the cardiovascular history Flashcards
ddx of chest pain the pain, causes, typical features
carcardiac pain - ischaemia or infarction - central, tight or heavy, may radiate to the jay or left arm
vascular pain - aortic dissection - very sudden onset radiates to the back
pleuropericardial pain
peri±myo carditis - pleuritic pain, worse when patient lies down
infective pleurisy - pleuritic pain
PTX - sudden onset sharp, associated with dyspnoea
pneumonia - often pleuritic, associated w/ fever and dyspneoa
AI disease - pleuritic pain
mesothelioma - severe & constant
Metastatic tumor - sever and constant, localised
chest wall pain
persistent cough - worse w/ movement, chest wall tender
muscular strains - same as above
intercostal myositis - sharp, localised, worse w/ movement
thoracic zoster - severe, follows nerve root distrubution, precedes rash
coxsackie B virus infx - pleuritic pain
thoracic nerve compression or infiltration - follows nerve root distribution
rib fracture - hx of trauma, localised tenderness
rib tumor, primary or metastatic - constant, severe localised
tietze’s syndrome - costal cartilage tender
G.I pain
gastro esophageal reflux - not related to exertion, maybe worse when pt lies down
diffuse oesophageal spasm - releved by swallowing e.g warm water
airway pain
tracheitis, central bronchial carcinoma, inhaled foreign body - pain in throat, breathing painful
central pain - panic attacks - often preceded by anxiety, ass w/ breathlessness and hyperventilation syx
mediastinal pain - mediastinitis, sarcoid adenopathy, lymphioma
ddx of chest pain if it favouring angina
- tight or heavy
- onset predictable w/ exertion
- relieved by rest
- relieved rapidly by nitrates
- not positional
- not affected by respiration
ddx of chest pain favouring pericarditis or pleurisy
- sharp or stabbing
- not exertional
- present at rest
- unaffected by nitrates
- worse supine ( pericarditis)
- worse w/ respiration pericardial or pleural rub
ddx of chest pain favouring oesophageal (acid) reflux pain
- burning
- not exertional
- present at rest
- unaffected unless spasm
- onset maybe when supine
- unaffected by respiration
ddx of chest pain favouring M.I (ACS)
- onset at rest
- severe pain
- sweating
- anxiety
- no relief w/ nitrates
- associated symptoms n/v
- central chest pain
- subacute onset (minutes)
- severe pain
ddx of chest pain favouring myocardial ischaemia
- exertional
- occurs w/ exertion
- brief episodes
- diffuse
- no chest wall tenderness ( only discriminates b/w infarction and chest wall pain)
the cardiovascular hx: presenting symptoms - major symptoms
Major symptoms
Chest pain or heaviness Dyspnoea: exertional (note degree of exercise necessary), orthopnoea, paroxysmal nocturnal dyspnoea Ankle swelling Palpitations Syncope Intermittent claudication Fatigue
the cardiovascular hx: presenting syx - past hx , social hx, family hx
Past history
History of ischaemic heart disease: myocardial
infarction, coronary artery bypass grafting
(CABG), coronary angioplasty, rheumatic fever,
chorea, sexually transmitted disease, recent dental
work, thyroid disease
Prior medical examination revealing heart disease
(e.g. military, school, insurance)
Drugs
Social history
Tobacco and alcohol use
Occupation
Family history
Myocardial infarcts, cardiomyopathy, congenital
heart disease, mitral valve prolapse, Marfan’s
syndrome
the cardiovascular hx presenting syx - coronary artery disease risk factors & functional status in established heart disease
Coronary artery disease risk factors
Previous coronary disease Smoking Hypertension Hyperlipidaemia Family history of coronary artery disease (firstdegree relatives) Diabetes mellitus Rheumatoid arthritis and chronic inflammatory rheumatological disease Obesity and physical inactivity Male sex and advanced age Erectile dysfunction
Functional status in established heart disease
Class I—disease present, angina* does not occur
during ordinary physical activity or cardiac
dysfunction, but no symptoms of dyspnoea
present†
Class II—angina or dyspnoea during ordinary
activity
Class III—angina or dyspnoea during less than
ordinary activity
Class IV—angina or dyspnoea at rest
questions to ask the pt w/ suspected angina
- Can you tell me what the pain or
discomfort is like? Is it sharp or dull, heavy
or tight? - When do you get the pain? Does it come
out of the blue, or does it come on when
you do physical things? Is it worse if you
exercise after eating? - How long does it last?
- Where do you feel it?
- Does it make you stop or slow down?
- Does it go away quickly when you stop
exercising?
! 7. Is it coming on with less effort or at rest?
(Unstable symptoms) - Have you had angina before, and is this
the same?
clinical classification of angina from the european society of cardiology
typical angina meets all three of the following
- characteristic retrosternal chest discomfort - typical quality and duration
- provoked by exertion or emotion
- relieved by rest or GTN (glyceryl trinitrate) or both
atypical angina - only meets two of the above characterisitics
non cardiac chest pain meets only one or none of the above
causes of orthopnoea
orthopnoea: dyspnoea that develops when a patient is supine due b/c in an upright position the patients interstitial oedema is an upright position the patients interstitial oedema is redistributed the lower zones of the lungs become worse and upper zones better
- cardiac failure
- uncommon causes
massive ascites
pregnancy
bilateral diaphgramatic paralysis
large pleural effusion
severe pneumonia
paroxysmal nocturnal dyspnoea PND
sudden failure of left ventricular output with an acute rise in pulmonary venous and capillary pressures; this leads to transudation of fluid into the interstitial tissues, which increases the work of breathing
Ankle swelling
presence of oedema alone is poorly correlated w/ HF
area is not painful or red
ankle oedema of cardiac origin is usually symmetrical and worse in the evenings, with improvements during the night
it maybe a syx of biventricular failure or RV failure secondary to a number of aetiologies.
as failure advances the oedema ascends to involve the legs, thighs, genitalia and abdomen
- important to find out if pt is taking vasodilating drugs eg CCH blockers
- oedema that affects the face likely to be to a kidney disease from nephrotic syndrome
palpitations ddx with feature and what it suggests
heart misses and thumps - ectopic beats worst at rest - ectopic beats very fast, regular - SVT (VT) instantaneous onset - SVT (VT) offset with vagal manoeuvres - SVT fast and irregular - AF froceful and regular ; not fast - Awareness of sinus rhythm (anxiety) severe dizziness or syncope - VT pre - existing HF - VT
