NSG 6420 MIDTERM EXAM WEEK 4
1. Which of the following is the most important question to ask during cardiovascular health history?
Student
... [Show More] Answer:
Number of offspring
Last physical exam
Sudden death of a family member
Use of caffeine
Instructor Explanation:
The sudden death of a family member is an important question to ask in the health history because it reveals the cardiovascular disease risk of the patient. Sudden death is usually due to an acute cardiovascular event, such as myocardial infarction, cardiac dysrhythmia, or stroke.
Family history is particularly important for cardiac assessment because CVD, HTN, hyperlipidemia, & other vascular diseases often have a familial association that is not easily ameliorated by lifestyle changes. If there are deaths in the family related to CVD, determine the age & exact cause of death, because CVD at a young age in the immediate family carries an increased risk compared with CVD in an elderly family member. Ask about sudden death, which might indicate a congenital disease such as Marfan's syndrome. This is especially important to ask during pre-sports physicals because sudden death in athletes is often related to congenital or familial heart disease. Familial hyperlipidemia is autosomal dominant & often leads to CAD & MI at a young age.
Family history of obesity & type 2 diabetes are also secondary risk factors for heart disease because the familial tendency for these is strong. Ask about smoking in the house, as secondhand smoke is a risk factor for respiratory & cardiac disease. (Goolsby 167-168)
Question 2.
A key symptom of ischemic heart disease is chest pain. However, angina equivalents may include exertional dyspnea. Angina equivalents are important because:
Student Answer:
a) Women with ischemic heart disease many times do not present with chest pain
b) Some patients may have no symptoms or atypical symptoms;
c) Diagnosis may only be made at the time of an actual myocardial infarction
d) Elderly patients have the most severe symptoms
A & B only
Instructor Explanation:
The key symptom of IHD is chest pain, but other common symptoms include arm pain, lower jaw pain, shortness of breath, & diaphoresis. These symptoms are referred to as angina equivalents & can also include fatigue or breathlessness. Some patients may have no symptoms or atypical ones so that CAD may not be diagnosed until they experience a myocardial infarction. (Kennedy-Malone 227)
Question 3. :
A 55-year-old post-menopausal woman with a history of hypertension complains of jaw pain on heavy exertion. There were no complaints of chest pain. Her ECG indicates normal sinus rhythm without ST segment abnormalities. Your plan may include:
Student Answer:
Echocardiogram
Exercise stress test
Cardiac catheterization
Myocardial perfusion imaging
Instructor Explanation:
Once all the results of the initial laboratory & ECG testing are reviewed, a pretest probability of disease can be generated & additional tests can be ordered.2 The probability of CAD can be calculated by considering the chosen noninvasive test's sensitivity & specificity.2 Selection of the proper cardiac test (see Table 115-1) for an individual depends on the person's risk stratification, age, & tolerable level of activity. The most common & least invasive test for diagnosis of CAD is the stress test, also called the exercise tolerance test (ETT) or treadmill exercise. (Buttaro 488)
Question 4.
Jenny is a 24 year old graduate student that presents to the clinic today with
Student Answer:
Mitral Valve Prolapse
Referred Pain from Cholecystitis
Pericarditis
Pulmonary Embolus
Instructor
Explanation: Pericarditis, inflammation of the pericardium, is usually not a solo disease process but is seen in conjunction with other diseases or conditions. Pericarditis may occur as a complication of MI (Dressler's syndrome) or coronary artery bypass surgery. It is also more commonly seen in patients with connective tissue disorders such as rheumatoid arthritis, systemic lupus erythematosus (SLE), scleroderma, & sarcoidosis. Bacterial, viral, or fungal infections, including HIV, are risk factors for pericarditis. Pericarditis can occur with kidney failure or metastatic neoplasias or as a reaction to medication, particularly phenytoin, hydralazine, & procainamide. Rarely, it is idiopathic & the cause unknown, although a common viral infection is suspected. Cardiac tamponade can occur as a serious complication, & it is an emergency requiring immediate pericardiocentesis. Constrictive pericarditis can occur over time due to scarring of the pericardial sac.
Signs & Symptoms: Unlike the symptoms associated with ACS, the pain accompanying pericarditis is sharp & stabbing; it may worsen with inspiration or when lying flat or leaning forward. Associated symptoms may include shortness of breath, fever, chills, & malaise. (Goolsby 179)
Question 5.
Which symptom is more characteristic of Non-Cardiac chest pain?
Student Answer:
Pain often radiates to the neck, jaw, epigastrium, shoulder, or arm
Pain tends to occur with movement, stretching or palpation
Pain usually lasts less than 10 minutes & is relieved by nitroglycerine
Pain is aggravated by exertion or stress
Instructor Explanation:
Palpate chest wall for tenderness & swelling. Chest pain present in only one body position is usually not cardiac in origin.(MSN 194)
Question 6.
What is the most common valvular heart disease in the older adult?
Student Answer:
Aortic regurgitation
Aortic stenosis
Mitral regurgitation
Mitral stenosis
Instructor Explanation:
Age: Present in 2% to 9% of persons over age 65, aortic stenosis is the most clinically significant cardiac valve lesion (Faggiano, 2006). Isolated aortic regurgitation is rarely seen & is usually accompanied by some degree of mitral valve involvement. Mitral regurgitation is more common than mitral stenosis in elderly individuals. Mitral valve disease, commonly caused by rheumatic heart disease, is usually acquired by younger patients; however, the effects may not be seen until they are in their forties or fifties. Mitral valve stenosis has a progressively slow course with latent symptoms over 20 to 40 years followed by rapid acceleration in later life. (Kennedy-Malone 259)
Question 7.
Jeff, 48 years old, presents to the clinic complaining of fleeting chest pain, fatigue, palpitations, lightheadedness, & shortness of breath. The pain comes & goes & is not associated with activity or exertion. Food does not exacerbate or relieve the pain. The pain is usually located under the left nipple. Jeff is concerned because his father has cardiac disease & underwent a CABG at age 65. The ANP examines Jeff & hears a mid-systolic click at the 4th ICS mid-clavicular area. The ANP knows that this is a hallmark sign of:
Student Answer:
Angina
Pericarditis
Mitral valve prolapse
Congestive heart failure
Instructor Explanation:
Mitral valve prolapse
Sharp left anterior chest pain, generally occurring in response to stress or emotional events Chest discomfort lasting seconds to days
Palpitations & dyspnea
Mitral valve click may be noted in systole at left lower sternal border (Buttaro 529) Buttaro, Terry, JoAnn Trybulski, Patricia Bailey, Joanne S&berg-Cook. Primary Care, 4th Edition. Mosby, 2013. VitalBook file.
MVP, also termed click-murmur syndrome, is a variant of mitral regurgitation & occurs in approximately 10% of young women. MVP generally is hemodynamically insignificant & characterized by normal heart size & dynamics, although the process can progress to hemodynamically significant mitral regurgitation. Characteristically, a portion of the mitral valve balloons into the left atrium, giving rise to a midsystolic click followed by a soft grade I murmur that crescendos up to S2. It is high-pitched & is heard best at the apex or left sternal border. Some patients with MVP have only a murmur & no click, & others have only a click & no murmur. (Goolsby 185)
Question 8.
The aging process causes what normal physiological changes in the heart?
Student Answer:
The heart valve thickens & becomes rigid, secondary to fibrosis & sclerosis
Cardiology occurs along with prolapse of the mitral valve & regurgitation
Dilation of the right ventricle occurs with sclerosis of pulmonic & tricuspid valves
Hypertrophy of the right ventricle
Instructor Explanation:
The aging process can also have an adverse effect on the cardiac valves. The valves tend to become thick & stiff secondary to arteriosclerosis & atherosclerotic plaques. (Kennedy-Malone 201)
During the past three decades, with the successful treatment of streptococcal pharyngitis, the etiology has shifted away from rheumatic to calcific. All such cases share a history of 20 to 30years of repetitive mechanical trauma of the blood against the valve, resulting in fibrosis, calcification, & eventually stenosis. This progress of calcification within the valve cusps is usually seen during the latter decades of life. An inflammatory process similar to that affecting the development of atherosclerotic plaques in coronaries may be a possible cause of the progression of AS. It has been noted that early lesions & calcification in AS are comparable to those found in coronary plaques.4 (Buttaro 602)
Question 9.
Dan G., a 65-year-old man, presents to your primary care office for the evaluation of chest pain & left-sided shoulder pain. Pain begins after strenuous activity, including walking. Pain is characterized as dull, aching; 8/10 during activity, otherwise 0/10. Began a few months ago, intermittent, aggravated by exercise, & relieved by rest. Has occasional nausea. Pain is retrosternal, radiating to left shoulder, definitely affects quality of life by limiting activity. Pain is worse today; did not go away after he stopped walking. BP 120/80. Pulse 72 & regular. Normal heart sounds, S1 & S2, no murmurs. Which of the following differential diagnoses would be most likely?
Student Answer:
Musculoskeletal chest wall syndrome with radiation
Esophageal motor disorder with radiation
Acute cholecystitis with cholelithiasis
Coronary artery disease with angina pectoris
Instructor Explanation:
With a complaint of chest pain, the most life-threatening diagnosis should be ruled out first. A thorough history identifying the quality & quantity of the pain, alleviating & aggravating factors, & associated symptoms assists in raising or lowering your index of suspicion for a myocardial origin of the pain. Age, gender, weight, vital signs, family history, & medical history also assist in diagnosis.
Signs & symptoms that are suspicious for myocardial ischemia include substernal chest pain or discomfort that may radiate into the neck or left arm, diaphoresis, nausea, shortness of breath, & perhaps weakness. Chest discomfort that increases with exertion
& resolves with rest or nitroglycerin can indicate myocardial ischemia. Chest discomfort that occurs in the early morning or wakes a patient at night can also be cardiac in origin. Chest discomfort or pain at rest is worrisome because it may signify ACS (unstable angina or an acute MI). Atypical symptoms such as jaw pain, fatigue, indigestion, & upper back pain are more common in women, the elderly, & patients with diabetes. (Goolsby 178-179)
Question 10
.A common auscultatory finding in advanced CHF is:
Student Answer:
Systolic ejection murmur
S3 gallop rhythm
Friction rub
Bradycardia
Instructor Explanation:
Pathological S3, also called a ventricular gallop, is heard in adults & is associated with decreased myocardial contractility, HF, & volume overload conditions, as can occur with mitral or tricuspid regurgitation. The sound is the same as a physiological S3 & is heard just after S2 with the patient supine or in the left lateral recumbent position. The sound is very soft & can be difficult to hear.(Goolsby 165)
Question 11.
Your 35-year-old female patient complains of feeling palpitations on occasion. The clinician should recognize that palpitations are often a sign of:
Student Answer:
Anemia
Anxiety
Hyperthyroidism
All of the above
Instructor Explanation:
Occasional palpitations occur physiologically in the majority of the population or as a result of other noncardiac conditions, such as anxiety, exercise, hyperthyroidism, & anemia. They can also occur with VHD, increased or decreased stroke volume, & arrhythmias. The patient may complain of palpitations or skipped beats, or an arrhythmia may be seen on EKG. Patients are often aware if their heart rate is slower or faster than normal or if it is irregular. With some arrhythmias, patients may complain only of fatigue, shortness of breath, weakness, or syncopal episodes. These are common symptoms in patients who have atrial fibrillation, &, if the ventricular response is slow, the patient may be unaware of the arrhythmia. Ask the patient about the frequency & duration of the palpitations & the presence of associated symptoms, such as loss of consciousness, lightheadedness, chest pain, shortness of breath, nausea, or vomiting.(Goolsby 173)
Question 12
The best way to diagnose structural ♥ disease/dysfunction non-invasively is:
Student Answer:
Chest X-ray
EKG
Echocardiogram
Heart catheterization [Show Less]