Free Essay

Cardiovascular Sciences

In: Science

Submitted By cforcecilia
Words 3492
Pages 14
Arrhythmias * Are common and often benign, but can indicate underlying heart disease. They often occur intermittently and so can be difficult to diagnose. * Can present with palpitations, chest pain, presyncope/syncope, hypotension, pulmonary oedema. Some are asymptomatic e.g. AF. * History taking make sure include: * Precipitating factors, onset, nature (fast/slow, regular/irregular), duration, associated symptoms (chest pain, dyspnoea, collapse). * Causes: * CARDIAC: * MI. * CAD. * LV aneurysm. * Mitral valve disease. * Cardiomyopathy. * Pericarditis. * Myocarditis. * Aberrant conduction pathways. * NON-CARDIAC: * Caffeine. * Smoking. * Alcohol. * Pneumonia. * Drugs (β2 agonist, digoxin, L-dopa, tricyclics). * Metabolic imbalance (K, Ca, Mg, hypoxia, hypercapnia, acidosis, thyroid disease, phaeochromocytoma). * Tests: * Bloods: FBC, U&E, glucose, Ca, Mg, TSH. * ECG: look for signs of IHD, AF, short P-R interval, long QT interval, U waves. * If ECG normal consider doing 24 hour tape. * Echo: look for structural heart disease. * Others: exercise ECG, cardiac catheterisation etc. * Types of Arrhythmias: * Bradycardias: * If asymptomatic and rate >40bpm then no treatment. * Look for cause and stop any drugs that may be the cause or contributing. * If rate <40bpm and patient’s symptomatic give atropine (consider external pacemaker). * Sick Sinus Syndrome: * SAN dysfunction – causing bradycardia with possible arrest; or SAN block; or superventricular tachycardia alternating with bradycardia/asystole. * Superventricular Tachycardia (aka Narrow Complex): * Narrow complex tachycardia (HR >100bpm, narrow QRS). * Acute management: vagotonic manoeuvres, IV adenosine/verapamil, DC shock if compromised. * Atrial Fibrillation: * Often incidental finding, but can present with chest pain, palpitations, dyspnoea or presyncope. * Atrial rhythm 300-600bpm (no P waves on ECG). * AVN responds intermittently causing irregular contraction of ventricles. * Risk of embolic stroke – give warfarin. * Common causes: * Heart failure. * HT. * Cardiac ischaemia. * MI. * Mitral valve disease. * Pneumonia. * Hyperthyroidism. * Alcohol. * O/E – pulse is irregularly irregular, first heart sounds is of variable intensity. * Investigations: * ECG – absent P waves, irregular QRS complexes. * Bloods: FBC, U&Es, cardiac enzymes. * Echo – look for LA enlargement, mitral valve disease, poor LV function and other structural abnormalities. * Control ventricular rate with digoxin. * Maintenance: digoxin, verapamil, β-blocker or amiodarone. * Atrial Flutter = continuous atrial depolarisation producing a ‘saw-tooth’ appearance on the ECG (possibly with 2:1 block). Carotid sinus massage transiently blocks the AVN and so can unmask flutter waves. Try AF treatment or consider ablation if unsuccessful. * Ventricular Tachycardia: * Broad complex tachycardia (HR >100bpm, widened QRS). * Acute management = IV lignocaine/amiodarone. DC shock if compromised. * Wolf Parkinson White: * Caused by congenital accessory conduction pathway between atria and ventricles. * Resting ECG: * Short P-R interval. * Widened QRS – slurred upstroke a ‘delta’ wave. * 2 types of WPW: 1. WPW type A = positive delta wave in V1. 2. WPW type B = negative delta wave in V1. * Present with superventricular tachycardia.
Infective endocarditis
Infective Endocarditis:

Fever (of unknown origin) and new murmur = infective endocarditis until proven otherwise. * Classification: * Normal valves – infection presents acutely with heart failure (tricuspid valve is usually involved). * Abnormal valves – subacute course. Patient will have an abnormal valve e.g. aortic or mitral disease. * Causes: * Bacteria: * Streptococcus viridans – lives in the mouth (think about recent dental work). * Staphylococcus aureus/epidermis – found on the skin (think about IV drug use). * UTI, urinary catheterization, cystoscopy, IV cannulation can increase the risk of infective endocarditis. * Often no cause is found. * Clinical Features: * Signs of infection: * Fever (of unknown origin)/rigors/night sweats. * Malaise/weight loss. * Anaemia. * Clubbing. * Splenomegaly. * Cardiac lesions: * New murmur or change in a pre-existing murmur. * Immune complex deposition: * Vasculitis. * Microscopic haematuria. * Roth spots (retinal haemorrhages). * Splinter haemorrhages. * Osler’s nodes (painful pulp infarcts in fingers or toes). * Janeway lesions (painless palmar or plantar macules). * Diagnosis: * Duke criteria: (need 2 major OR 1major and 3 minors OR 5 minor). * MAJOR CRITERIA: * Positive blood culture – typical organism in 2 cultures. * Endocardium involvement – positive ECHO (vegetation, abscess etc.) or new valvular regurgitation. * MINOR CRITERIA: * Predisposition (cardiac lesion, IV drug use). * Fever >38deg. * Vascular/immunological signs. * Positive blood culture – doesn’t meet major criteria. * Positive ECHO that doesn’t meet major criteria. * Treatment = Antibiotics.

* Is a risk factor for stroke and MI. * Difficult to define a high BP, but need to treat those with a BP >160/100mmHg; consider treating those with a BP >140/90mmHg if they’ve a risk of coronary events, have diabetes or signs of end organ damage. * ‘Malignant HT’: * Severe HT (>200/130mmHg). * Bilateral retinal haemorrhages and exudates. May see papilloedema. * Patients often have symptoms e.g. visual disturbances/headaches. * Need to find underlying cause e.g. phaeochromocytoma. * Management: * Controlled reduction of BP over days (NOT hours). * Need to avoid sudden drops in BP as cerebral autoregulation is poor and so stroke risk can be increased. * Bed rest, start loop diuretic ± thiazide. * Causes: * Essential HT: * Primary HT – cause unknown. * Accounts for 95% of cases. * Secondary HT: * Accounts for 5% of cases. * Causes include: * Renal disease e.g. glomerulonephritis, polyarteritis nodosa, polycystic kidneys, renovascular disease. * Endocrine e.g. Cushing’s, Conn’s, phaeochromocytoma, acromegaly, hyperparathyroidism. * Others – coarctation, pregnancy, steroids, MAOI, contraceptive pill. * Signs and Symptoms: * Usually asymptomatic unless malignant. * Always examine CVS and check for retinopathy. * Look for causes of secondary hypertension e.g. Cushing’s etc. * Look for end organ damage e.g. LV hypertrophy, retinopathy and proteinuria. * Long standing HT may cause proteinuria, added heart sounds (S4), heave/bruits and LVH. * Investigations: * Bloods: * FBC. * U&Es. * Creatinine. * Cholesterol. * Glucose. * Urine analysis. * ECG. * Specific tests for primary cause if secondary hypertension. * Treatment: * Lifestyle changes. * Drugs (remember ABCD): * Thiazide diuretics – first choice. * β-blockers – contraindicated in asthmatics and diabetics. * ACE-i – can be first choice in diabetics with microalbuminuria/proteinuria; or those with LVH. Contraindicated in renal artery stenosis and aortic stenosis. * Ca-channel antagonists.

Valve disease

* First heart sound (S1): * Represents closure of mitral and tricuspid valves. * Second heart sound (S2): * Represents closure of aortic and pulmonary valves. * Can be physiologically split on breathing. * Third heart sound (S3): * Rare. * Occurs after S2 – is low pitched and best heard with the bell. * Is pathological over the age of 30 years. * Occurs in a dilated left ventricle causing rapid ventricular filling (mitral regurgitation or VSD); or poor LV function (post-MI or dilated cardiomyopathy). * When auscultating think ‘Kentucky’ for the rhythm. * Fourth heart sound (S4): * Occurs just before S1. * Always pathological – represents atrial contraction against a stiff, non-compliant ventricle. * Several cause e.g. hypertensive heart disease, aortic stenosis. * When auscultating thing ‘Tennessee’ for the rhythm.

Cardiac murmurs
Consider any murmur in terms of character, timing, loudness, area where loudest, radiation and accentuating manoeuvres.
When in doubt, rely on echocardiography.

* Character and Timing: * There are four types of murmur: 1. Ejection systolic: a. Crescendo-decrescendo in nature. b. Common in children and high output states (tachycardia, pregnancy). c. Causes = aortic stenosis, aortic sclerosis, pulmonary stenosis and hypertrophic cardiomyopathy. 2. Pansystolic: d. Uniform intensity and merges with S2. e. Occurs in mitral or tricuspid regurgitation or VSD. 3. Early diastolic: f. High pitched. g. Usually indicates aortic regurgitation (rarely occurs in pulmonary regurgitation). 4. Mid-diastolic: h. Low pitched and rumbling. i. Occurs in mitral stenosis, rheumatic fever and aortic regurgitation. * Intensity: * Graded as so: * 1 = very soft, only heard after listening for a while. * 2 = soft, but detectable immediately. * 3 = clearly audible, no palpable thrill. * 4 = clearly audible, palpable thrill. * 5 = audible with stethoscope partially touching the skin. * 6 = can be heard without placing a stethoscope on the skin. * Systolic murmurs are louder than diastolic (only graded 1-4).

* Area where loudest: * Mitral murmurs tend to be louder over the apex and radiating into the axila. * Aortic murmurs = right 2nd intercostal space. * Pulmonary murmurs = left 2nd intercostal space. * Tricuspid murmurs = left sternal edge. * Radiation: * Aortic stenosis classically radiates to the carotids. * Mitral regurgitation classically radiates to the axilla. * Accentuating manoeuvres: * Leaning forward – aortic regurgitation. * Leaning to left lateral position – mitral stenosis. * Expiration – left sided murmurs. * Inspiration – right sided murmurs.

Common Heart Murmurs:

Aortic Stenosis: * Causes: * Senile dysfunction is the commonest, can also be congenital (bicuspid valve, William’s syndrome). * Symptoms: * Angina. * Dyspnoea. * Syncope/faints. * Systemic emboli if infective endocarditis. * Congestive cardiac failure. * Signs: * Slow rising pulse with narrow pulse pressure (feel for diminished and delayed carotid upstroke). * Heaving, un-displaced apex beat. * LV heave. * Aortic thrill. * On auscultation: * Ejection systolic murmur – heard best in the right 2nd intercostal space. * As stenosis worsens – A2 is increasingly delayed. Commonly a quiet S2 is heard. * Tests: * ECG – look for LV hypertrophy with strain pattern, left anterior hemiblock, poor R wave progression, LBBB or complete AV block. * CXR – LV hypertrophy, calcified aortic valve, post-stenotic dilation of ascending aorta. * Echo – diagnostic. * Don’t forget differential is hypertrophic cardiomyopathy. * Management: * Symptomatic patients have a poor prognosis. * Prompt valve replacement.

Aortic sclerosis is senile degeneration of the valve. There is an ejection systolic murmur, no carotid radiation, and normal pulse (character and volume) and S2

Aortic Regurgitation:

* Causes: * Congenital, rheumatic fever, infective endocarditis, rheumatoid arthritis, SLE. * Aortic root disease caused by: hypertension, trauma, aortic dissection, seronegative arthritic conditions (ankylosing spondylitis etc), Marfan’s etc. * Symptoms: * Dyspnoea. * Palpitations. * Cardiac failure. * Signs: * Collapsing pulse with wide pulse pressure. * Displaced hyper-dynamic apex beat. * On auscultation: * High pitched early diastolic murmur – heard best in expiration with patient sitting forward. * Associated signs: * Corrigan’s sign – carotid pulsation. * de Musset’s sign – head nodding. * Quincke’s sign – capillary pulsations in nail beds. * Duroziez’s sign – femoral diastolic murmur as blood flows backwards in diastole. * Traube’s sign – pistol shot sound over femoral arteries. * In severe aortic stenosis may hear an Austin flint murmur. * Tests: * ECG – look for LV hypertrophy. * CXR – cardiomegaly, dilated ascending aorta, pulmonary oedema. * Echo – diagnostic. * Management: * Surgery – if increasing symptoms, cardiac enlargement, ECG deterioration (T wave inversion in lateral leads).

Mitral Stenosis:

* Causes: * Rheumatic, congenital, malignant carcinoid, prosthetic valve. * Symptoms: * Dyspnoea. * Fatigue. * Palpitations. * Chest pain. * Systemic emboli. * Haemoptysis. * Signs: * Malar flush. * Low-volume pulse. * AF is common. * Tapping un-displaced apex beat (palpable S1). * On auscultation: * Loud S1. * Opening snap. * Rumbling mid-diastolic murmur (heard best in expiration with the patient lying on their left side). * Possible Graham Steell murmur. * If more severe – longer diastolic murmur and the opening snap is closer to S2. * Tests: * ECG – look for AF, RVH, progressive right axis deviation. * CXR – LA enlargement, pulmonary oedema, mitral valve calcification. * Echo – diagnostic. * Management: * AF – digoxin (need control rate <90bpm, use beta-blocker if digoxin not enough). * Anticoagulate – warfarin. * Diuretic to decreased preload/pulmonary venous congestion. * Complications: * Pulmonary hypertension. * Emboli. * Pressure from large LA on local structures e.g. left recurrent laryngeal nerve causing hoarseness, bronchial constriction.

Mitral Regurgitation:

* Causes: * Functional (LV dilation), annular calcification (elderly), rheumatic fever, infective endocarditis, mitral valve prolapse, ruptured chordae tendinae, papillary muscle dysfunction/rupture, connective tissue disorders, cardiomyopathy, congenital. * Symptoms: * Dyspnoea. * Fatigue. * Palpitations. * Infective endocarditis. * Signs: * AF. * Displaced hyper-dynamic apex. * RV heave. * On auscultation: * Soft S1. * Split S2 – loud P2 (pulmonary hypertension). * Pansystolic murmur at apex radiating to axilla. * The more severe, the larger the LV. * Tests: * ECG – look for AF, LV hypertrophy. * CXR – enlarged LA and LV, mitral valve calcification, pulmonary oedema. * Echo – assess LV function. * Management: * If fast AF – digoxin. * Anticoagulation if: fast AF; history of embolism; prosthetic valve; additional mitral stenosis. * Diuretics improve symptoms. * Surgery if no improvement.

Mitral valve prolapse aka Barlow syndrome aka click murmur syndrome
The most common valvular abnormality
A mid-systolic click followed by a late systolic murmur is heard at the apex as the thickened mitral valve leaflet is displaced into the left atrium during systole.

Austin flint murmur
A low pitched, mid-diastolic rumble at the apex, classically MV displacement as well as aortic turbulence due to regurg = Austin flint murmur. It occurs in severe aortic regurgitation. It is due to the fluttering of the anterior mitral valve cusp caused by regurgitant flow

Constant machinery murmur
Produced by a patent ductus arteriosus. Patient is clubbed and cyanosed

Graham Steell murmur
Heard best at the left sternal edge, second intercostal space during inspiration. High pitched early diastolic murmur plus pulmonary hypertension. It is caused by pulmonary regurgitation which is secondary to pulmonary hypertension, which is caused by mitral stenosis.
Carey Coombs murmur
A short, mid-diastolic rumble heard best at the apex due to turbulent blood flow over a thickened mitral valve, most often due to rheumatic fever. Due to thickened mitral valve leaflets.

Ventricular septal defect
Harsh pan-systolic murmur loudest at lower left sternal edge. Inaudible at the apex. Apex is not displaced

Atrial septal defect
Fixed splitting of the second heart sound
Aortic aneurysm * True aneurysms – abnormal dilations of arteries. * False aneurysms – collections of blood around the vessel wall, can occur after trauma. * Common sites: * Aorta. * Iliac. * Femoral. * Popliteal. * Usual cause = atheroma, but can be caused by connective tissue disorders (Marfan’s, Ehler-Danlos) and infections (endocarditis, tertiary syphilis). * Thoracic Aorta Dissection: * Blood causes a splitting of the aortic media – causing sudden tearing chest pain that radiates to the back. * As the dissection progresses branches of the aorta become occluded giving rise to specific symptoms depending on the branch. For example: hemiplegia (carotid), unequal arm pulses/BP (arch), paraplegia (anterior spinal artery) and anuria (renal). * Ruptured AAA: * Signs/symptoms: * Intermittent or continuous abdominal pain, can radiate to the back, iliac fossae or groin. * Collapse. * Expansile abdominal mass. * Unruptured AAA: * Often symptomless, but can cause abdominal/back pain. * Needs monitoring to measure diameter.

Stroke: * Types – ischaemic or haemorrhagic. * Causes: * Thrombosis-in-situ. * Heart emboli (AF, MI). * Atherothrombolism e.g. from carotids. * CNS bleed (Increased BP, trauma, aneurysm rupture). * Risk factors: * Increased BP. * Smoking. * Diabetes. * Heart disease (valvular, ischaemic, AF). * PVD. * Past TIA. * The contraceptive pill in those who smoke. * Excess alcohol. * Clotting abnormalities e.g. increased plasma fibrinogen. * Signs: * Sudden onset, or step-wise progression over hours. Signs depend on area affected. * Cerebral hemisphere infarcts: * Contralateral hemiplegia - initially flaccid, but becomes spastic (is an UMN lesion). * Contralateral sensory loss. * Homonymous hemianopia. * Dysphasia. * Brainstem infarct: * Wide range of effects including quadriplegia, disturbances of gaze/vision and locked in syndrome. * Lacunar infarct: * Small infarcts around the basal ganglia, internal capsule thalamus and pons. * Can cause pure motor, pure sensory, mixed motor/sensory signs; or ataxia. * Have intact cognition and consciousness. * Investigations: * Look for: * Long-standing hypertension – retinopathy, enlarged heart on CXR. BP is often raised, acutely, in early stroke. * Cardiac source of emboli: * AF – look at ECG, CXR, echo. * Post-MI – mural thrombus best seen on echo. * Carotid artery stenosis. * Hypoglycaemia, hyperglycaemia and hyperlipidaemia. * Giant cell arteritis e.g. is ESR is increased (treat with steroids). * Syphilis. * Thrombocytopenia, polycythaemia and other bleeding disorders. * To do: * Pulse and BP. * Bloods – FBC, U&Es, clotting, ESR, lipids, glucose. * ECG, carotid doppler, consider echo. * Imaging – CXR, CT head. * Differentials: * CNS tumour. * Subdural bleed. * Migraine. * Hypoglycaemia. * Possible drug overdose.

It’s very difficult to clinically distinguish between haemorrhagic and ischaemic strokes. But pointers to haemorrhagic strokes = meningism, severe headache and coma within hours. Pointers to ischaemic strokes = carotid bruit, AF, past TIA.
Peripheral vascular disease
Limb Embolism and Ischaemia:

Chronic ischaemia:

* Always due to atherosclerosis. * Main feature is intermittent claudication, which is a cramping pain in the calf, thigh or buttock after walking. * Critical ischaemia: * Ulceration. * Gangrene. * Foot pain at rest (often a burning pain at night relieved by hanging the leg out of the bed). * Signs: * Absent pulses. * Cold, white leg. * Atrophic skin. * Punched out ulcers – often painful. * Postural colour change. * REMEMBER the 6 P’s: * Pain. * Pallor. * Paraesthesia. * Paralysis. * Pulselessness. * Perishing with cold. * Tests: * Are they diabetic? Good control? * Look for arteritis – measure ESR and CRP. * FBC – look for anaemia and infection. * U&Es – check renal function. * Lipids – dyslipidaemia? * Syphilis serology. * Clotting/group and save if operating. * ECG – cardiac ischaemia? * Ankle-brachial pressure index (Doppler) – normal is 1, claudication 0.9-0.6, rest pain is 0.3-0.6, impending gangrene is <0.3. * Do a duplex to assess extent and location of stenosis and quality of distal vessels (‘run off’). * Management: * Conservative treatments – stop smoking, lose weight, increase exercise, treat pre-existing conditions e.g. diabetes, hypertension and hyperlipidaemia. * Surgical treatments: * Percutaneous transluminal angioplasty – for short stenoses in large arteries. Inflate a balloon and leave a stent to maintain patency. * Amputation – may relieve intractable pain and prevent death from sepsis/gangrene.

Acute ischaemia:

* Causes: thrombosis in-situ, emboli, graft/angioplasty occlusion or trauma. * Signs/symptoms: * 6 P’s: * Pain. * Pallor. * Paraesthesia. * Paralysis. * Pulselessness. * Perishing with cold. * Fixed mottling implies irreversibility. * Emboli commonly arise from the heart (infarcts, AF) or an aneurysm (aorta, femoral or popliteal). * Management: * Is an emergency – may require urgent surgery. * Anticoagulate with heparin.

Deep vein thrombosis
Deep Vein Thrombosis (DVT):

* Differentials diagnoses – cellulitis (can co-exist), ruptured Baker’s cyst (can also co-exist). * 10 Questions to ask a patient with swollen legs: 1. Are both legs affected? 2. Are they pregnant? 3. Are they mobile? 4. Any recent trauma? 5. Any pitting? 6. Any pain? 7. Any skin changes? 8. Any oedema elsewhere? 9. Any past history of DVT, cellulitis? 10. What drugs are they on? * Risk factors: * Old age. * Pregnancy. * Synthetic oestrogen (contraceptive pill). * Surgery (especially pelvic/orthopaedic). * Previous DVT. * Malignancy. * Obesity. * Immobility. * Thrombophilia. * Pretest Clinical Probability Scoring for DVT: * Active cancer (1pt). * Paralysis, paresis or recent plaster immobilisation of leg (1pt). * Major surgery or recently bed-ridden for >3days in last 4weeks (1pt). * Local tenderness along distribution of deep venous system (1pt). * Entire leg swollen (1pt). * Calf swelling >3cm compared to asymptomatic leg (measure 10cm below tibial tuberosity) (1pt). * Pitting oedema – most noticeable in affected leg (1pt). * Collateral superficial veins (non-varicose) (1pt). * Alternative diagnosis as likely or more likely than that of DVT (-2pts). * Signs: * Calf may be warm, tender or swollen. * Mild fever. * Pitting oedema (Homans’ sign – increased resistance/pain on forced foot dorsiflexion – DON’T perform as it may dislodge the thrombus). * Investigations: * Bloods – FBE, U&Es, CRP, clotting, D-dimer. * D-dimer is sensitive but not specific for DVT as it can be raised in infection, pregnancy, malignancy and post-operatively. * A negative D-dimer in someone with few risk factors can rule out DVT. * Ultrasound scan. * Prevention: * If having surgery: * Stop contraceptive pill 4 weeks pre-op. * Mobilise early. * Heparin infusion. * TED stockings. * Treatment: * Heparin (LMWH) and warfarin. * Stop heparin when INR is 2-3.

Pulmonary Embolism * Causes: * Usually arise from a venous thrombosis in the legs or pelvis. * Rare causes: * Right ventricular thrombus (post-MI). * Septic emboli (right-sided endocarditis). * Fat. * Air. * Risk factors (Any cause of immobility or hypercoagulability): * Recent surgery. * Recent stroke or MI. * Disseminated malignancy. * Thrombophilia (antiphospholipid syndrome). * Prolonged bed rest. * Pregnancy; post-partum; the pill; HRT. * ALWAYS ASK ABOUT RISK FACTORS and FAMILY HISTORY! * Symptoms: * Acute breathlessness. * Pleuritic chest pain. * Haemoptysis. * Dizziness/syncope. * Signs: * Pyrexia. * Cyanosis. * Tachypnoea. * Tachycardia. * Hypotension. * Raised JVP. * Pleural rub/pleural effusion. * LOOK for signs of cause e.g. swollen leg, recent surgery. * Investigations: * CXR – often normal; can show dilated pulmonary artery, linear atelectasis, diminished vascular markings. * ECG – may be normal, or show tachycardia, RBBB. * ABG – may show low PaO2 and PaCO2, increased pH. * Bloods – U&Es, FBC, clotting, D-dimer. * V/Q scan or CTPA (V/Q less radiation). * Management: * Anticoagulate with low molecular weight heparin (e.g. dalteparin) and start warfarin. * Stop heparin when INR >2, but continue warfarin for 3 months (aim for INR 2-3). * Prevention: * Give heparin to all immobile patients. * Prescribe TED stockings – encourage early mobilization. * Women to stop HRT and the pill pre-operatively. * Patients with a family history of thromboembolism should be investigated for thrombophilia.

Varicose veins
Varicose Veins:

* Cause: * Incompetent valves between the deep and superficial veins. * Therefore allowing backflow of blood from deep veins back into the superficial veins. * Incompetent valves can be caused by: * Venous hypertension: * Prolonged standing. * Pregnancy – occlusion by the fetus. * Ovarian tumour. * Previous DVT. * Symptoms: * Patient complaining of ‘ugly legs’. * May also mention: * Pain. * Cramps. * Tingling. * Heaviness and tingling legs. * Signs: * Oedema. * Eczema. * Ulcers. * Haemosiderin skin staining. * Haemorrhage. * Phlebitis. * Method of Examination: (Start with patient standing) 1. Any signs of poor skin nutrition, ulcers? Inspect the legs from anterior thigh to medial calf (long saphenous); and back of the calf (short saphenous). Palpate veins for tenderness and hardness. 2. Feel for cough impulse at the sapheno-femoral junction – if present indicates incompetence. The percussion test: tap the top of a vein and feel how far down its length you can feel the repercussions (valves prevent transmission). 3. Doppler ultrasound – listen to flow in incompetent valves. * Saphena varix: * A dilation in the saphenous vein at its confluence with the femoral vein. * One of the many causes of a lump in the groin. * It can be mistaken for an inguinal/femoral hernia due to its cough impulse. But, on closer inspection, it may have a bluish tinge and it disappears when the patient lies down.

Cardiac arrest

* Do not stop CPR for >10s except to defibrillate. * Shockable rhythm – give amiodarone 300mg IV with first dose of adrenaline. Alternatives for amiodarone are lidocaine or procainamide. * Asystole/PEA – give adrenaline 1mg immediately, if there are P waves – may need pacing. * Treat acidosis with good ventilation, sodium bicarbonate may worsen intracellular acidosis and precipitate arrhythmias so only use in severe acidosis.

Similar Documents

Free Essay

Tp Tp Tp Tp

...The Future of Cardiovascular Diagnostics THE MARKET, TRENDS & FUTURE DIRECTIONS Extracted on: 20 Apr 2011 Reference Code: BI00021-008 Publication Date: 02 Mar 2010 Publisher: Datamonitor © Datamonitor This content is a licensed product, no part of this publication shall be reproduced, sold, modified or stored in a retrieval system or transmitted in any form by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of Datamonitor. The information in this document has been extracted from published research by a registered user of the Datamonitor360 platform. Datamonitor shall not be responsible for any loss of original context and for any changes made to information following its extraction. All information was current at the time of extraction although the original content may have been subsequently updated. Please refer back to the website to view the most recent content and the original source of the information. To the maximum extent permitted by applicable law we exclude all representations, warranties and conditions relating to the facts of all publications. At time of publication no guarantee of accuracy or suitability, whether express or implied, shall attach to this publication (including, without limitation, any warranties implied by law of satisfactory quality, fitness for purpose and/or the use of reasonable care and skill). Please note that the findings, conclusions and......

Words: 9155 - Pages: 37

Premium Essay

Non Modifiable Risk Factors for Cardio Vascular Disease

...Modifiable Risk Factors for Cardiovascular Disease By: Fawn R. Stephen-Odle June 2012 Cardiovascular disease is caused by disorders of the heart and blood vessels, and includes coronary heart disease (heart attacks), cerebrovascular disease (stroke), raised blood pressure (hypertension), peripheral artery disease, rheumatic heart disease, congenital heart disease, and heart failure. The major causes of cardiovascular disease are tobacco use, physical inactivity, an unhealthy diet and harmful use of alcohol. Unfortunately, there are four non-modifiable risk factors that contribute to CVD (cardiovascular disease). Race and Ethnicity: Race and ethnicity have quite a bit to do with risk factors for cardiovascular disease. Studies show that African Americans have a higher risk for Cardiovascular Disease because of higher blood pressure levels, overweight and obesity, compared to Caucasians. Higher blood pressure levels are among the highest in African Americans in the world. Mexican Americans and Native Americans are also at higher risk for heart disease because of higher rates of obesity, diabetes, and smoking. Studies also show that about 77% of African American women, 72% of Mexican American women, and 61% of Native American women are overweight or obese, compared to 57% of Caucasian women. Taking precautions such as eating a proper diet, exercise, lessen use of alcohol, and quitting smoking can reduce a person’s chances of contracting Cardiovascular Disease. All......

Words: 1018 - Pages: 5

Premium Essay

Sentence Outline

...Adverse Cardiovascular Effects from Excessive Endurance Exercise.” Mayo Clinic Proceedings 87.6 (2012): 587–595. PMC. Web. 8 Aug. 2015. I found this article by searching Google Scholar, and using a string search of “Hypertrophic Cardiomyopathy” + endurance athlete. This type of search returned a moderate amount of results in which to start my research. This article was written as a peer review for the Mayo Clinic website. The article contains a significant amount of information describing different scientific studies performed in regards to high intensity exercise performed by endurance athletes vs. people who lead a sedentary lifestyle, with little or no exercise at all. It also touches on describing exercise as a pharmacological agent, as in performing exercise in moderation (a “recommended dose”), or exercising to the extreme, which could be considered an excessive dose. The article also points out how exercise can be used in the prevention of certain disease processes, such as diabetes, hypertension and coronary artery disease. I think this peer review is somewhat biased towards exercise in moderation, because a lot of the studies reviewed tend to point out the negative effects of endurance sports and the training that goes along with them. Although this article is somewhat biased towards minimalist types of exercise, I believe it will be beneficial to my research. It is because of the different studies that are reviewed and how they relate to cardiovascular......

Words: 1294 - Pages: 6

Free Essay

Youth Development

...Proposal Letters Components of a good letter proposal: Ask for the gift: The letter should begin with a reference to your prior contact with the funder, if any. State why you are writing and how much funding is required from the particular foundation. Describe the need: In a much abbreviated manner, tell the funder why there is a need for this project, piece of equipment, etc. Explain what you will do: Just as you would in a fuller proposal, provi interest. Describe precisely what will take place as a result of the grant. Provide agency data: Help the funder know a bit more about your organization by including your mission statement, brief description of programs offered, number of people served, and staff, volunteer and board data, if appropriate. Include appropriate budget data: Even a letter request may have a budget that is a half page long. Decide if this information should be incorporated into the letter or in a separate attachment. Whichever course you choose, be sure to indicate the total cost of the project. Discuss future funding only if the absence of this information will raise questions. Close: As with the longer proposal, a letter proposal needs a strong concluding statement. Attach any additional information required: The funder may need much of the same information to back up a small request as a large one: board list, a copy of your IRS determination letter, financial documentation, and brief resumes of key staff...

Words: 777 - Pages: 4

Premium Essay


...Evaluate the importance of regular exercise in maintaining a healthy body and mind; to what extent should the state play a role in ensuring that its citizens exercise regularly? Refer to at least two countries in your answer. Abstract Recent years have witnessed a dramatic increase in physical activity and fitness around the world. This essay will focus on the benefits of exercise for both physical and mental health. It is obvious that exercise helps people prevent a variety of diseases such as diabetes, cardiovascular, depression and Parkinson’s. This also raises an argument on whether government should play an important role in promoting physical activity. This essay will clarify that it is reasonable for the state to take responsibilities in order to make sure that social health would be improved in the following years. 1/ Introduction A healthy lifestyle and longer lives are always the target that everyone wants to achieve, specifically; it is obvious that one of the most effective ways to do this is through exercise. Exercise generally means physical activity that makes your body strong and healthy. In addition, exercise also benefits mental health, especially in stressful work conditions which can affect individuals who lead busy lives. Therefore, in my opinion, it will be reasonable for the government (the state) to be responsible for ensuring regular exercise of all citizens. This essay consists of three main parts which will discuss the reasons why......

Words: 2279 - Pages: 10

Free Essay

Cholesterol Guidelines

...Cholesterol: The new guidelines Ann K. McCullough Northern Illinois University Background There are 71 million American adults that have elevated low-density lipoproteins (LDL) cholesterol and only 33% of adults with high LDL’s are being treated (CDC, 2012). Dyslipidemia is a major risk factor for coronary artery disease (CAD) and it has shown to be a contributing factor for CAD. An estimated 785,000 Americans will have a new CAD event and approximately 470,000 will have a recurrent attack. The cost of CAD is astounding and is estimated at $172 billion annually (Heidenreich, el. al., 2011). Cardiovascular disease (CVD) is the leading cause of death in the United States (US) and is responsible to 17% of the national health expenditures. It has been eight years since new cholesterol guidelines have been updated and the new guidelines have created a little controversy. The ATP IV guidelines set by the American College of Cardiology/American Heart Association (ACC/AHA) have created many waves in the treatment of cholesterol and lipid management. The guidelines stress the prevention of stroke as well as heart disease and focuses on statin therapy rather than other alternative unproven therapeutic agents. It also recognizes that more intensive treatment is superior to less intensive treatment for many patients. History Cholesterol screening guidelines have evolved and changed over the past couple of years, but there continues to be gaps in care with an......

Words: 2310 - Pages: 10

Premium Essay

The Importance of Cardiovascular Conditioning

...Cardiovascular fitness shows how the heart and lungs supply oxygen-rich blood to the working muscle tissues and the ability of the muscles to use oxygen to produce energy for movement. The ability to deliver oxygen to the muscles is affected by many physiological parameters, including heart rate, stroke volume, cardiac output, and maximal oxygen consumption. Cardiovascular conditioning utilizes and transports the necessary oxygen and nutrients to body tissues. In order for the body to deliver adequate oxygenated blood and nutrients to the muscles, the body has to be well conditioned. By the body being well conditioned it improves the muscles capacity to use extra oxygen. Cardiovascular training is the most important style of training both for general health and for overall athletic performance. Cardiovascular Benefits of Conditioning The circulatory system is one of the major systems which is effected by cardiovascular conditioning. Your circulatory system consists of your heart, blood vessels and blood, and is responsible for transporting life-giving oxygen throughout your body. When you exercise, your body's need for oxygen increases; the harder you work out, the more oxygen your body demands. To ensure that sufficient oxygen is available for your muscles during activity, your body makes short- and long-term changes. The heart becomes strong and is able to use energy more efficiently with proper exercise. Blood pressure becomes lower as the heart muscle does not have to......

Words: 2996 - Pages: 12

Free Essay

Final Essay Exam

...FINAL ESSAY Your name Course Name Date 1. Describe the major hormonal changes that occur during adolescence. Describe girls’ reactions to menarche and boys’ reactions to spermarche during puberty. What factors influence the way adolescents respond? Describe the impact of puberty on parent–child interaction and the adaptive value of this change in adolescents’ relationships with their parents. Hormonal change is at its peak during adolescence and is a period of rapid psychological and physiological transformation. During puberty boys and girls sweat and their oil glands become more active. This will result in body odour and acne. They also get underarm and pubic hair in the body. The brain releases Gonadotropin – releasing hormone (GnRH) for stimulating pituitary gland. Pituitary gland is also known as the Master gland releases luteinizing hormones and follicle stimulating hormone. In boys, interstitial cell stimulating hormone and it stimulates interstitial cells to produce to from hormones in male organ of testicles. Both male and females have estrogens and androgen in their body in low level and after puberty, males begin to have more androgen including testosterone. In female they get more oestrogen as puberty crosses. Menarche is the first menstrual bleeding in a girl and her reaction to this event can be both emotional and physical. It is a sign of growing up and happens between the age of 9 and 15 years. The girls usually show stress, irritability......

Words: 2851 - Pages: 12

Premium Essay


...COMMENTARIES 3. 25]. Available from: Petch E, Ronson B, Rootman I. Literacy and health in Canada: what we have learned and what can help in the future? A research report. Clear language edition [monograph on the Internet]. Ottawa, ON: Canadian Institutes of Health Research; 2004 [cited 2011 Nov 25]. Available from: uploads/portals/h-l/literacy_e.pdf Public Health Agency of Canada [homepage on the Internet]. Ottawa, ON: Public Health Agency of Canada; 2003 [updated 2011 Oct 21; cited 2011 Nov 26]. What determines health?; [about 3 screens]. Available from: http:// Scott Murray, Data Angel Policy Research, Incorporated, Rima Rudd, Harvard School of Public Health, Irwin Kirsch, Educational Testing, Service, Kentaro Yamamoto, Educational Testing Service and, Sylvie Grenier, Statistics Canada. Health literacy in Canada: initial results from the International Adult Literacy and Skills Survey 2007 [monograph on Internet]. Ottawa, ON: Canadian Council on Learning; 2007 [cited 2011 Nov 26]. Available from: Rao JK, Anderson LA, Inui TS, Frankel RM. Communication interventions make a difference in conversation between physician and patients: a systemic review of the evidence. Med Care. 2007;45(4):340-9. Stewart MA. Effective physician–patient communication and health outcomes: a review. CMAJ.......

Words: 2477 - Pages: 10

Premium Essay

Dream Act

...PUBLIC SPEAKING(UHL 4012)2011/2012 Semester I | Exercising is part of a healthy lifestyle | PERSUASIVE SPEECH OUTLINE | | | PREPARED BY: STI FAIRUN ANNISHA BINTI HASSAN KE10064 SECTION 3 01 NOVEMBER 2011 PREPARED FOR: Madam Ainol Haryati Ibrahim, Associate Professor Center of Modern Languages and Human Sciences. Title: Exercising is part of a healthy lifestyle. General purpose: To persuade Specific purpose: To persuade my audience to do some exercising. Central Main Idea: Lack of exercise is harmful to our health. Exercise is not a large investment, but the yield is very high. So we should all exercise to take advantage of this. INTRODUCTION: Attention getter: Are you getting a bit tired of that three inch spare tire around your waist? Are you becoming increasingly lazy, fat? Let's see, exercise, and improve your fitness level, or sit down with a glass of soft drink and watch your favorite evening television show. What would you do? Background information of the topic: We all want to keep our bodies young and healthy so that we can live long, happy and fulfilling lives. There is one simple thing you can do every day to help you deflect those health problems and protect your body from damage and deterioration: exercise. Preview of the speech (central idea); I want to persuade the audiences that exercise plays a major role in protecting your health and your life. So lack of exercise is harmful to our health and we must take fully...

Words: 1724 - Pages: 7

Premium Essay

Nutrition Research Critique

...1. Introduction This assignment is a critique on the study published in The New England Journal of Medicine (NEJM) entitled ‘Homocysteine Lowering and Cardiovascular Events after Acute Myocardial Infarction’ by Bonaa et. al (2006) (also known as The NORVIT study). NEJM’s most recent impact factor was 51.296 (in 2006). NEJM boasts the largest paid circulation among medical journals, with close to 200,000 paying subscribers. It is printed weekly in the United States, Canada, the Netherlands, and Japan, and a range of translated articles reaches approximately 140,000 (New England Journal of, 2006). The NORVIT study was designed as a randomized, controlled, double-blind, intervention study. It included 3,749 men and women who had suffered and acute myocardial infarction within the last 7 days. The rationale behind the study was that high homocysteine levels are considered a risk factor for cardiovascular disease (Bonaa et al, 2006). The aim was to measure how effective lowering blood serum homocysteine levels with B vitamins was in preventing a secondary event. A collaborative meta-analysis published in The Journal of the American Medical Association, states that homocysteine levels are an independent predictor of ischemic heart disease and that studies on disease risk of genetic variants affecting homocysteine may help establish whether homocysteine is causally linked to vascular disease (2002: cited by Bonaa et al, 2006). The meta-analysis suggests that a......

Words: 3026 - Pages: 13

Premium Essay

Mind and Body Article

...Mind Travis Harris Mind-Body Article Review The article i choose was a very simple article that covered basically everything we went over during class. It was an article i pulled from the "New York Times Opinon Page" titled, Exercise and Academic Performance. The articles starts off by stating that the research they based the article on was preformed by the Institute of Medicine, which is part of the National Academy of Science. The findings concluded that exercise was incredibly important to improve childrens academics performance. It went on to explain what the research had found, and the benefits of exercise were greater muscular strength, lower body fat, and better cardiovascular and mental health. The benefit of the exercise correlated with the academics in a way that children were found to be able to focus better, perform simple task quicker, and even have better working memories. The most imporant thing i believe they found was that they preform better on the standerdized test. Which i believe to be quite funny since the part of the reason they are cutting physical exercise from schools is to try to preform better on testing. The reports conclusion stated that students should get at least 60 minutes of exercise a day. The final sentence to the article i think is a strong one, editorial board said (2013), "Physical activity should be a core educational concern, not a dispendable option." Overall i think they article was well written, and made a strong and precise...

Words: 522 - Pages: 3

Premium Essay


...are. Pet Therapy is a fairly new and changing technique in the health care field. The hope of pet therapy is that during visits to the hospital it will help divert parent and children’s attention during painful procedures. Thus making the visit a more enjoyable and tolerant experience. It also examines the possible effect of lowering blood pressure on individuals who recently suffered a myocardial infarction or experience cardiovascular problems. Studies show that individuals living in a nursing home or monitored community of similar nature lack feeling of social status, suffer from psychological and physical ailments and feel the desire to be needed. This examines the possible steps that pet therapy can have in those areas of concern, as well as possibly improving not only the length of an individual’s life living in one of those settings, but also the quality of that life. Health care is an extremely important and every growing field. Pet Therapy is the concept of bringing a particular pet whether it is dog, cat, or a different pet of interest into a health care setting. In hopes of both improving the condition of the patient, as well as improve the success of the particular visit or procedure taking place. The researcher feels this is a very important technique to research because any advances in the health care field should be seen as positive. If there is any way to improve the treatment and success Pet Therapy 3 of those treatments on patients, than they should......

Words: 276 - Pages: 2

Free Essay


...ill with physician-assisted suicide. Many people frown upon this and even protest saying it’s inhumane. If a family member were on life support and only living because of the tubes connected to their body, what would you do? What if they wanted to die, to be free of pain and agony? What if the hospital they were in, not only denied them this right to die but kept them alive against their will? This was the situation in the court case of Bartling v. Superior Court. In this case, William Bartling, a mentally competent patient being of sound mind and body was put on artificial life support against his will. Before even coming to the Glendale Adventist Medical Center, Mr. Bartling was suffering from pulmonary emphysema, atherosclerotic cardiovascular disease, coronary arteriosclerosis, an abdominal aneurysm and lung cancer ("Bartling v. Superior Court," 2012). He had many medical illnesses and refused the ventilator even knowing that doing such a thing would cause him to cease living quicker. Mr. Bartling asked many times for them to remove the ventilator and when they denied him this request, he attempted to take it out himself. He was at that time tied down and secured to prevent him from removing or attempting to remove it ("Bartling v. Superior Court," 2012). In my opinion, the hospital had no right to force the ventilator on him or deny him his request to take the ventilator out. This man had zero chance of living regardless and was competent enough to make a......

Words: 637 - Pages: 3

Free Essay

Phed-1106-Py1 Walking and Fitness

...Course PHED-1106-PY1 Walking and Fitness Test Quiz: Unit 7 - Lifestyle Diseases Started 7/9/13 8:03 PM Submitted 7/9/13 8:14 PM Status Completed Score 100 out of 100 points Time Elapsed 11 minutes out of 1 hour. Instructions Question 1 10 out of 10 points A cancer preventing diet should include Answer Selected Answer: 5. All of the above Question 2 10 out of 10 points Lifestyle choices affects which form of diabetes? Answer Selected Answer: 2. Type 2 Question 3 10 out of 10 points Dystolic pressure refers to Answer Selected Answer: 2. The pressure applied to the walls of the arteries when the heart relaxes Question 4 10 out of 10 points One is considered to be pre-diabettic when the fasting blood sugar level is above Answer Selected Answer: 4. 100 Question 5 10 out of 10 points Which of the following is not a warning signal for cancer? Answer Selected Answer: 5. All of the above are warning signs Question 6 10 out of 10 points At least ___________ percent of people with diabetes will die from some form of CVD? Answer Selected Answer: 4. 65 Question 7 10 out of 10 points An optimal level of LDL cholesterol is Answer Selected Answer: 4. Between 100 – 150 Question 8 10 out of 10 points Systolic pressure refers to Answer Selected Answer: 1. The pressure applied to the walls of the arteries when the heart contracts Question 9 10 out of 10 points Regular aerobic exercise......

Words: 294 - Pages: 2