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
