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Taking the CARDIOVASCULAR HISTORY

Taking the CARDIOVASCULAR HISTORY. Dr. J.A. Coetser GKV 353 CoetserJA@ufs.ac.za 0833542861. CASE STUDY. A 56 year old white male presents to casualties at 3h40am, complaining of severe chest pain that started 30min earlier. WHICH IMPORTANT ASPECTS WOULD YOU ELICIT FROM THE HISTORY?.

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Taking the CARDIOVASCULAR HISTORY

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  1. Taking theCARDIOVASCULARHISTORY Dr. J.A. Coetser GKV 353 CoetserJA@ufs.ac.za 0833542861

  2. CASE STUDY A 56 year old white male presents to casualties at 3h40am, complaining of severe chest pain that started 30min earlier. WHICH IMPORTANT ASPECTS WOULD YOU ELICIT FROM THE HISTORY?

  3. Presenting symptoms:Chest pain • When evaluating symptomatic complaints • Site • Onset • Character • Radiation • Alleviating factors • Timing • Exacerbating factors • Severity

  4. Presenting symptoms:Chest pain • Determine the cause! • 4 cardinal features • Duration (timing) • Location (site) • Quality (character) • Precipitating and aggravating factors

  5. Presenting symptoms:Chest pain • Angina • Crushing pain, heaviness, discomfort or choking sensation in retrosternal area • Central rather than left chest • May radiate to jaw and/or arms • Rarely below umbilicus • Typical vs. atypical angina

  6. Presenting symptoms:Chest pain • Pain from acute coronary syndromes (myocardial infarction and unstable angina) • Often comes on at rest • Pain present >30min

  7. Angina Acute coronary syndromes • Clot dissolves • Coronary blood flow returns • No cardiac muscle damage • Clot persists • Coronary blood flow cut off • Cardiac muscle dies UNSTABLE ANGINA MYOCARDIAL INFARCT

  8. Presenting symptoms:Chest pain • Pleuritic pain • Due to movement of pleural surfaces on one another • Inflammation of pleura or pericardium • Viral infection of pleura • Pneumonia • Pulmonary embolism • Made worse by inspiration • Often relieved by sitting up and leaning forward

  9. Presenting symptoms:Chest pain • Dissecting aneurysm • 3 features • Severe, tearing pain • Rapid onset • Radiates to back • Proximal aorta dissection = anterior chest pain • Descending aorta dissection = interscapular pain • Hx of HPT, or connective tissue disorder e.g. Marfan’s syndrome

  10. Presenting symptoms:Chest pain • Massive pulmonary embolism • Sudden onset • May be retrosternal/angina-like • Can be associated with dyspnoea, collapse and cyanosis

  11. Presenting symptoms:Chest pain • Spontaneous pneumothorax • Sharp pain and severe dyspnoea • Localized to one part of chest

  12. Presenting symptoms:Chest pain • Oesophageal disorders • Reflux disease can mimic angina • Oesophageal spasm • Especially after drinking hot or cold fluid • Associated with dysphagia • Relieved by nitrates

  13. Presenting symptoms:Chest pain • Don’t forget: • Cholecystitis • Herpes zoster

  14. Presenting symptoms:Dyspnoea • Dyspnoea definition: unexpected awareness of breathing • Sensation of increased force needed for work of breathing • Need to distinguish between cardiac and respiratory causes

  15. Presenting symptoms:Dyspnoea • Cardiac dyspnoea • LV output fails to rise during exercise • Increased LV end-diastolic pressure • Raised pressure in LA • Raised pressure in pulmonary venous system • Leakage of fluid into interstitial space • Decreased lung compliance

  16. Presenting symptoms:Dyspnoea • Orthopnoea • Dyspnoea in the supine position • In supine position, interstitial oedema distributes to all lung zones, decreasing overall oxygenation • In sitting position, oedema redistributes to lower zones, leaving upper zones free for oxygenation • Other causes of orthopnoea • Massive ascites • Pregnancy • Bilateral diaphragmatic paralysis • Large pleural effusion • Severe pneumonia

  17. Presenting symptoms:Dyspnoea • Paroxysmal nocturnal dyspnoea (PND) • Severe dyspnoea that wakes patient from sleep • Has to sit up and gasps for breath • Mechanism • Sudden failure of LV • Reabsorption of peripheral oedema at night while supine with overload of LV • Don’t forget anxiety as cause of dyspnoea • Inability to take deep enough breath to fill lungs in satisfying way

  18. Presenting symptoms:Ankle swelling • Ankle oedema of cardiac origin • Usually symmetrical • Worst in evenings, improves during night • As failure progresses, involves legs, thighs, genitalia and abdomen • Find out if pt is on a calcium channel blocker, i.e. Adalat XL® (nifedipine), amlodipine, etc., which can also cause ankle oedema • If oedema also involves face, think of nephrotic syndrome

  19. Presenting symptoms:Palpitations • Definition palpitations: unexpected awareness of the heartbeat • Ask pt to tap out beat with finger • Ask if palpitations are slow or fast, regular or irregular, and what the duration is • Any fast arrhythmia can produce angina if pt also has ischaemic heart disease

  20. Presenting symptoms:Palpitations • Atrial fibrillation • Completely irregular rhythm • Atrial or ventricular ectopic beat • Sensation of skipped beat, followed by particularly heavy beat • Ventricular tachycardia • Rapid palpitations followed by syncope

  21. Presenting symptoms:Syncope, presyncope and dizziness • Syncope = transient loss of consciousness resulting from cerebral anoxia, usually due to inadequate cerebral blood flow • Presyncope = transient sensation of weakness without loss of consciousness (I’m about to faint) • NB: ask about family history of sudden death • Long QT syndrome / Brugada syndrome

  22. Presenting symptoms:Syncope, presyncope and dizziness • Postural syncope • LOC when standing for long periods or standing up suddenly • Ask about drugs that can cause postural hypotension • Micturition syncope • LOC when passing urine • Vasovagal syncope • LOC with emotional stress • Syncope due to arrhythmia • LOC regardless of position • Exertional syncope • Aortic stenosis • Hypertrophic cardiomyopathy

  23. Presenting symptoms:Intermittent claudication and peripheral vascular disease • Claudication = pain in one or both calves (thighs or buttocks) on walking more than a certain distance (claudication distance) • 6 P’s of peripheral vascular disease • Pain • Pallor • Pulselessness • Parasthesiae • Perishingly cold • Paralysed • Lumbar spinal stenosis (pseudo claudication) • Pain relieved by flexing spine • Exacerbated by walking downhill

  24. Presenting symptoms:Fatigue • Common symptom of cardiac failure • Remember other causes • Lack of sleep • Anaemia • Depression

  25. Risk factors for coronary artery disease • Previous ischaemic heart disease • Hypercholesterolaemia • Smoking • Hypertension • Family history • 1st degree relatives (parents of siblings) • Especially if <60yrs • Diabetes mellitus • DM is a coronary heart disease equivalent • Risk of diabetic for MI is the same as a non-diabetic who has had an infarct • Chronic kidney disease

  26. Treatment • Which medications? • Any side-effects? • Previous procedures, e.g. CABG, angioplasty • Ask how many arteries were bypassed? • How many stents were placed?

  27. Past history • Previous MI or angina? • Increases risk for further events • Rheumatic fever • Hypertension • Alcohol use • Salt intake • Obesity • Lack of exercise • Kidney disease • NSAIDs

  28. Social history • Ischaemic heart disease can interfere with daily functioning • Is patient still working? • Has living arrangements changed? • Enquire about rehabilitation programs

  29. QUESTIONS?

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