CVD history and examination pt.1 Flashcards
Patient presents with chest pain, what are questions to ask?
-Is it exertional, positional, pleuritic, tender, or does it occur at rest?
- Site? Central?
- Onset? (Sudden? What was the patient doing?)
- Character? Ask patient to describe pain (Crushing? Heavy?).
- Radiation? Ask specifically if moves to arm, neck, or jaw?
- Associations? Ask specifically about shortness of breath, nausea, sweating
- Timing? Duration?
- Exacerbating and alleviating factors? Worse with respiration or movement
(less likely to be angina)? Relieved by GTN? Worse on inspiration and better when sitting forwards (pericarditis)?
- Severity: out of 10?
- Is patient known to have angina or chest pain; better/worse/same as
usual pain; is it more frequent? Decreasing exercise tolerance?
- NB: ‘heartburn’ more likely if ‘burning’, onset after eating/drinking,
worse lying flat, or associated with dysphagia.
Patient presents with palpitations, what are questions to ask?
Ever aware of your own heartbeat’? Have the patient tap out the beat with his/her hands. When and how did it start/stop? Duration? Onset sudden/gradual? Associated with blackout (how
long)? Chest pain? Dyspnoea? Food related (eg caffeine)?
Nature of palpitations and likely cause
- Regular fast palpitations may reflect paroxysmal supraventricular
tachycardia (SVT) or ventricular tachycardia (VT). - Irregular fast palpitations are likely to be paroxysmal AF, or atrial flutter with variable block
- Dropped or missed beats related to rest, recumbency, or eating are likely to be atrial or ventricular ectopics
- Regular pounding may be due to anxiety
- Slow palpitations are likely to be due to drugs such as -blockers, or
bigeminus
Reassurance is vital and can be therapeutic. Check a TSH and consider a
24h ECG (Holter monitor, p125). An event recorder, if available, is better
than 24h ECGS.
Patient presents with palpitations, what are questions to ask?
- Ever aware of your own heartbeat’? When and how did it start/stop? Duration? Onset sudden/gradual? Associated with blackout (how
long)? Chest pain? Dyspnoea? Food related (eg caffeine)? - Reassurance is vital and can be therapeutic
Nature of palpitations and likely cause
- Regular fast palpitations may reflect paroxysmal supraventricular tachycardia (SVT) or ventricular tachycardia (VT).
- Irregular fast palpitations are likely to be paroxysmal AF, or atrial flutter with variable block
- Dropped or missed beats related to rest, recumbency, or eating are likely to be atrial or ventricular ectopics
- Regular pounding may be due to anxiety
- Slow palpitations are likely to be due to drugs such as beta-blockers, or bigeminus
Patient presents with dyspnea, what are questions to ask (relating to CVD)?
- Duration? At rest? On exertion? Determine exercise tolerance (and any other reason for limitation, eg arthritis). NYHA classification?
- Worse when lying flat, how many pillows does the patient sleep with (orthopnoea)?
- Does the patient ever wake up in the night gasping for
breath (paroxysmal nocturnal dyspnoea), and how often? - Any ankle swelling?
Patient presents with diziness/blackouts, what are questions to ask (relating to CVD)?
- Dizziness is a loose term, so try to clarify if your patient means: did patient lose consciousness, and for how long (short duration suggests
cardiac while longer duration suggests a neurological cause) Any warning (pre-syncope)? What was patient doing at the time? Sudden/
gradual? Associated symptoms? Any residual symptoms, eg confusion? - How long did it take for patient to return to ‘normal’? Tongue biting, seizure, incontinence? Witnessed? Memory loss pre/post
event?
What is vertigo?
The illusion of rotation of either the patient or their surroundings ± difficulty walking/standing, patients may fall over
What is imbalance?
A difficulty in walking straight but without vertigo
What is faintness?
Light headedness
Which conditions do we see faintness?
Seen in anaemia, low BP, postural hypotension, hypoglycaemia, carotid sinus hypersensitivity, and epilepsy
When taking CVD history, what should be asked in drug history?
Particularly note aspirin/GTN/beta-blocker/diuretic/ACE-inhibitors/digoxin/statin/anticoagulant
use.
When taking CVD history, what should be asked in family history?
- Enquire specifically if any 1st-degree relatives having cardiovascular events (especially if <60yrs)
- History of hyperlipemedia, hypertension, diabetes in the family
When taking CVD history, what should be asked in social history?
Smoking, recereational drugs, impact of symptoms on daily life, alcohol (clarify number of units), hobbies, exercise
What are risk factors for ischemic heart disease?
- Hypertension.
- Smoking.
- Diabetes mellitus.
- Family history (1st-degree relative <60yrs old with IHD).
- Hyperlipidaemia.
