Discussion: SOAP Notes

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CHAPTER

The Cardiovascular System - Cardiology

After studying this chapter, you will be able to:

9.1 Identify the roots/word parts associated with the cardiovascular system.

9.2 Translate the Subjective terms associated with the cardiovascular system.

9.3 Translate the Objective terms associated with the cardiovascular system.

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Learning Outcomes

Talking Points:

Discuss the objectives for this chapter. Relate the objectives to the SOAP note plan.

Learning Outcomes

9.4 Translate the Assessment terms associated with the cardiovascular system.

9.5 Translate the Plan terms associated with the cardiovascular system.

9.6 Distinguish terms associated with the cardiovascular system in the context of electronic health records.

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Talking Points:

Discuss the objectives for this chapter. Relate the objectives to the SOAP note plan.

Introduction and Overview of the Cardiovascular System

The heart functions to move blood throughout the body’s blood vessels

Four chambers

2 atria

2 ventricles

Separated into the left and right sides

Right side receives blood from the body and delivers blood to the lungs

Left side receives blood from the lungs and delivers oxygen-rich blood to the body

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Talking Points:

The heart pumps blood to be circulated to the body’s organs and tissues.

It is made up of four chambers. The two upper chambers are called atria. The two bottom chambers are called ventricles. The heart is divided into right and left sides by a muscular structure called the septum.

Introduction and Overview of the Cardiovascular System

A valve is placed between each atrium and ventricle

Right atrioventricular valve

Left atrioventricular valve (mitral valve)

A valve is placed between each ventricle and large artery

Pulmonary valve

Aortic valve

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Talking Points:

Valves are pieces of tissue that keep blood flowing in only one direction.

A valve is placed between each atrium and ventricle:

Right atrioventricular valve

Left atrioventricular valve (mitral valve)

A valve is placed between each ventricle and large artery:

Pulmonary valve – positioned between the right ventricle and the pulmonary artery

Aortic valve – positioned between the left ventricle and the aortic artery

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9.1 Word Parts of the Cardiovascular System

Word parts associated the anatomy of the heart

atri/o

atrium

atrial fibrillation

sept/o

atrial septal defect

septoplasty

Talking Points:

Word parts associated the anatomy of the heart:

atri/o means atrium.

atrium – an upper chamber of the heart

atrial fibrillation – quivering of the atrial heart muscle

sept/o means septum.

atrial septal defect – abnormal presence of a hole between the right and left atria

septoplasty – surgical repair of the septum

9.1 Word Parts of the Cardiovascular System

ventricul/o

ventriculotomy

cardi/o

cardiology

cardiac arrest

myocarditis

coron/o

coronary artery

coronary thrombosis

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Talking Points:

ventricul/o means ventricle.

ventriculotomy – incision into the ventricle

cardi/o means heart.

cardiology – study of the heart

cardiac arrest – heart is not beating

myocarditis – inflammation of the heart muscle

coron/o means heart.

coronary artery – artery that delivers oxygen and nutrients to the heart muscle

coronary thrombosis – a clot in a coronary artery

9.1 Word Parts of the Cardiovascular System

Blood vessels are a set of tubes that connect to the heart

Two specific circulations

Pulmonary

Systemic

Three types of vessels

Arteries – take blood away from the heart

Veins – take blood back to the heart

Capillaries – connect arteries and veins

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Talking Points:

The cardiovascular system is a closed system of tubes that carry blood to and from the heart. There are two specific circulations.

The purpose of the pulmonary circulation is to take blood from the right side of the heart, leaving out the pulmonary artery, and go to the lungs to pick up oxygen and get rid of carbon dioxide. The blood is then returned to the heart in the left atrium.

The purpose of the systemic circulation is to take the oxygenated blood and deliver it to the tissues. It delivers oxygen and nutrients to the tissue and then picks up carbon dioxide and waste products such as urea.

There are three types of vessels, each with a specific function. Arteries take blood from the heart, veins carry blood back to the heart, and capillaries connect arteries and veins. Capillaries are the only vessels where nutrients, wastes, and gases leave and enter the blood.

9.1 Word Parts of the Cardiovascular System

Word parts associated with the vessels

aort/o

aortitis

aortolith

arteri/o

arteriosclerosis

endarterectomy

ather/o

atherosclerosis

phleb/o, ven/o

phlebotomy

venospasm

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Talking Points:

Word parts associated with the vessels:

aort/o means aorta (the vessel that carries blood from the left ventricle to the systemic circulation).

aortitis – inflammation of the aorta

aortolith – stone in the aorta

arteri/o means artery (muscular vessel that takes blood away from the heart).

arteriosclerosis – hardening of the artery

endarterectomy – removal of the inside of the artery

ather/o means fatty plaque.

atherosclerosis – hardening of the artery due to fatty plaque

phleb/o, ven/o mean vein (vessels that take blood back to the heart).

phlebotomy – incision into a vein

venospasm – constriction of a vein

The most common complaint is chest pain

Another complaint patients express is the feeling of a jumping sensation

Pain can be felt in the blood vessels

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9.2 Patient History, Problems, Complaints

Talking Points:

The most common complaint is chest pain (pectoralgia). Chest pain related to the heart is angina pectoris.

The feeling of a jumping sensation is called palpitation.

An odd rhythm is called an arrhythmia or dysrhythmia.

Complaints associated with the heart

pectoralgia

angina pectoris

palpitation

arrhythmia, dysrhythmia

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9.2 Patient History, Problems, Complaints

Talking Points:

Complaints regarding the heart:

pectoralgia – pain in the chest (not necessarily due to the heart)

angina pectoris – chest pain due to irregular flow to the heart

palpitation – rapid or irregular beating of the heart

arrhythmia, dysrhythmia – irregular heartbeat

Conditions associated with the circulation

aortalgia

phlebalgia

hemorrhage

diaphoresis

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9.2 Patient History, Problems, Complaints

Talking Points:

Conditions associated with the circulation:

aortalgia – pain in the aorta

phlebalgia – pain in the vein

hemorrhage – loss of blood

diaphoresis – profuse sweating

Indicators of how well the heart is pumping or the vessels are circulating blood

Skin color

Pulse

Blood pressure

Signs of heart function

Heart sounds

Electrocardiogram

Echocardiogram

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9.3 Observation and Discovery

Talking Points:

Indicators of how well the heart is pumping or the vessels are circulating blood:

Skin color – blue and pale are indicators of poor perfusion

Pulse – felt in the arteries; used to measure heart rate; also felt for strength

Blood pressure – felt in the arteries; due to the contraction of the heart (systole) followed by relaxation of the heart (diastole)

Signs of heart function:

Heart sounds – closing of the heart valves; the first sound (S1) is the closing of the atrioventricular valves; S2 is the closing of the aortic and pulmonary valves

Electrocardiogram – record of the electrical activity of the heart

Echocardiogram – ultrasound of the heart; can be used to view the structures of the heart (valves and layers) as well as blood flow through the heart

9.3 Observation and Discovery

Visualize the blood vessels with an angiogram to see abnormalities

Deposits of fat

Floating material

Cutoff in flow

Dilation of a vessel

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Talking Points:

Visualize the blood vessels with an angiogram to see abnormalities:

Deposits of fat (atherosclerosis)

Floating material (embolus)

Cutoff in flow (occlusion)

Dilation of a vessel (ectasia)

9.3 Observation and Discovery

Words relating to heart structure

endocardium

myocardium

epicardium

pericardium

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Talking Points:

Words relating to heart structure:

endocardium – inner lining of the heart

myocardium – middle layer of the heart, made of muscle

epicardium – tissue lining the outside of the heart

pericardium – tissue around the heart

9.3 Observation and Discovery

Condition of heart size

cardiomegaly

Conditions of heart rate

bradycardia

tachycardia

Miscellaneous condition

murmur

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Talking Points:

Condition of heart size:

cardiomegaly – enlarged heart

Conditions of heart rate:

bradycardia – slow heartbeat

tachycardia – fast heartbeat

Miscellaneous conditions:

murmur – abnormal heart sound (due to blood flow)

9.3 Observation and Discovery

Words relating to vessel structure

vena cava

superior vena cava

inferior vena cava

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Talking Points:

The vena cava is a large-sized vein that returns blood to the right atrium. It is divided into the superior vena cava and the inferior vena cava. The superior vena cava collects blood from the head, neck, upper chest, and arms. The inferior vena cava collects blood from everywhere else (the lower body regions).

9.3 Observation and Discovery

Condition of the aorta

aortic stenosis

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Talking Points:

Words relating to the aorta:

aortic stenosis – narrowing of the aorta

9.3 Observation and Discovery

Conditions relating to arteries

arteriosclerosis

arteriorrhexis

atherosclerosis

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Talking Points:

Conditions relating to arteries:

arteriosclerosis – hardening of an artery

arteriorrhexis – rupture of an artery

atherosclerosis – hardening of an artery due to the build-up of fatty plaque

9.3 Observation and Discovery

Conditions associated with clots

embolus

embolism

ischemia

thrombus

Conditions of veins

varicose veins

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Talking Points:

Conditions associated with clots:

embolus – mass of matter that was formed elsewhere and moved to another location

embolism – condition of having an embolus

ischemia – reduction in blood flow (usually due to clot formation)

thrombus – clot

Conditions of veins:

varicose veins – enlarged, dilated veins toward the surface of the skin

X-ray of types of vessels

angiogram

arteriogram

venogram

Process of taking an x-ray of vessels

angiography

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9.3 Observation and Discovery

Talking Points:

X-ray of types of vessels:

angiogram – x-ray of vessel

arteriogram – x-ray of artery

venogram – x-ray of vein

Process of taking an x-ray of vessels:

angiography – process of taking an x-ray of the vessels

An angioscope is a device used to look inside a vessel.

9.3 Observation and Discovery

Diagnostic procedures for the heart

cardiac catheterization

echocardiography

echocardiogram

transesophageal echocardiogram

electrocardiography

electrocardiogram

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Talking Points:

Diagnostic procedures for the heart:

cardiac catheterization – process of sticking a hollow tube (catheter) into the heart

echocardiography – using ultrasound waves to produce an image of the heart

echocardiogram – image of the heart produced by ultrasound

transesophageal echocardiogram – sonograph is inserted into the esophagus; it is used to obtain a clearer image of the heart using ultrasound waves

electrocardiography – process of recording the electrical activity of the heart

electrocardiogram – record of the electrical activity of the heart

9.3 Observation and Discovery

Professions in the cardiovascular field

cardiology

cardiologist

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Talking Points:

Professions in the cardiovascular field:

cardiology – study of the heart

cardiologist – specialist in the study of the heart

9.4 Diagnosis and Pathology

Abnormalities of the heart can be present at birth

structural defect

Abnormalities of the heart

electrical defect

diseased heart muscle

Infections of the heart

Lack of blood supply to heart muscle

Heart muscle failure

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Talking Points:

Abnormalities of the heart can be present at birth:

structural defect – usually a hole that is present through the atrial or ventricular septal wall

Abnormalities of the heart:

electrical defect – will cause arrhythmias (dysrhythmias is a synonym)

diseased heart muscle – cardiomyopathy; can lead to cardiac insufficiency

Infections of the heart – different layers can be inflamed (endocarditis, myocarditis, pericarditis)

Lack of blood supply to the heart muscle – ischemia; if blood flow is not restored, can have tissue death or myocardial infarction

Heart muscle failure – typically hear congestive heart failure; this causes a back up of blood in the veins which leads to tissue swelling

9.4 Diagnosis and Pathology

Abnormal conditions of blood vessels

inflammation

weakened area that bulges

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Talking Points:

Inflammation – phlebitis, vasculitis

Weakened area that bulges – aneurysm

9.4 Diagnosis and Pathology

Conditions of the heart related to inflammation

endocarditis

myocarditis

pericarditis

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Talking Points:

Conditions of the heart related to inflammation:

endocarditis – inflammation of the inner lining of the heart

myocarditis – inflammation of the heart muscle

pericarditis – inflammation of the outer lining of the heart

Congenital heart defects

atrial septal defect

ventricular septal defect

Abnormal heart conditions

cardiac arrest

myocardial ischemia

myocardial infarction

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9.4 Diagnosis and Pathology

Talking Points:

Congenital heart defects:

atrial septal defect – hole in the septum that separates the left and right atria

ventricular septal defect – hole in the septum that separates the left and right ventricles

Abnormal heart conditions:

cardiac arrest – heart does not beat, resulting in a stoppage in blood circulation

myocardial ischemia – reduced blood flow to the heart tissue

myocardial infarction – death of heart tissue (usually due to a prolonged period of myocardial ischemia)

9.4 Diagnosis and Pathology

Condition of the tissue surrounding the heart

pericarditis

Conditions of blood vessels

aneurysm

angioma

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Talking Points:

Condition of the tissue surrounding the heart:

pericarditis – inflammation of the tissue that surrounds the heart

Conditions of blood vessels:

aneurysm – bulge in a blood vessel (due to a weak area of the vessel wall)

angioma – tumor of blood vessels

9.4 Diagnosis and Pathology

Conditions of arteries

arteriopathy

arteritis

Conditions of veins

deep vein thrombosis

phlebitis

thrombophlebitis

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Talking Points:

Conditions of arteries:

arteriopathy – disease of the arteries

arteritis – inflammation of the arteries

Conditions of veins:

deep vein thrombosis – formation of clot in a deep vein; usually in the leg

phlebitis – inflammation of a vein

thrombophlebitis – inflammation of a vein due to a clot

9.4 Diagnosis and Pathology

General conditions of the circulation

hypertension

hypotension

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Talking Points:

General conditions of the circulation:

hypertension – high blood pressure

hypotension – low blood pressure

9.5 Treatments and Therapies

Medications that treat heart conditions address

angina

arrhythmias

Medications that treat vascular conditions address

hypertension

hypotension

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Talking Points:

Medications that address chest pain due to low oxygen delivery to the heart are antianginal medications.

Medications that treat arrhythmias are antiarrhythmics.

Cardioversion delivers a small, timed shock to the heart to allow it to reset to a normal rhythm.

Medications that treat blood pressure abnormalities act to reduce hypertension by dilating blood vessels. They correct hypotension by causing the blood vessels to constrict.

9.5 Treatments and Therapies

Surgical procedures for the heart address

congenital heart defects

coronary atherosclerosis

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Talking Points:

Sometimes it is necessary to correct heart problems with surgery. Congenital heart defects such as atrial septal defect and ventricular septal defect are corrected by closing the abnormal hole in the septum.

Coronary atherosclerosis causes a reduction in blood flow to the cardiac muscle. There are several ways this can be corrected:

coronary artery bypass surgery – creates an anastomosis with a vessel that goes around a blocked area

cardiac catheterization – a tool is advanced into the blocked coronary artery, and it can compress the plaque, widening the vessel; a stent can also be placed during the compression of the plaque

9.5 Treatments and Therapies

Drug to treat chest pain due to heart problems

antianginal

Drug to stop abnormal heart rhythms

antiarrhythmic

Drugs to treat clots

anticoagulant

thrombolytic

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Talking Points:

Drug to treat chest pain due to heart problems:

antianginal – against angina (chest pain)

Drug to stop abnormal heart rhythms:

antiarrhythmic – against arrhythmia (abnormal heartbeat pattern)

Drugs to treat clots:

anticoagulant – prevents clot

thrombolytic – breaks down clot

9.5 Treatments and Therapies

Drugs to treat high blood pressure

antihypertensive

vasodilator

Drug to treat low blood pressure

vasopressor

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Talking Points:

Drugs to treat high blood pressure:

antihypertensive – reduces high blood pressure

vasodilator – widens the blood vessel

Drug to treat low blood pressure:

vasopressor – constricts the blood vessel

9.5 Treatments and Therapies

Surgical heart procedures of the coronary arteries

coronary artery bypass surgery

coronary artery bypass graft (CABG)

cardiopulmonary bypass

percutaneous coronary intervention

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Talking Points:

Cardiothoracic surgery requires cutting through the chest wall to get to the heart.

Surgical heart procedures of the coronary arteries:

coronary artery bypass surgery – going around a blocked coronary artery

coronary artery bypass graft (CABG) – using a borrowed vessel to go around a blocked coronary artery

cardiopulmonary bypass – device that will act as the lungs (provides oxygen, removes carbon dioxide) and the heart (circulates the blood) during surgery if the heart is purposely stopped

percutaneous coronary intervention – does not required cardiothoracic surgery; tools are passed through a blood vessel and into the coronary arteries for treatment; percutaneous means “across the skin,” which is the puncture of the skin to the blood vessel (usually in the groin)

9.5 Treatments and Therapies

Surgical procedures performed on the valves

valvotomy

valvuloplasty

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Talking Points:

Heart procedures performed on the valves:

valvotomy – incision into a valve

valvuloplasty – surgical repair of a valve

9.5 Treatments and Therapies

Nonsurgical heart procedure

cardiopulmonary resuscitation (CPR)

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Talking Points:

Cardiopulmonary resuscitation is used to mimic the heart and lung function. The cardiac function (circulate blood) is accomplished by heart compressions. The pulmonary function (get oxygen into the body, get carbon dioxide out of the body) is accomplished when breathing into the patient.

Procedures performed to the pericardium:

pericardiocentesis – puncture into the pericardium (usually to remove excess fluid)

pericardiotomy – incision into the pericardium

9.5 Treatments and Therapies

Suturing of vessels

angiorrhaphy

aortorrhaphy

arteriorrhaphy

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Talking Points:

Suturing of vessels:

angiorrhaphy – suturing of a vessel

aortorrhaphy – suturing of the aorta

arteriorrhaphy– suturing of an artery

9.5 Treatments and Therapies

Surgical repair of vessels

angioplasty

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Talking Points:

Surgical repair of vessels:

angioplasty – surgical repair of a vessel

9.6 Electronic Health Records

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Talking Points:

Discuss consult note. The consult note helps the learner see the use of the terms presented thus far in context.

After studying this chapter, you should be able to:

9.1 Identify the roots/word parts associated with the cardiovascular system.

9.2 Translate the Subjective terms associated with the cardiovascular system.

9.3 Translate the Objective terms associated with the cardiovascular system.

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Learning Outcomes

Talking Points:

Summarize the objectives for this chapter. Relate the objectives to the SOAP note plan.

Learning Outcomes

9.4 Translate the Assessment terms associated with the cardiovascular system.

9.5 Translate the Plan terms associated with the cardiovascular system.

9.6 Distinguish terms associated with the cardiovascular system in the context of electronic health records.

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Talking Points:

Summarize the objectives for this chapter. Relate the objectives to the SOAP note plan.