cardio exam theory Flashcards by Malcolm Moss

What are some important cardiovascular medical histories?

IHD: MI, coronary artery bypasses

Rheumatic fever

Sexually transmitted disease

Drug use

Past medical examination revealing cardiac disease

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What are some important social histories for cardiovascular health?

Tobacco, alcohol or drug use

Occupation

Lifestyle (exercise, diet)

Stress

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What are some important family medical histories for cardiovascular health?

IHD

Cardiomyopathy

Congenital heart disease

Marfan’s syndrome

Diabetes

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What are some coronary artery risk factors?

Previous coronary disease

Smoking

HTN and hyperlipidaemia

Relevant family history

Diabetes, obesity, physical inactivity

Male sex and advanced age

Raised homocysteine levels

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What is a cardiac cause of chest pain, and how does it present?

Central, tight and/or heavy

May radiate to the jaw or left arm

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What are two vascular causes of chest pain and how do they present?

Aortic dissection

Aortic aneurysm

Very sudden onset, and radiate usually to the back

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What are pleuropericardial causes of chest pain?

Pericarditis +/- myocarditis

Infective pleurisy

Pneumothorax

Pneumonia

Autoimmune disease

metastatic tumour

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What pleuropericardial causes of chest pain cause pleuritic pain?

Pericarditis +/- myocarditis

Infective pleurisy

Pneumonia (with fever and dyspnoea)

Autoimmune disease

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Which pleuropericardial causes of chest pain cause a severe and constant pain?

Mesothelioma

Metastatic tumour (localised)

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Does pain from pericarditis get worse when standing or lying down?

Lying down

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Both pneumothorax and pneumonia cause pleuropericardial chest pain and dyspnoea: what are their differences in symptoms?

Pneumothorax has a very sudden onset and is sharp

Pneumonia has an insidious onset and is also associated with fever and sputum production with cough

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What are some causes of chest pain resulting directly from the chest wall?

Persistent cough and other muscular strains

Intercostal myositis

Rib fracture or tumour (primary or metastatic)

Thoracic zoster

Coxsackie B virus infection

Thoracic nerve compression or infiltration

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What are the three chest wall causes of chest pain that are worse with movement?

Persistent cough

Muscular strains

Intercostal myositis

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Which chest wall causes of chest pain follows nerve root distribution?

Thoracic zoster (precedes rash)

Thoracic nerve compression or infiltration

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What gastrointestinal conditions can lead to chest pain?

Reflux (worse with lying down, not related to exertion)

Diffuse oesophageal spasm

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Which GIT condition, associated with chest pain, is also associated with dysphagia?

Diffuse oesophageal spasm

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What are some causes of chest pain that occur in the airways?

Tracheitis

Central bronchial carcinoma

Inhaled foreign body

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What is at least one circumstance in which it is not best to ask a patient about ‘pain’, but rather about ‘discomfort’ with relation to chest pain?

With angina, the symptoms may be felt as a dull ache rather than something that the patient would consider pain, thus they may not report it

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Do patients always think of typical angina as a cardiac symptom? If not, why not?

Sometimes not

The ache usually is central rather than left sided, so many patients don’t consider it to be related to the heart

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Where does angina pain radiate?

Jaw or arms

Very rarely travels below the umbilicus

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What is the classic catalyst for the development of anginal pain?

Exertion (in low grade angina)

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What is the classic thing that a patient will say stops their anginal pain?

Cessation of exertion (in low grade angina)

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In high grade angina, how does the presentation of the patient differ?

Becomes brought on by less and less exertion with higher grades

Highest grade is when it occurs at rest

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Should a change in the pattern of onset of angina be taken seriously?

Yes

This represents a change from stable angina to unstable angina, which could mean the patient’s status is deteriorating

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Is the efficacy of sublingual nitrates necessarily specific to the patient having angina?

No They can also relieve oesophageal spasm, another cause of chest pain They also can have a substantial placebo effect

How long do sublingual nitrates typically take to bring about cessation of anginal pain?

A few minutes

How does the pain associated with acute coronary syndrome (MI or unstable angina) differ from typical stable angina?

Occurs at rest More severe and painful Lasts longer Less liable to be reduced in intensity by sublingual nitrates

If chest pain is present for multiple days, is it likely to be acute coronary syndrome (MI or unstable angina) or stable angina?

Neither!

If chest pain is present for more than half an hour, is it more likely to be acute coronary syndrome or stable angina?

Acute coronary syndrome

What are some associated symptoms of MI?

Dyspnoea Diaphoresis Anxiety Nausea Faintess

What is the name of chest pain made worse by inspiration?

Pleuritic pain

How can pleuritic pain be relieved with a movement?

By the patient sitting up and leaning forwards

What is the cause of pleuritic pain?

Inflamed pleural or pericardial surfaces moving on one another

What usually makes chest wall pain worse?

Respiration Or movement of the shoulders rather than with exertion

What usually characterises the pain of arterial dissection?

Very severe pain, greatest at moment of onset Pain described as 'tearing' Pain radiating to the back

How does an arterial dissection involving the ascending aorta present differently to one involving the descending aorta?

Involving the ascending usually radiates to the anterior chest Involving the descending aorta usually radiates to the back, between the scapulae

What are some risk factors for arterial dissection?

History of HTN Connective tissue disorders such as Marfan's or Ehlers-Danlos syndrome

How do patients usually describe the pain of pulmonary embolism?

Very sudden onset Rentrosternal

What are some associated symptoms of PE?

Collapse Dyspnoea Cyanosis

In what cases can the pain of PE be identical to angina?

If associated with right ventricular ischaemia

What is the pain of spontaneous pneumothorax like?

Sharp Localised to one part of the chest

What signs associated with chest pain would make you favour an MI diagnosis?

Onset at rest Sweating Anxiety No relief with nitrates Nausea and vomiting

What signs associated with chest pain would make you favour an angina diagnosis?

Onset with exertion Less severe No sweating Mild or no anxiety Rapid relief with nitrates

What signs associated with chest pain would make you favour an arterial dissection diagnosis?

Very severe pain radiating to the back Instantaneous onset Risk factors

What signs associated with chest pain would favour a chest wall pain diagnosis?

Positional and localised Often worse at rest Tenderness on the chest wall

What is the pathogenesis of cardiac dyspnoea on exertion?

Failure of LV to increase output Increase in LVEDP Raised pulmonary venous pressure Interstitial fluid leakage Reduced lung compliance and capacity

What does the absence of orthopnoea suggest about a patient's dyspnoea?

That LV failure is likely not the cause

What are more uncommon causes of orthopnoea?

Large pleural effusion Severe pneumonia Massive ascites Bilateral diaphragmatic paralysis

What is the pathogenesis of paroxysmal nocturnal dyspnoea (PND)?

Sudden failure of LV output Acute rise of pulmonary venous and capillary pressures Transudation of fluid into interstitial tissues Increases WOB

What cardiac disease can cause lower limb oedema?

Right ventricle or biventricle failure

Is ankle oedema caused by RV failure symmetrical or asymmetrical? And worse at night or morning?

Symmetrical Worse at night

What medical history is relevant for a patient with ankle oedema, especially if they have other cardiac conditions?

Whether they are on vasodilatory medications, eg calcium channel blockers

What can cause oedema of the face rather than the ankles?

Nephrotic syndrome

What associated features questions should you ask of a patient that complains of palpitations?

Faintness Pain dyspnoea

Awareness of rapid palpitations followed by syncope suggests what?

Ventricular tachycardia

Is ectopic beats or ventricular tachycardia the more likely cause of palpitations at rest?

Ectopic beats

Do early and mid-inspiratory crackles favour heart failure or lung disease as a cause of dyspnoea?

Heart failure Lung disease would be suggested by fine, end-inspiratory crackles

What would make you think syncope was vasovagal?

Young LOC short duration, no after-effects Associated with emotional distress

What would make you think syncope was due to orthostatic hypotension?

Onset when getting up quickly Known low systolic BP, with or without use of antihypertensive medication Brief duration More common when fasted or dehydrated

What would make you think syncope was due to 'situational syncope'?

Occurs during micturition Occurs with prolonged coughing

What would make you think syncope was due to left ventricular outflow obstruction (AS, HCM)?

Occurs during exertion

What would make you think syncope was due to cardiac arrhythmia?

History of rapid palpitations No warning (heart block -- Stokes-Adams attack) History of cardiac disease (ventricular arrhythmias) Anti-arrhythmic medication

What would make you think syncope was due to epilepsy?

Prodrome with an aura Tongue biting Classical witness reports of jerking and head turns Post-ictal state, + muscle pain

cardio exam theory Flashcards

(63 cards)