventricular (LV) outflow
tract may also occur. It is caused by hyperdynamic motion of the basal left ventricular
myocardium and may be heard in patients with an apical infarct.
§ A new murmur may reflect papillary muscle dysfunction. Rales on pulmonary
examination may suggest LV dysfunction or mitral regurgitation.
§

• HEADACHE
The increase in intra-cardiac pressure during angina attacks could
also result in release of natriuretic peptides with consequent vasodilatation of
the cerebral vasculature resulting in headache
 • LIGHT HEADEDNESS
Poor blood circulation.
Conditions such as cardiomyopathy, heart attack, heart arrhythmia and
transient ischemic attack could cause dizziness. And a decrease in blood
volume may cause inadequate blood flow to your brain or inner ear.
• DIAPHORESIS
Sweating (or diaphoresis) is often cited as one of the most frequent
presentation symptoms of ACS, maybe being a signal of the activation of the
sympathetic nervous system, but only recently this clinical manifestation has
been extensively evaluated.

DDX:MI MIMICKERS

1. PERICARDITIS
One differentiating feature from ACS is that the pain associated with pericarditis is
usually positional in nature—the patient states the pain worsens when lying down,
taking a deep breath, or coughing. Leaning forward while sitting may alleviate the pain
associated with pericarditis.
Other signs and symptoms of pericarditis are low-grade fever, dyspnea, tachypnea,
and malaise. A pericardial friction rub with a superficial scratchy or squeaking quality
may be auscultated and is a good indication that the patient has pericarditis

2. COSTRPCHRONDITIS
The pain lasts for hours to days at a time. As for the difference between this condition
and a heart attack, costochondritis typically feels like a dull or sharp soreness in your
chest. Heart attack pain typically feels like a crushing weight or pressure on your chest
rather than sharp or aching pain.

Another difference between costochondritis and heart attack pain is that

with costochondritis you'll have the typical tender spots along your
breastbone
 3. ANXIETY

ACUTE RHEUMATIC FEVER

LATENT PERIOD for strep infection: 3 weeks

§ Prior sore throat infection
§ Polyarthritis
§ Carditis

Þ Arthritis- hot swollen red tender joints involvement of more than 1 joint, often
migratory, AFFECTS KNEES, ANKLES, HIPS, ELBOWS- ASSYMETRIC- highly
responsive to NSAIDS
Þ CHOREA- usually affects females, darting of the tongue
Þ SKIN: ERYTHEMA MARGINATUM- Pink macules clear centrally, serpiginous,
spreading edge, TRUNK, LIMBS NEVER ON THE FACE
Þ SUBCUTANEOUS NODULES:
The history should include the timing of the edema, whether it changes with position,
and if it is unilateral or bilateral, as well as a medication history and an assessment for
systemic diseases (Table 2). Acute swelling of a limb over a period of less than 72
hours is more characteristic of deep venous thrombosis (DVT), cellulitis, ruptured
popliteal cyst, acute compartment syndrome from trauma, or recent initiation of calcium
channel blockers (Figures 1 and 2). The chronic accumulation of more generalized
edema is due to the onset or exacerbation of chronic systemic conditions, such as
congestive heart failure (CHF), renal disease, or hepatic diseas

CHRONIC KIDNEY DISEASE