Cardio History and Examination Flashcards
(39 cards)
cardiac red flags in syncope?
abnormal 12 lead ECG HF heart murmur new or unexplained SOB structural HD >65 with TLOC and no prodrome e.g. nausea, sweating, dizziness. FH of sudden cardiac death under the age of 40yrs-people drowning or car accidents? TLOC during exercise
characteristics of syncope?
rapid onset
short duration
spontaneous complete recovery
cardiac arrhythmias that may be responsible for syncope episodes?
bradyarrhythmia- SAN disease (sick sinus syndrome), AVN conduction system disease-stokes-adams attacks, drugs- beta blockers, digoxin, verapamil (rate-limiting).
paroxysmal SVT, VT
inherited- long QT, Brugada’s syndrome*
pacemaker or ICD malfunction
In a patient presenting with syncope, and querying cardiac but pt thinks no FH of cardiac disease, what may it be important to ask in terms of the FH?
any sudden cardiac death in the family under the age of 40 yrs- anyone young died suddenly? e.g. car accident, drowning?
in considering PMH, how might you ask the pt whether they have PVD?
asking if they have ever had tment for clots in their legs
characteristics of the JVP?
non-pulsatile
double waveform- moving inwards, A and V waves, the A corresponding to atrial systole, x descent, then V wave- tricuspid valve prolapse into RA when RV contracts in early systole. The A wave is lost in AF.
able to change position in the neck, lowering the bed will make the JVP move up the neck.
waves will disappear if occlude the IJV at the bottom between the 2 heads of SCM.
causes of lower limb oedema?
chronic venous disease lymphoedema heart failure- congestive and R sided vasodilator drugs e.g. amlodipine (dihydropyridine \ca2+ channel blocker) liver cirrhosis nephrotic syndrome AKI/CKD pericarditis* cardiomyopathy
what is it important to ask about the presenting complaint in a pt with chest pain?
site- central, R of L side of the chest, back?, does it move to the jaw, neck, shoulders or arms?- even if pt says they only feel pain in their chest, qualify this by asking if they have pain in these specific places.
quality- dull? non-specific?- suggest angina, central crushing, consticting-?MI sharp?- pleuritic e.g. chest infection, PE, pericarditis- flu-like prodrome, assoc. SOB and fever, tearing- aortic dissection.
intensity- what has it stopped you from doing?
timing- gradual onset e.g. MI, sudden onset- minimum time to max pain- PE, pneumothorax or aortic dissection, how long for? at rest or on exertion?
aggravating factors e.g. inspiration-pleuritic, pericarditis, lying down- pericarditis
relieving factors- sitting forward?-pericarditis, GTN- angina, MI, oesophageal spasm
previous episodes- how does it compare?
secondary symptoms e.g. SOB, sweating, nausea, vomiting, fever.
CVS R/V- SOB, palpitations, syncope, oedema, IC?
RESP R/V- SOB, cough, sputum, haemoptysis, wheeze
3 causes of sudden onset chest pain?
PE
pneumothorax
aortic dissection
important points in drug history for cardiac symptom presentation?**
syncope- ?bradycardia- beta blocker tment or Ca2+ blockers, recent addition to tment or increase dose?
drugs post previous MI- aspirin, 2nd antiplatelet, ACEI, beta blocker, statin
IV drug use?- infective endocarditis risk, and increased risk of MI in young individual, can cause ischaemia through CA spasm* e.g. cocaine use.
define syncope
an abrupt onset of transient LOC of short duration, assoc. with loss of voluntary muscle tone, with spontaneous and complete recovery.
causes of exertional syncope- a red flag sign?
hypertrophic cardiomyopathy
aortic stenosis
AVRT
the 6 P’s of a simple faint?
posture
provoking symptoms
pro-dromal features-dizziness, feeling hot, abdo discomfort, nauseous, visual changes- darkening from the periphery
post-syncope N or V
post recovery recurrence provoked by sitting or standing
previous episodes
advice to pts who suffer vasovagal episodes?
reassure
avoid triggers- prolonged sitting/standing, fear, pain, emotion
ensure adequate hydration, limit alcohol
factors that make epilepsy more likely than syncope?
circumstance e.g. watching TV, flashing lights. position- asleep or lying down
assoc aura e.g. unusual taste/smell, deja-vu, hearing voices.
abnormal behaviour
head turning to 1 side
typical tonic-clonic movements
incontinence
tongue biting-side of tongue
prolonged post-ictal drowsiness, confusion, amnesia and transient focal paralysis (Todd’s palsy)
why might people with vasovagal syncope appear to ‘fit’?
reflex anoxic seizure- O2 lack from cerebral hypoperfusion
what makes orthostatic/postural hypotension more likely as cause of syncope?
prolonged standing espec. in crowded, hot places
standing up too quickly
increased dose of vasodilator drug e.g. isosorbide mononitrate for angina
presence of autonomic neuropathy e.g. DM, parkinsonism
standing after exertion
endocrine disorder e.g. Addison’s disease
prolonged immobility or bed rest
classification of syncope?
neurally mediated/reflex syncope e.g. vasovagal, situational-cough, micturition and carotid sinus hypersensitivity
orthostatic hypotension
cardiac-arrhythmias, AS, HOCM
what makes cardiac syncope more likely?
sudden LOC, no warning
pallor
recovery within s to min, often with flushing- may also occur with vasovagal
definite structural HD
FH of sudden cardiac death or channelopathy
during EXERTION or supine
sudden onset palpitation followed by syncope
ECG abnormalities: bifascicular block= LBBB or RBBB with L anterior or posterior fascicular block
intraventricular conduction abnormalities- QRS 120ms or more
Mobitz type 1 2nd degree AV block (Wenckebach)
asymptomatic inappropriate sinus bradycardia (HR less than 50), SA block or sinus pause 3s or more in absence of negatively chrontropic medications
short or long QT intervals
pre-excited QRS complexes
early repolarisation
non-sustained VT (less than 30s)
RBBB pattern with ST elevation in V1-V3 (Brugada syndrome)
negative T waves in R precordial leads, epsilon waves and ventricular late potentials suggestive of ARVC- arrhythmogenic RV cardiomyopathy
Q waves suggesting MI
what does syncope post fear e.g. hearing a loud noise, make you worry about?
long QT syndrome
investigations in cardiac syncope if an arrhythmia is likely?
ambulatory ECG, inpatients can be monitored via cardiac monitor, consider implantable loop recorder if infrequent episodes (less than every 2 weeks)
ECHO if known HD or suspicion of structural HD
EP study in older pts with LV dysfnction or abnormal ECG
carotid sinus massage in those >40
causes of orthostatic syncope?
high dose vasodilator med e.g. isosorbide mononitrate
autonomic neuropathy e.g. DM, parkinsonism
multi-system atrophy
hypovolaemia
in querying syncope, when is the diagnosis of postural orthostatic tachycardia syndrome (POTS) indicated?
rise in HR of 30beats/min or more on standing
or to rate of 120bpm or more with significant hypotension
can be diagnosed with tilt studies
when should carotid sinus massage be avoided?
those with history of TIA, stroke or MI within past 3 mnths
those with carotid bruits- excep if Carotid Doppler studies have excluded significant stenoses.
