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
palpitations
- ask the pt what he/she notices, whether the palpitations are slow/fast regular/ irregular, and how long they last
- there maybe missed beat followed by particularly heavy beat can be due to atrial or ventricular ectopic beat
- ask if they are sudden or gradual onset and offset
- arrythmias are usually instantaenous in onset and offset whereas the onset and offset of sinus tachycardia is more gradual
- ask about ass syx pain, dyspnoea or faintness.
questions to ask the patient with palpitations
- Is the sensation one of the heart beating abnormally, or something else?
- Does the heart seem fast or slow? Have you counted how fast? Is it faster than it ever goes at
any other time, e.g. with exercise? - Does the heart seem regular or irregular: stopping and starting? If it is irregular, is this the feeling
of normal heart beats interrupted by missed or strong beats—ectopic beats; or is it completely
irregular? (Atrial fibrillation) - How long do the episodes last?
! 5. Is it accompanied by chest tightness or dyspnoea? - Do the episodes start and stop very suddenly? (Supraventricular tachycardia [SVT])
- Can you terminate the episodes by deep breathing or holding your breath? (SVT)
- Is there a sensation of pounding in the neck? (Some types of SVT12)
- Has an episode ever been recorded on an ECG?
! 10. Have you lost consciousness during an episode? (Ventricular arrhythmias)
! 11. Have you had other heart problems such as heart failure or a heart attack in the past?
(Ventricular arrhythmias?) - Is there heart trouble of this sort or of people dying suddenly in the family? (Sudden death
syndromes, e.g. Brugada syndrome or a long QT interval syndrome)
ddx of syncope and dizziness favouring vasovagal syncope (most common cause)
- onset in teens or 20s
- occures in response to emotional distress e.g sight of blood
- ass w/ nausea and clamminess
- injury uncommon
- unconsciousness brief, no neurological signs on waking
ddx of syncope and dizziness favouring orthostatic hypotension
brief duration injury uncommon more common when fasted or dehydrated known low systolic Bp use of antihypertenisve medications
ddx of syncope and dizziness favouring situational syncope
occurs during micturition
occurs w/ prolonged coughing
ddx of syncope and dizziness favouring syncope due to left ventricular outflow obx (Aortic stenosis, HCM)
occurs during exertion
ddx of syncope and dizziness favouring caridac arrythmia
family hx of sudden death (brugada or long or short QT syndromes)
antiarrhythmic medication (prolonged QT)
hx of cardiac disease (ventricular arrhythmias)
hx of rapid palpitations
no warning (heart block - stokes - adam attack)
ddx of syncope and dizziness favouring vertigo
no loss of consciousness
worse when turning head
head or room seems to spin
ddx of syncope and dizziness favouring seizures and metabolic cause of syncope (coma)
prodrome - aura tongue bitten jerking movements during episode head turns during episode cyanosis during episode sleepiness afterwards muscle pain afterwards follows emotional stress
- fvouring metabolic cause of syncope
hypoglycaemic agents, low blood sugar
drugs and syncope associated w/
- QT interval prolongation and ventricular arrythmias
- associated w/ bradycardia
- ass w/ postural hypotension
-Associated with QT interval prolongation and
ventricular arrhythmias
Antiarrhythmics; flecainide, quinidine, sotalol,
procainamide, amiodarone
Gastric motility promoter; cisapride,
domperidone
Antibiotics; clarithromycin, erythromycin
Antipsychotics; chlorpromazine, haloperidol
-Associated with bradycardia Beta-blockers Some calcium channel blockers (verapamil, diltiazem) Digoxin
-Associated with postural hypotension
Most antihypertensive drugs, but especially
prazosin and calcium channel blockers
Anti-Parkinsonian drugs
fatigue
- common symptom of cardiac failure
- maybe ass w/ a reduced cardiac output and poor blood supply to skeletal muscles
- many other causes of fatigue: lack of sleep , anaemia and depression
questions to ask the patient w/ suspected peripheral vascular disease
1. Have you had problems with walking because of pains in the legs? 2. Where do you feel the pain? 3. How far can you walk before it occurs? 4. Does it make you stop? 5. Does it go away when you stop walking? ! 6. Does the pain ever occur at rest? (Severe ischaemia may threaten the limb) 7. Have there been changes in the colour of the skin over your feet or ankles? 8. Have you had any sores or ulcers on your feet or legs that have not healed? 9. Have you needed treatment of the arteries of your legs in the past? 10. Have you had diabetes, high blood pressure or problems with stroke or heart attacks in the past? 11. Have you been a smoker?
questions to ask about possible cardiovascular risk factors
1. Have you had angina or a heart attack in the past? 2. Do you know what your cholesterol level is? Before or after treatment? 3. Are you a diabetic? How well controlled is your diabetes? 4. Have you had high blood pressure and has it been treated? 5. Are you now or have you been a smoker? How long since you stopped? 6. Have you had kidney problems? 7. Do you have rheumatoid arthritis? 8. Do you drink alcohol? How much? 9. For men: Have you had any problems with sex? Obtaining erections? 10. Have people in your family had angina or heart attacks? Who? How old were they?
questions to ask the patient w/ hypertension
- Do you use much salt in your diet, or eat
salty prepared or snack foods? - Have you put on weight recently?
- How much alcohol do you drink?
- What sort of exercise do you do and how
much? - Do you take your blood pressure at
home? What readings do you get? - Are you taking any blood pressure tablets
now? Have you taken these medications
in the past? Do the tablets cause you any
problems? - Are you taking arthritis drugs (NSAIDs)?
Steroids? - Have you had any kidney problems?
Blood in the urine? Ankle swelling?
Shortness of breath?
