CV: History Taking + Exam Flashcards
According to Nobel Peace Prize Laureate Dr Bernard Lown the medical history provides sufficient information in what proportion of patient encounters to make the diagnosis before performing a physical examination and additional tests ?
75%
Describe the different parts of the consultation according to Roger Neighbor.
1) CONNECTING (build rapport, identify patient’s views and expectations)
2) SUMMARISING
3) HANDING OVER (agree on doctor and patient agenda, give ownership of management to patient)
4) SAFETY NETTING (follow-up, advice or referral)
5) HOUSEKEEPING (Dr recognises importance of looking after oneself)
What are some conditions to consider in past medical history, wrt CVS history ?
- History of Vascular disease: Coronary artery / Cerebrovascular /Peripheral vascular
- Diabetes
- Hyperthyroidism
- Renal disease
- Hypertension
- Hypercholesterolaemia
What constitutes a young age, for each of males and females, when considering family history of CV disease at a young age ?
1st degree male relative <55 years
1st degree female relative <65 years
What are possible symptoms to look for in a CV system enquiry ?
• Chest pain • Breathlessness (including Orthopnoea and Paroxysmal Nocturnal Dyspnoea) • Palpitations • Syncope / dizziness • Oedema • Peripheral vascular symptoms (Intermittent claudication etc.) • Fatigue
Identify the main risk factors of CV disease.
NON-MODIFIABLE:
- Age
- Gender
- Genetic factors
- Race and ethnicity
MODIFIABLE:
- High BP
- Smoking
- Diabetes
- Physical inactivity
- High blood cholesterol
- Obesity
Identify possible sites of chest pain and the associated CV cause of chest pain.
- Retrosternal —> Angina or MI
- Retrosternal/Interscapular —> Aortic dissection
- Retrosternal/Left-sided —> Pericardial pain
- Retrosternal/epigastric —> Oesophageal pain
Define angina and myocardial infarction (both causes of chest pain)
ANGINA = A clinical syndrome of chest pain or pressure precipitated by activities such as exercise or emotional stress which increase
myocardial oxygen demand
MYOCARDIAL INFARCTION = death of the cells of an area of the heart muscle (myocardium) as a result of oxygen deprivation, which in turn is caused by obstruction of the blood supply (usually due to occlusion of a coronary artery)
Define acute coronary syndrome (ACS).
Spectrum of acute myocardial ischaemia that includes MI, non-ST-segment elevation myocardial infarction (NSTEMI), and unstable angina (NOT stable angina).
Distinguish MI from angina, especially wrt:
- Sites
- Precipitated
- Relieved
- Anxiety
- Sympathetic activity
- Nausea/vomiting
MI is part of acute coronary syndrome but not stable angina (unstable angina is part of ACS also).
- SITES: same between both (retrosternal, radiating to arm, epigastrium, neck, jaw)
- PRECIPITATED: by exercice or emotion (angina) vs spontaneous (MI)
- RELIEVED: rapidly by rest and nitrates (angina) vs by neither of those (MI)
- ANXIETY: Absent or mild (angina) vs severe (MI)
- Sympathetic activity: none (angina) vs increased (MI)
- Nausea or vomiting: unusual (angina) vs common (MI)
Distinguish oesophageal pain from angina, especially wrt:
- Sites
- Precipitation
- Relieved
- Wakes patient from sleep ?
- Relation to heatburn
- Duration
- SITES: retrosternal, radiating to arm, epigastrium, neck, jaw (angina) vs retrosternal or epigastric, sometimes radiates to arm or back (oesophageal pain)
- PRECIPITATED: by exercice or emotion (angina) vs can be worsened by excretion but often present at other times (oesophageal pain)
- RELIEVED: rapidly by rest and nitrates (angina) vs not rapidly relieved by rest, often relieved by nitrates (oesophageal pain)
- WAKES PATIENT FROM SLEEP: seldom (angina) vs often (oesophageal pain)
- RELATION TO HEARTBURN: none but patients often have wind (angina) vs sometimes (oesophageal pain)
- DURATION: Typically 2-10 minutes (angina) vs variable (oesophageal pain)
Describe the main characteristics of pericarditis as a cause of chest pain, especially:
- Definition
- Causes
- Clinical Presentation
- Site
- Onset
- Nature of pain
- Exacerbating factors
- Alleviating factors
- Inflammation of the pericardium (Non Ischaemic), accompanied by pericardial rub
- CAUSES: mainly idiopathic (but most likely viral in origin)
- CLINICAL PRESENTATION: acute onset of chest pain (pleuritic in nature), eased by sitting up and leaning forward
- SITE: pain may be anywhere over the anterior chest wall, but it is usually retrosternal, may radiate to the arm or to trapezius ridge (i.e. back or shoulder, usually left shoulder) latter is specific for pericarditis related chest pain)
- ONSET: no obvious initial precipitating factor, tends to fluctuate in intensity
- NATURE: stabbing, raw (sharp)
- EXACERBATING FACTORS: Changes in posture, respiration
- ALLEVIATING FACTORS: By analgesics (especially NSAIDs)
Describe the main characteristics of aortic dissection as a cause of chest pain, especially:
- Definition
- Site
- Onset
- Nature of pain
- Definition: A defect in the tunica intima of the aorta allows an opening or tear to develop
- Site: Retrosternal/Interscapular, radiates to left shoulder/back.
- Nature: Tearing and deep
- Onset: sudden and severe
Define dyspnoea.
Shortness of breath
Identify questions to ask when enquiring about dyspnoea.
• Acute, chronic or acute-on-chronic?
• How disabling? At rest / on exertion / exercise
tolerance?
• Orthopnoea / Paroxysmal nocturnal dyspnoea (PND)?
• Response to diuretic?
• Associated symptoms e.g. cough / sputum / chest pain / palpitations ?
Define orthopnoea and paroxysmal nocturnal dyspnoea (PND).
- Orthopnoea= sensation of breathlessness in the recumbent position, relieved by sitting or standing (improved with more pillows)
- Paroxysmal nocturnal dyspnoea (PND)= sensation of shortness of breath that awakens the patient, often after 1 or 2 hours of sleep, and is usually relieved in the upright position
Identify the main causes of dyspnoea (a common symptom of CV disease).
1) CARDIAC CAUSES
- Cardiac failure (orthopnoea/PND)
- Associated with angina or MI
2) RESPIRATORY CAUSES
- Asthma, COPD, pneumothorax, pneumonia, bronchitis, bronchiectasis, pulmonary fibrosis
3) OTHER CAUSES
- Anaemia, obesity, hyperventilation, anxiety, metabolic acidosis
Define palpitations.
Unexpected awareness of heart beating in chest.
How fast and regularly do palpitations occur ?
May be fast, slow, regular and irregular.
Notably, may occur in:
- Sinus rhythm (normal heart beat) e.g. anxiety
- Intermittent irregularities of heartbeat e.g. Ectopic beats (extrasystoles)
- Abnormal rhythm (arrhythmia)
Do all patients with arrhythmias experience palpitations ?
Not all
Identify the main kinds of arrhythmias with their distinguishing feature.
1) VENTRICULAR OR ATRIAL EXTRASYSTOLES
- Heart flutters/misses a beat
2) ATRIAL FIBRILLATION
- Heart racing, associated breathlessness
- May be unnoticed!
3) SUPRAVENTRICULAR TACHYCARDIA
- Heart racing or fluttering, associated polyuria
4) VENTRICULAR TACHYCARDIA
- Heart racing or fluttering, associated breathlessness
- May be present as syncope rather than palpitations
Identify questions to ask when enquiring about arrythmia.
- Ask the patient to tap it out!
- Onset and termination
- Precipitating/ relieving factors
- Frequency and duration
- Associated symptoms (Chest pain / collapse / sweating / dyspnea)
- Past medical history (e.g. Cardiovascular/thyroid disease)
Define syncope.
Loss of consciousness and postural tone caused by diminished cerebral blood flow.