Makindo Medical Notes.com

Related Subjects: |Cardiac Examination |Cardiac History Taking |Respiratory Examination |Gastroenterology Examination |Cardiac Anatomy and Physiology |Coronary Artery Anatomy and Physiology |Cardiac Electrophysiology |Cardiac Embryology

Introduction

• Get a good history of the current presenting complaints and try to get quantitative estimates e.g. distance walked, cigarettes smoked, pillows slept on.
• Always establish a timeline - patients can be very imprecise but push "Awhile", "Is that a day, a week, a month, a year..?" "about 6 weeks doctor"
• Smoking, Hypertension, Family history, diabetes, hypercholesterolaemia, rheumatic fever, alcohol play a major role in heart disease in many patients and should not be neglected.
• Don't forget to ask how their disease impacts their life, can they do stairs at home, are they too breathless to do housework or to even wash and dress, do they need help...
• When presenting a history of cardiac chest pain always then as part of it present the risk factors. This allows the clinician to work out their a priori risk of actually having IHD. The same pain in 25-year-old women with no risk factors may be assessed quite differently to that in a 60-year-old male diabetic chain-smoking hypertensive.
• The commonest symptoms are chest pain, fatigue and breathlessness, palpitations, syncope and presyncope

Chest pain

• Differential of acute chest pain
  • Acute Coronary Syndrome - ECG,Troponin, Echo
  • Pulmonary embolism - D-Dimers, CTPA
  • Aortic Dissection - CXR, CT, TOE
  • Oesophageal rupture - history/ CXR
  • Pneumothorax/ Tension Pneumothorax - Expiratory CXR diagnostic
  • Pleurisy - Pneumonia - CXR, Fever, Systemically unwell
  • Herpes Zoster
  • Rib or Sternal fracture - history
• When due to a cardiac cause is usually down to myocardial ischaemia or infarction and reflects a situation in which myocardial oxygen demand is not being met and there is a localised build-up of lactate or with infarction, there is actual tissue necrosis.
• With myocardial infarction the pain is worse and there are often additional features such as pallor, nausea and vomiting and the patient is grey and sweaty.
• By resting to decrease MO₂ demand or using perhaps GTN to relax the coronary vessels and reduce myocardial work the pain can be relieved. However, the presence of rest pain must make one consider myocardial infarction.
• Classically the pain is central chest and feels like a weight pressing down on the chest. Some will use a clenched fist in front of their sternum to represent the pain.
• In diabetics and the elderly ischaemia and infarction may be silent and an ACS only present with its complications.
• Chest pain may also be due to pericarditis but this is more of a constant pain unrelated to exertion and eases on sitting forwards. Worse with deep inspiration and a rub may be heard.
• A dissecting thoracic aneurysm typically has pain front and back, a tearing interscapular pain, however subtler presentations abound and it is not uncommon for dissections to be treated as ACS or diagnosed at post mortem.
• Chest pain (Angina), like breathlessness, can be graded and scales such as the Canadian cardiovascular society exist but in reality, I would rather you tell me exactly what level of exertion provokes pain rather than quote scales. Is it at rest, minimal, moderate or severe exertion?

Breathlessness

• This is usually associated with heart failure when the bodies needs in terms of primarily oxygen delivery is not being made.
• It may suggest that there is increased alveolar oedema and incipient pulmonary oedema.
• Breathlessness can be worse at night when one lies flat due to central redistribution of fluid and this is called orthopnea.
• Occasionally pulmonary oedema can come on minutes to hours after recumbency and the patient wakes up acutely breathless and often has to get out of bed or sit on side of the bed or by a window until the breathlessness has eased. This is paroxysmal nocturnal dyspnoea. Oedema
• Ankle oedema usually suggests right heart failure. As it progressed oedema climbs until it affects the thigh and even up to the abdomen with scrotal oedema, ascites etc and pleural effusion. Hepatomegaly may also be seen.

Fatigue

• A subtle sign but often an early feature of heart failure or cardiac impairment but also seen with anaemia, hypothyroidism, malignancy, viral illnesses
• Often too subtle by itself to be useful but often good to see how a day in a patient's life has changed now as it compares with before

Palpitations

• Abnormal awareness of the heartbeat. Get patient to tap it out. Is it regular, fast or slow, associated with symptoms?
• If fast and stops is there polyuria after (SVT).
• If it is just a large occasional thump it may simply be due to the heartbeat with the increased cardiac output after an ectopic which is usually harmless.

Syncope or presyncope

• Should always be taken very seriously. Look for murmurs and evidence of arrhythmias.
• Take an accurate history. Know exactly what the patient was doing when the episode happened.
• Interrogate the patient. Know exactly what happened when they recovered. Do all you can to get a witness report.
• I have rung neighbours and others to get vital information with the patient's consent of course. The history is key.
• Investigations where cardiac cause suspected include ECG,Echo, 24 hr tape
• Cardiac Causes of syncope
  • Severe aortic stenosis
  • Severe bradycardia e.g. complete heart block or sinus pauses
  • Vasovagal syncope exacerbated by medications
  • Ventricular tachycardia
  • Stokes-Adams attack

Cardiac arrest

• By definition there is no cardiac output with no pulse and no breathing.
• Causes
  • Pulseless VT
  • Ventricular fibrillation
  • Asystole
  • Electromechanical dissociation

Can be the initial presentation of ischaemic heart disease or hypertrophic cardiomyopathy or other cardiac causes of sudden death - see topic. Defibrillation of VF/VT can be lifesaving.