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Junior Medicine & Surgery > Cardiac History > Flashcards

Cardiac History Flashcards

0
Q

What are the key diseases we need to know about ?

A 
Angina
Acute coronary syndromes
Heart failure 
Hypertension 
Valvular heart disease 
Tachyarrhythmias
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1
Q

Questions to ask when someone presents with chest pain?

A

SOCRATES

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2
Q

What are the main symptoms of ischaemic heart disease?

A

Angina, ACS and heart failure

However some people may not have symptoms before it is diagnosed

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3
Q

What is another term for ischaemic heart disease?

A

Coronary heart disease

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4
Q

How can cardiac pathologies present in hospital?

A 
Chest pain
Palpitations 
SOB
Syncope (see neuro)
Swollen ankles
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5
Q

Chest pain

What are the most common causes of acute chest pain?

A

CVS: ACS
Stable angina
Pericarditis (better leaning forward)
Aortic dissection (radiates to back)
Coronary spasm

Resp: Pleurisy
PE
Pneumothorax

GI:     Oesophagitis (2ndary to GORD or hiatus hernia)
          Oesophageal spasm
          Peptic ulcer 
          Cholesystitis
          Pancreatitis

Other: Musculoskeletal
Anxiety

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6
Q

Chest pain

What are the CVS risk factors?

A

Smoking, DM, HTN, hypercholest, FHx

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7
Q

Chest pain

What from the history would indicate an ACS?

A 
Sudden onset
Central chest pain 
Radiates to jaw, neck, arm 
Previous Hx or angina/ACS
CVS risk factors
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8
Q

Chest pain

On examination what may indicate an ACS?

A

CHOLESTEROL
xanthomata (hands), xanthomata (eyes), corneal arcus (but in elderly is normal)

ATHEROSCLEROSIS
weak pulse, peripheral cyanosis, ulcers, Bruits on carotids

ANAEMIA (can cause or exacerbate IHD)
Koilonychia, Conjunctival pallor, glossitis, angular stomatitis

ARRHYTHMIAS
AF - irregularly irregular

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9
Q

Chest pain

What is a typical ‘aortic dissection’ history?

A

Sudden onset
Central, ripping/tearing chest pain
Radiates to the back

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10
Q

Chest pain

What might you find O/E that could suggest an aortic dissection?

A

Absent pulse in one arm
Hypertension (in 50%) or hypotension (in 25%)
Difference in BP of >20mmHg between each arm
Pleural effusion (normally on LHS) -
tracheal deviation away from effusion, reduced chest expansion,
Reduced tactile fremitus, stony dull, reduced/absent breath
sounds

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11
Q

Chest pain

How would a pneumothorax history present?

A

Sudden onset

Pleuritic chest pain + breathlessness (BUT can be painless sob)

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12
Q

Chest pain

What would be found OE of a patient with a pneumothorax?

A

Hyperinflated chest wall with impaired chest expansion
Tracheal deviation (away from pneumo in tension)
Hyperresonant to percuss
Absent breath sounds

Trauma

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13
Q

Chest pain

Typical history of a PE?

A

A diagnosis of exclusion!! Very vague presentation so exclude everyone else first.

Sudden onset
SOB +/- haemoptysis +/- pleuritic chest pain +/- tender calf +/- risk factors

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14
Q

Chest pain

What are the risk factors of a PE

A 
Immobility
Surgery 
DVT/Previous emboli 
Pill
Malignancy
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15
Q

Chest pain

What might you find OE of a patient with a PE?

A 
Signs of hypoxia: pale, Cold hands, Lethargic/confused 
Raised JVP (right heart strain)

WELLS CRITERIA to diagnose a suspected PE

16
Q

Chest pain

What history would a patient with oesophagitis typically have?

A

Heartburn - retrosternal pain that may radiate. Worse after eating, lying down, straining. Relieved by antacids
Acid brash
Odynophagia

17
Q

Chest pain

How might you investigate oesophagitis?

A

Endoscopy

Barium swallow - may show hernia or stricture

18
Q

Chest pain

How might you treat oesophagitis?

A 
Lose weight 
Stop smoking 
Reduce alcohol intake 
Avoid eating late at night 
Sleep with pillows 
Drugs - PPIs, antacids
Surgery - if severe. Make a new functional sphincter
19
Q

Chest pain

History from a patient with peptic ulcer disease?

A

Chest + epigastric pain
Duodenal - pain worse at night. Better during eating.
Gastric - pain worse when eating or just before.

Will have some of the risk factors:
A - alcohol
S - smoking
S - steroids
H - H pylori 
O - blood group O
N - NSAIDS
20
Q

Chest pain

What signs and symptoms would make you more concerned about a patient presenting with peptic ulcer disease?

A 
A - anaemia 
L - weight loss
A - anorexia
R - recent onset or progressive symptoms
M - malaena or haematemesis 
S - swallowing difficulties
21
Q

Chest pain

What would you find OE and on investigation of a patient with perforated peptic ulcer?

A

Signs of hypovolaemic shock
Generalised peritonitis - 1. rebound tenderness, 2. involuntary guarding, 3. washboard rigidity, 4. distended abdo, 5. absent bowel sounds

Pneumo peritoneum on CXR
+ve urea breath test - h pylori

22
Q

Chest pain

How would you manage a patient with perforated peptic ulcer ?

A
  1. Treat the generalised peritonitis
    IV Fluids, ABx, analgesia
  2. Laparotomy/laparoscopy
    Peritoneal washout
    Repair ulcer
23
Q

Chest pain

What discharge meds would you give a patient with a perforated peptic ulcer?

A

A PPI = omeprazole + an H2 R antagonist

24
Q

Chest pain

If a patient tests positive for H pylori what is prescribed?

A

Triple therapy: PPI + amoxicillin + clarityromycin

25
Q

Chest pain

How would you investigate chest pain?

A

ECG
BLOODS: troponin (shows cardiac m damage), serum cholesterol, FBC (anaemia) + WCC, U&Es (K = arrhythmias), CRP, ESR, glucose
Erect CXR (pneumothorax and aortic dissection)
D dimer

26
Q

Chest pain

How are all ACS patients initially managed when they arrive in hospital? And why would you give each one?

A

MONABASH

Morphine (analgesia) + metoclopramide (antiemetic)
Oxygen
Nitrates (vasodilate)
Antiplatelets (prevent further thrombosis)
B-blockers (reduce myocardial oxygen demand)
ACEi (stop ventricular remodelling = arrhythmias, reduce angiotensin 2-
induced vasoconstriction, +ve effect on endothelial function)
Statins (reduce cholesterol + loads of other benefits)
Heparin (LMWH - prevent coronary thrombosis)

27
Q

Chest pain

In addition to MONABASH, what should STEMI patients be given?

A

Either thrombolysis or angioplasty. Must deliver within 12hr after the onset of pain but ASAP!!

28
Q

Chest pain

In addition to MONABASH, what should NSTEMI patients be given?

A

Nothing - monitor. DO NOT thrombolyse.

If TIMI risk score >/= 3 do coronary angioplasty

29
Q

Chest pain

What is the TIMI risk score?

A

TIMI risk score for NSTEMI unstable angina

Age >65
>/= 3 RF for coronary artery disease
Coronary stenosis >50%
Aspirin use in last 7 days
>/= 2 symptoms or severe angina in last 24h
Raised cardiac markers
ST deviation of >/= 0.5mm

(All = 1)

35
Q

Palpitations

How would you describe palpitations to a patient?

A

Are you ever aware of your heart beating?

36
Q

Palpitations

What questions would you ask in a palpitation history?

A

Tap it out
When do they happen
How long do they last
Does any thing trigger them - caffeine, stress etc
Associated symptoms
Do you have any underlying heart conditions

38
Q

Palpitations

What associated symptoms may indicate the patient is haemodynamically unstable? (Needs drugs or mechanical support to maintain BP or adequate CO)

A

Chest pain, SOB, Syncope (these are also the 3 Cardinal symptoms in aortic stenosis)

39
Q

Palpitations

How would you investigate Palpitations?

A

TSH (thyrotoxicosis)

12 hour ECG or 2 week event monitor

40
Q

Palpitations

How might the patient describe their palpitations and what would each suggest?

A
  1. Irregular (atrial) and fast - paroxysmal AF or atrial flutter with variable heart block
  2. Regular (ventricular) and fast - paroxysmal SVT or VT
  3. Missed beats whilst eating or resting - ectopics
  4. Regular pounding - anxiety
  5. Slow palpitations - drugs (B blockers) or Bigeminus

Junior Medicine & Surgery (3 decks)

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