ICP Flashcards
what vertebrae levels are the important jerks
L3,L4 - knee jerk
S1, S2 - ankle jerk
other jerks included in neurological examination are
Bicep - C5
supinator - C6 /brachioradialis muscle
triceps - C7
plantar response /babinski reflex
whats koilonychia and leukonychia
Koilonychia = spoon shaped nails which is a sign of iron deficiency anaemia
Leukonychia = white spots on the nails due to low albumin levels so found in chronic liver failure
Scncope definition and 2 types
Syncope refers to transient loss of consciousness. There are two main types of cardiac syncope and the history may go a long way to help determine the diagnosis.
Vasovagal Syncope (fainting) and variations
Stokes-Adams attacks
vasovagal syncope - description
o loss of consciousness and muscle strength characterised by a fast onset, short duration, and spontaneous complete recovery. It is caused by a decrease in blood flow to the brain, typically from low blood pressure. There is frequently a prodrome which may include feeling warm, lightheaded, blurred vision, nausea and an unpleasant gastric sensation accompanied occasionally by borborygmi and eructation.
o Common descriptions are those of pallor, sweating, and dilated veins which may cause a grey colour. Recovery of consciousness is sudden and complete with no sequelae although normal motor function may take a few minutes.
o Vasovagal Syncope may also be associated with a short episode of muscle twitching. When consciousness and muscle strength are not completely lost, it is called presyncope. It is recommended that presyncope be treated the same as syncope
vasovagal syncope - history/ descriptions
Precipitating factors (emotion, sight of blood, pain)
Prodromal symptoms (nausea, blurred vision)
Colour change (pallor, grey, and sweatiness)
Recovery (spontaneous, sudden, complete)
There should be an absence of confusion or drowsiness
Pallor and sweating indicate release of catecholamines to overcome hypotension
Vasovagal syncope may run in families
Collateral history from a witness is very valuable and should be sought in every case
strokes-adams attacks - description
o Typically an attack occurs without warning, leading to sudden loss of consciousness. During an attack, a patient may be pale with hypoperfusion. Abnormal movements may be present, typically consisting of twitching after 15–20 seconds of unconsciousness. (These movements, which are not seizures, occur because of brainstem hypoxia and not due to cortical discharge as is the case for epileptiform seizures). Breathing typically continues normally throughout the attack, and, upon recovery, the patient becomes flushed as the heart rapidly pumps the oxygenated blood from the pulmonary beds into the systemic circulation, which has become dilated due to hypoxia.
o As with any syncopal episode that results from a cardiac dysrhythmia, the fainting does not depend on the patient’s position. If it occurs during sleep, the presenting symptom may simply be feeling hot and flushed on waking.
strokes adams attacks - history/ symptoms
o History
A prodrome may precede Vasovagal Syncope
A prodrome is absent in Stokes-Adams attacks
Pallor by a flush as consciousness returns is typical
A cold sweat is less of a feature of Stokes-Adams attacks
Recovery is sudden and complete without sequelae
May occur with tachycardia as well as bradycardia
what causes strokes adam attacks after exercise
o Syncope during exercise suggests structural heart disease
o Syncope related to exercise should always be thoroughly evaluated
o The causes are often reversible and would include:
Cardiac failure and cardiomyopathy
Outflow tract obstruction (aortic stenosis and HCM)
Aberrant origin of the RCA
Occasionally VVS after severe exertion (benign)
simple ectopic beats
Ectopic beats are common. Many people without any cardiac disease experience ectopic beats. Many asymptomatic people will have ectopic beats on routine ambulatory ECG monitoring.
In some people they are very intrusive and cause symptoms.
They are often described as “missed beats” when in fact they are premature additional beats. Because they are premature cardiac filling is incomplete and so the beat may be impalpable at the wrist, hence the “missed beat” sensation.
They commonly occur at rest, for example lying in bed, sitting and after meals. They may occur in runs and last for a variable amount of time. They frequently superess with activity.
They are more frequent with any intercurrent illness, stress, fatigue and anxiety.
sinus tachycardia
Sinus tachycardia is common
Catecholamine hormones (adrenaline and noradrenaline will make the heart beat harder and faster
Increased circulating concentrations of these hormones occur with anxiety, stress, panic disorder
Sinus tachycardia may occur with thyrotoxicosis (increased sensitivity to catecholamines) and anaemia
While the onset of tachycardia may be sudden the sensation of palpitation eases off gradually
cardiac arrhythmia
A cardiac arrhythmia occurs independent to external influences
They occur secondary to an intra-cardiac circuit or due to an automatic focus discharging
They are sudden in onset
They terminate abruptly
They usually have a rapid rate (which is constant apart from AF)
They may be regular (SVT or VT) or irregular (AF)
There may be associated symptoms
There may be precipitating and relieving factors (Valsalva Maneuver)
They may be followed by polyuria
Considerations
• Younger patients consider sinus tachycardia or SVT
• Older patients suspect paroxysmal atrial fibrillation if irregularity of rhythm is described during tachycardia
• Patients with heart disease (particularly previous myocardial infarction or cardiomyopathy) especially if there is a history of syncope or pre-syncope following the onset of tachycardia consider ventricular tachycardia
• Remember to ask for family history of Sudden Cardiac Death
atrial fibrillation
• Atrial fibrillation is the commonest cardiac arrhythmia. It may be permanent, persistent or paroxysmal. It may occur in the young or the older patient. The key feature of the history is that the cardiac rhythm is irregular.
• In younger patients it may be related to :
o Training
o Alcohol
o Thyrotoxicosis
• In older patients it may be related to :
o Obesity
o Sinoatrial disease (common)
o Hypertension
o Sleep apnoea syndrome
• While mitral stenosis due to rheumatic fever remains the classic cardiac disease to cause atrial fibrillaton any cardiac disease that increases left atrial pressure may be associated with atrial fibrillation. Cardiac failure, myocardial infarction, cardiomyopathy and valve disease
• One of the major complications off atrial fibrillation is embolic stroke and systemic embolism. This can be prevented by anticoagulation treatment. There is a score that can be calculated from the history.
types of chest pain - how to differentiate
- There are many causes for chest pain
- All structures in the chest may cause pain
- Chest wall pain (muscles, ribs, sinews, cartilage) - feels muscular
- Pain radiating from the spine and nerves - short lived and severe
- The lungs and pleura (pleuritic pain) - worse with respiration
- The oesophagus - heartburn worse after hot drinks or meals or lying flat and relieved by antacids or milk
- The heart - pericardium worse when leaning forwards and backwards
- The aorta - may be between shoulder blades and have a tearing quality
- CAD is increasingly commonly detected (increasing use of CT) and many individuals will have coronary disease and have no symptoms
angina
• It may be caused by coronary artery disease
• It may be due to cardiomyopathy
• It may be due to aortic stenosis
• It is precipitated by effort and relieved promptly by rest
• Prompt relief by using the GTN (Glyceryl trinitrate) is characteristic
• It may present in the chest, and radiate to arms, jaw and teeth
• Breathlessness and chest tightness are not always angina
• Angina is believed to be due to myocardial ischaemia. This occurs when myocardial oxygen demand exceeds myocardial oxygen delivery. Exercise or effort increases oxygen demand.
• Myocardial ischaemia can be demonstrated on the ECG recording as ST segment depression. Myocardial ischaemia will increase with continuing exercise and resolve promptly with rest
• Exercise increases heart rate and blood pressure (increases myocardial work and myocardial oxygen demand) and rest reduces heart rate and blood pressure. GTN causes immediate vasodilatation and will lower blood pressure. True angina resolves very quickly within a minute or two. Chest tightness that resolves over the course of many minutes is unlikely angina
• Angina is more easily precipitated after a meal. This is because eating increases myocardial work. There is an increase blood flow (cardiac output) to the gut.
• Heart rate increases just as it would with exercise. Blood pressure falls due to splanchnic vessel dilatation. Peripheral blood vessels (systemic) constrict and this also contributes to the increasing in myocardial work.
• There is good reason to ask if the angina or discomfort is more easily precipitated after a meal
• Angina is more troublesome or more easily precipitated in cold weather. This is because exposure to cold increases peripheral resistance due to vasoconstriction and blood pressure.
This means that angina develops with less effort in cold weather because the person is starting with increased cutaneous vasoconstriction. This is why your hands go white in the cold.
This is why we ask patients if the angina is more easily precipitated in cold weather.
breathlessness
- Breathlessness due to the heart is thought to be related to an increase the left atrial pressure. This increasing in left atrial pressure is transmitted back to the pulmonary capillaries. This changes the trans-capillary pressure gradient and fluid exudes into the alveoli causing pulmonary oedema. The reduction in capacity for gas exchange due to the oedema causes breathlessness.
- The most important determinant of the left atrial pressure is Starling’s Law of the heart. This states that the heart will contract more, the more it is stretched. The more cardiac filling the more blood it will eject. This will occur until the filling pressure reaches the critical point that affects the trans-pulmonary capillary pressure gradient. In a diseased myocardium the curve is much flatter.
- Breathlessness (dyspnoea) is an important symptom that may indicate cardiac disease
- It is also an important symptom for respiratory disease
- Breathlessness may occur with anaemia
- Breathlessness may occur with obesity
- Breathlessness may occur with hyperventilation
- Cardiac dyspnoea occurs in any situation where there is an increase in left atrial pressure
- Exercise, lying flat, sleep and transfusion of blood and fluids will all increase filling pressures
- Typically cardiac dyspnoea occurs with effort (muscle contraction increases venous return)
- Typically cardiac dyspnoea occurs when lying flat due to increased venous return : orthopnoea
- Typically cardiac dyspnoea causes the patient to wake suddenly from sleep and sit up : paroxysmal nocturnal dyspnoea
cardio exam - position
lying down with bed at 45 degrees
cardio exam - hands
- Tobacco staining
- Tendon xanthomata
o Build up of cholesterol on extensor tendons
o Familial hypercholesterolemia - Pallor
o anaemia - Signs of endocarditis
- Clubbing
o CVD, endocarditis - Peripheral perfusion
capillary refill time
- Apply pressure to nail; bed then release
- Blood should return in 2 seconds if perfusion good
radial pulse
feel at lateral edge of risk using 3 fingers
- Rate
o Count no. pulses in 15 seconds and x by 4 to estimate pulse rate in bpm
o Compare on each side – if difference could be peripheral vascular disease, or aortic coarctation or dissection - Rhythm
- Synchrony
collapsing pulse a sign of aortic regurgitation (pulse vol. exaggerated when arm extended vertically bc of gravity dependant fall in diastolic pressure)
brachial pulse
- For pulse volume and character
- Support arm around the elbow
- feel pulse with thumb medial to biceps tendon
