Symptom Analysis

Question 1

What are the causes of syncope?

Answer 1

CVSO

Cardiac - palpitations
Vasovagal - temperature, eating, toilet, stress
Seizure - tongue biting and movement. Time to recovery
Orthostatic - standing?

Question 2

What are some causes of dizziness?

Answer 2

Headturning
Central - headache, ataxia, nausea, dyarthria, diplopia
Peripheral - tinnitus ear ache

Question 3

What are the symptoms associated with pericarditis?

Answer 3

Substernal pain 
Pain relieved by sitting forward
Pain more intense breathing in 
Low grade fever 
Pulsus paradoxus
Jugular distension
Rub

Question 4

What are some differentials for chest pain?

Answer 4

Main:
Cardiovascular - Angina (<30 minutes), STEMI or NSTEMI. Dull, crushing pain
Respiratory - sharper pain/ pleuritic PE.
Oesophageal: spasm and oesophagitis, dysphagia, odynophagia
MSK: Costochronditis/ Tietze syndrome

Question 5

Angina

Answer 5

Suggested by: central pain ± radiating to jaw and either arm (left usually). Intermittent, brought on by exertion, relieved by rest or nitrates, and lasting <30 minutes. May be associated with transient ST depression or T inversions or, rarely, ST elevation.
Confirmed by: no troponin rise after 12 hours (excludes MI). Stress test showing inducible ischemia

Question 6

STEMI

Answer 6

Suggested by: central chest pain ± radiating to jaw and either arm (left usually). Continuous, usually over 30 minutes, not relieved by rest or nitrates
Confirmed by: ST elevation 1 mm in limb leads or 2 mm in chest leads on serial ECGs (this is regarded as sufficient evidence to treat with thrombolysis). Raised troponin indicates episode of muscle necrosis up to 2 weeks before. Raised troponin may not be present in the first 4 hours after the onset of chest pain.

Question 7

NSTEMI

Answer 7

Suggested by: central chest pain ± radiating to jaw and either arm (left usually). Continuous, usually over 30 minutes, not relieved by rest or nitrates
Confirmed by: elevated troponin after 12 hours. T-wave and ST-segment changes but no ST elevation on serial ECGs

Question 8

Oesophagitis and oesophageal spasm

Answer 8

Suggested by: past episodes of pain when supine, after food. Relieved by antacids
Confirmed by: no increase in troponin after 12 hours and no ST-segment changes on ECG. Improvement with antacids. Esophagitis on endoscopy

Question 9

PE

Answer 9

Suggested by: central chest pain, also abrupt shortness of breath, cyanosis, tachycardia, loud second sound in pulmonary area, associated deep vein thrombosis, (DVT) or risk factors such as cancer, recent surgery, immobility
Confirmed by: V/Q scan with mismatched ventilation and perfusion, spiral (helical) CT (CT-pulmonary angiogram) showing clot in pulmonary artery

Question 10

Pneumothorax

Answer 10

Suggested by: abrupt pain in center or side of chest with abrupt breathlessness. Resonance to percussion over site
Confirmed by: expiration CXR showing dark field with loss of lung markings outside sharp line containing lung tissue

Question 11

Aortic aneurysm

Answer 11

Suggested by: ‘tearing pain often radiating to back and not responsive to analgesia, abnormal or absent peripheral pulses, early diastolic murmur, low blood pressure, and wide mediastinum on CXR
Confirmed by: loss of single clear lumen on CT scan or MRI

Question 12

Costochondritis

Answer 12

Suggested by: chest pain and localized tenderness of chest wall or chest pain on twisting of neck or thoracic cage. Tenderness on touching.
Confirmed by: no rise in troponin after 12 hours, and no ST-segment changes or T-wave changes serially on ECG. Response to rest and analgesics

Question 13

Causes of SOB

Answer 13

Acute:
Respiratory:
Asthma
Acute exacerbation of COPD (infective or non-in
Lower respiratory tract infection (LRTI)
Bacterial (i.e. pneumonia); viral; other
Pulmonary embolism (PE)
Pneumothorax

Cardiac
Pulmonary oedema (from any cause, usually decompensated heart failure)
Arrhythmia 
Other
Panic attacks/ Psychosomatic
Metabolic acidosis

Chronic:
Respiratory
COPD
Pulmonary fibrosis
Pleural effusion
Bronchiectasis
Cystic fibrosis
Chronic infection (e.g. TB)
Cardiac
Heart failure (chronic)
Chronic arrhythmia
Other
Anaemia

Question 14

What questions can you ask for SOB?

Answer 14

Onset and duration of shortness of breath
If they are uncertain about the start of the shortness of breath, a good question is: “When were you last well?”
Acute, chronic, constant, intermittent
Exacerbating factors
Effort, dust exposure
Alleviating factors
Rest, inhalers, GTN spray
Timing
Relation to exertion, time of day (morning dips in asthma)
Associated symptoms
Wheeze or stridor?
Cough: productive or dry, colour of sputum, change in colour of sputum?
Hemoptysis: how much (teaspoonful, cupful), how frequently?
Chest pain: pleuritic, cardiac-sounding, nausea, sweating?
Constitutional symptoms: fever, weight loss (quantify how much), night sweats?
Cardiac symptoms: palpitations, ankle swelling, PND, orthopnoea?
Exercise tolerance
Quantify how far the patient can walk before stopping due to shortness of breath (e.g. number of stairs, distance on the flat)