Cardiorespiratory Histories Flashcards
What are the associated features questions you would ask a patient with chest pain?
- Feel sick with the pain? (nausea)
- Have you been sweating much since it started?
- Do you get breathless?
- Breathless on lying flat? (orthopnoea)
- How many pillows do you sleep with at night? (orthopnoea)
- Do you ever wake up gasping for breath? (parxymal ND)
- Palpitations e.g. awareness of your heart beating?
- if YES - fast or slow or irregular palpitations?
- Noticed a cough? anything brought up? blood?
- Weight loss? appetite? (constitutional)
- Pain worse on movement? hurt to press on the area? (MSK)
What are some differentials to think about in chest pain?
- Acute coronary syndrome
- Stable angina
- Aortic dissection
- Pulmonary embolism
- Tension pneumothorax
- pneumonia
- musculoskeletal pain inc. costochrondritis, aka Tietze’s syndrome
- Gastro-oesophageal refluz disease
- Pericarditis
What investigations should you do in chest pain presentations?
- Cardioresp exam
- 12 lead ECG [esp. promptly if Acute coronary syndrome is suspected]
- bloods- FBC, U&E, CRP and cardiac markers (baseline and 12 hours)
- Blood cultures
- Chest X-ray
- CT can for suspected AAA
- If PE suspected: CT Pulmonary Angiography or V/Q scan
- D-dimer –> rule this out even if you dont suspect PE
- Stress ECG (not in the acute stting) or myocardial perfusion scans of coronary calcium score if available
- angiogram
- oesophageal manometry and pH studies
- Endoscopy
What are the symptoms of acute coronary syndrome?
- Sudden
- severe
- crushing chest pain
- radiates to arm and/or jaw
- Associated:
- breathlessness
- nausea
- vomiting
- sweating
- Associated:
- Typically in
- old, obese, male, smoker with a sedentary lifestyle
- Angina often coexists but the pain is described as different to their usual pain
What are the symptoms of stable angina?
- Angina = symptomatic, reversible myocardia ischaemia
- Central chest pain that may radiate to the arm and/or jaw
- pain brought on by exercise and relieved by rest
- no relation to food
- associated
- breathlessness
- BUT NOT nausea, sweating, vomiting (not typical)
- associated
- Less likely to be simple angina if the pain remains after 20 minutes of rest and there is no relief from GTN spray
- [unstable angina/crescendo if its angina of increasing frequency or severity; occurs on minimal exertion or at rest; assoc with increased risk of MI]
What are the symptoms of aortic dissection?
- Sudden onset
- severe tearing/ripping pain
- felt betwen the shoulder blades
- possible history of recent trauma
- inc. RTA, background of HTN or ehler-danlos/marfans syndrome
- symptoms are widely ranging and secondary too interruption of blood flow from the aorta so can present (sometimes confusingly) with:
- ischaemic limbs
- cerebral vascular accidents
- Acute MI
What are the symptoms of pulmonary embolism?
- sudden onset
- pleuritic pain
- associated
- SOB
- fever
- haemoptysis
- associated
- PH of having noticed a swollen, hot, tender leg, unilaterally
- Risk factors:
- malignancy
- pregnancy
- clotting disorders
- recent long haul flights
- surgery w/subsequent immobility
What symptoms are there of tension pneumothorax?
- Sudden onset of pleuritic chest pain with associated SOB
- background history of
- lung disease
- collagen disease e.g. marfans
- recent chest trauma e.g. recent insertion of a central line
What are the symptoms of pneumonia?
- Hx of cough and purulent sputum with
- general malaise
- fever
- Pleuritic chest pain
- haemoptysis
- wheezing
- SOB
- potentially a background Hx of respiratory disease e.g. COPD
What are the symptoms of MSK pain? e.g. costochondritis (tietze syndrome) - in chest pain ddx
- localised
- superficial
- pleuritic pain
- no other associated symptoms
- may or maynot be PMH of trauma
- consider if
- younger patient
- long standing chest pain
- consider if
What are the symptoms of gastro-oesophageal reflux disease?
- Retrosternal burning sensation
- worse on
- lying flat
- after eating large meals
- bending foraward
- straining
- relieved by
- swallowing saliva
- water
- antacids
- associated with the sensation of some regurgitation of acid and a sour taste
What are the symptoms of pericarditis?
- pleuritic pain typically felt retrosternally
- agrevated by coughing
- classically pain is better on sitting forward
- worse lying back
What are the ddx for heart palpitations?
Cardiac causes
Atrial fibrillation
atrio-ventricular nodal re-entry tachycardia
ventricular tachycardia
ectopic beats
NB: palpitations may represent an arrhythmia but most arrhythmias do not produce palpitations. syncope or history of ischaemic heart disease makes ventricular tachycardia and other serious arrhythmias more likely –> promptly investigate…
Non-cardiac causes
thyrotoxicosis
anxiety
phaeochromocytoma
What investigations should be done for palpitations?
- CVS examination
- 12-lead ECG
- 24-48 hour ambulatory ECG tape
- transtelephonic event monitoring for less frequent attacks
- FBC, U&Es, TFTs
- echocardiogram if ECG is abnormal
- anxiety questionnaire e.g. HAD10
- electrophysiological studies
- 24 hour urine catecholamines [pheochromocytoma]
What are the symptoms of atrial fibrillation?
- often asymptomatic
- maybe signs and symptoms of heart failure
- recent history of cardiac event of major surgery
- maybe paroxysmal, persistant or permanent
- Symptoms can include;
- IHD
- valvular disease
- thyrotoxicosis
- alcohol
- pneumonia
What are the symptoms of atrio-ventricular notal re-entry tachycardia?
Paroxysmal palpitations and sometimes associated syncope
e.g. wolff-parkinson-white syndrome
What are the symptoms of ventricular tachycardia?
Often short lived and asymptomatic
prolonged episodes may cause haemodynamic compromise
typically occurs in patients with cardiac pathology e.g. IHD, heart failure, cardiomyopathy or long QT syndrome
family history may reveal a sudden death in a family member
what are the symptoms of ectopic beats?
Typically patients feel a skipped beat; followed by an uncomfortable lurch in the chest
some patients describe an inability to catch their breath
the palpitations maybe more evident when the patient lies flat, commonly at night-time –> related to the natural slowing of the heart rate at this time
What are the symptoms of thyrotoxicosis?
Hx of:
- weight loss
- heat intolerance
- hair loss
- altered appetite
- loose bowels
- tremor
- neck swelling
- palpitations
- menstural irregularity
what are the symptoms of anxiety?
- Hx of anxiety, agitations, sweating, nausea and dry mouth
- an intense feeling of panic or anxiety usually precedes the palpitations
- palpitations are often regular, slughtly fast and tend to come and go gradually
