The Cardiovascular System Flashcards
Chest pain: angina (pectoris)
Pain caused by myocardial ischaemia.
‘Choking’ pain/discomfort.
As the brain cannot interpret pain from the heart per se, it is felt over the central part of the anterior chest and can radiate up to the jaw, shoulder, or down the arms or even to the umbilicus.
Retrosternal, ‘crushing’, ‘heaviness’, or ‘like a tight band’.
Worse with physical or emotional exertion, cold weather, and after eating.
Relieved by rest and nitrate spray (within a couple of minutes).
Not affected by respiration or movement.
Sometimes associated with breathlessness.
Chest pain: myocardial infarction
‘Heart attack’.
Similar to pain of angina but much more severe, persistent (despite GTN spray), and associated with nausea, sweating and vomiting.
Feeling of impending doom/death (‘angor animi’).
Chest pain: pericarditis
The commonest causes are viral or bacterial infection, MI, or uraemia. Constant retrosternal 'soreness'. Worse on inspiration- pleuritic. Relieved slightly by sitting forwards. Not related to movement or exertion
Chest pain: oesophageal spasm
Often mistaken for MI or angina. A severe, retrosternal burning pain. Onset often after eating or drinking. May be associated with dysphagia. May have a history of dyspepsia. May be relieved by GTN as this is a smooth muscle relaxant, but will take up to 20 minutes to relieve OS pain compared to a few minutes for angina pain.
Chest pain: gastro-oesophageal reflux disease (GORD, heartburn)
Retrosternal, burning pain.
Relieved by antacids, onset after eating.
Chest pain: dissecting aortic aneurysm
Must be differentiated from an MI as thrombolysis here may prove fatal.
Severe, ‘tearing’ pain.
Felt posteriorly- classically between the shoulder blades.
Persistent, most severe at onset.
Patient is usually hypertensive and ‘marfanoid’.
Chest pain: pleuritic (respiratory) pain
May be caused by a wide range of respiratory conditions, particularly pulmonary embolus and pneumothorax.
Sharp pain, worse on inspiration and coughing.
Not central- may be localised to one side of the chest.
No radiation.
No relief with GTN.
Associated with breathlessness, cyanosis, etc.
Chest pain: musculoskeletal pain
May be caused by injury, fracture, chondrites, etc.
Will be localised to a particular spot on the chest and worsened by movement and respiration.
May be tender to palpation.
Tietze’s syndrome is costochondritis (inflammation fo the costal cartilage) at ribs 2, 3 and 4. Will be associated with tender swelling over the costa-sternal joints.
Differentials for chest pain
Angina MI Pericarditis Oesophageal spasm GORD Dissecting aortic aneurysm Pleuritic respiratory pain Musculoskeletal pain
Cardiovascular history: Dyspnoea (breathlessness)
Abnormal awareness of breathing.
How far can the patient walk on the flat before they have to stop (march tolerance)?
What about stairs and hills- can they make it up a flight?
Are they sure they stop for breathlessness or is it some other reason, e.g. arthritic knees?
Has the patient had to curtail their normal activities in any way?
NYHA classification: I = nil at rest, some on vigorous exercise; II = nil at rest, breathless on moderate exercise; III = mild breathlessness at rest, worse on mild exertion; IV = significant breathlessness at rest and worse on even slight exertion (often bed bound).
Cardiovascular history: Orthopnoea
Breathlessness when lying flat.
How many pillows does the patient sleep with and has this changed? some sleep upright in a chair.
If the patient sleeps with a number of pillows, ask why. Are they breathlessness when they lie down or is it some other reason?
Cardiovascular history: Paroxysmal nocturnal dyspnoea
Episodes of breathlessness occurring at night- usually thought to be due to pulmonary oedema.
Waking in the night and spluttering and coughing, end up sitting up or standing, going to the window for ‘fresh air’ in an attempt to regain normal breathing.
Do they wake up at night coughing and trying to catch their breath?
If so, how often and how badly is their sleep cycle disturbed by it?
Cardiovascular history: Cough
Pulmonary oedema may cause a cough productive of frothy white sputum.
This may be flecked with blood (‘pink’) due to ruptured bronchial vessels.
Cardiovascular history: Ankle oedema
How long has this been going on for?
Is it worse at any particular time of day? (typically cardiac oedema is worse toward the evening and resolves somewhat overnight as the oedema redistributes itself).
How extensive is the swelling? Is it confined to the feet and ankles, or does it extend to the shin, knee, thigh, or even the buttocks, genitalia, and anterior abdominal wall?
Is there any evidence of abdominal swelling and ascites?
Cardiovascular history: Fatigue
Most people will claim to be more tired than normal if asked.
Pathological fatigue is caused by reduced cardiac output and decreased blood supply to muscles.
Quantify.
Is the patient able to do less than they were previously?
Is any decrease in activity due to fatigue or some other symptom (e.g. breathlessness).
What activities has the patient had to give up due to fatigue?
What are they able to do before they become too tired?
Cardiovascular history: Palpitations
Awareness of heart beating.
When did the sensation start and stop?
How long did it last?
Did it come on suddenly or gradually?
Did the patient blackout? For how long?
Was the heartbeat felt fast, slow, or some other pattern?
Was it regular or irregular? Tap out the rhythm.
What was the patient doing when the palpitations started?
Is there any relationship to eating or drinking? particularly tea, coffee, wine, chocolate?
Could it have been precipitated or terminated by any medication?
Has this ever happened before? What circumstances?
Any associated symptoms? (chest pain, shortness of breath, syncope, nausea, dizziness).
Did the patient have to stop their activities or lie down?
Was the patient able to stop the palpitations somehow? Valsalva, cough, swallow.
Cardiovascular history: Syncope
Faint/swoon.
True loss of consciousness, not feeling about to faint (pre-syncope).
Can the patient remember hitting the floor?
Witnesses? Collateral history?
Was the onset gradual or sudden?
How long was the loss of consciousness?
What was the patient doing at the time? (standing, urinating, coughing).
Were there any preceding or associated symptoms, e.g. chest pain, palpitations, nausea, sweating?
Was there any relationship to the use of medication? e.g. antihypertensives and GTN spray.
When the patient came round, were there any other symptoms remaining?
Was there any tongue biting or urinary or faecal incontinence?
Was there any motor activity during the unconscious episode?
How long did it take for the patient to feel back to normal?
Cardiovascular history: Claudication
Muscle pain that occurs during exercise as a sign of peripheral ischaemia.
Feels like a tight ‘cramp’ in the muscle.
Usually occurs in the calf, thigh, buttock, and foot.
Appears only on exercise.
Disappears at rest.
May also be associated with numbest or pins-and-needles on the skin of the foot (blood diverted from skin to ischaemic muscle).
Quantify- claudication distance.
Cardiovascular history: Rest pain
Similar pain to claudication, but comes on at rest and is usually continuous- a sign of severe ischaemia.
Continuous, severe pain in the calf, thigh, buttock, or foot.
‘Aching’ in nature.
Lasts through the day and night.
Exacerbations of the pain may wake the patient from sleep.
The patient may find slight relief by hanging the affected leg off the side of the bed.
Cardiovascular history: Cardiac risk factors
Age: increased risk with age.
Gender: risk in males > females.
Obesity: how heavy is the patient? calculate their BMI.
Smoking: quantify in pack-years.
Hypertension: when was it diagnosed? how was it treated? is it being monitored?
Hypercholesterolaemia: when was it diagnosed? how is it treated and monitored?
Diabetes: what type? when was it diagnosed? how is it treated and monitored? what are the usual glucose readings?
Family history: 1st degree relatives who have had cardiovascular events/diagnoses before 60.
Cardiovascular history: Past medical history
Angina- if they have a GTN spray, how often do they need to use it and has this changed significantly recently?
MI: when? how was it treated?
Ischaemic heart disease: how was the diagnosis made? any angiograms? what other investigations have they had?
Cardiac surgery: bypass? how many arteries?
AF or other rhythm disturbances: what treatment? on warfarin?
Rheumatic fever.
Endocarditis.
Thyroid disease.
Cardiovascular history: Drug history
Take particular note of cardiac medication and attempt to assess compliance and the patient’s understanding of what the medication does.
Cardiovascular history: Social history
Take note of the patient’s employment- how the disease has affected their ability to work and bear in mind how any cardiac diagnosis may affect employability.
Home arrangements- are there carers presents, aids or adaptations, stairs, etc.?
Framework for the cardiovascular examination
General inspection. Hands. Radial pulse. Brachial pulse. Blood pressure. Face. Eyes. Tongue. Carotid pulse. JVP and pulse waveform. Inspection of the precordium. Palpation of the precordium. Auscultation of the precordium. Auscultation of the neck. Dynamic manoeuvres (if appropriate). Lung bases. Abdomen. Peripheral pulses (lower limbs). Oedema.
Cardiovascular examination: Positioning
Seated, leaning back at 45 degrees, supported by pillows with their chest, arms, and ankles exposed.
Head should be well supported allowing relaxation of the muscles in the neck.
Ensure the room is warm and there is enough privacy.
In an ‘exam’ condition, the patient should be undressed to their underwear.
Cardiovascular examination: General inspection
As always, take a step back and take an objective look at the patient.
Do they look ill? In which way?
Are they short of breath at rest?
Is there any cyanosis?
What is their nutritional status? Are they overweight? Are they cachectic (underweight with muscle wasting)?
Do they have features of any genetic syndrome such as Turner’s, Down’s, or Marfan’s?
Cardiovascular examination: Hands
Take the patient’s right hand in yours as if to greet them, look at it carefully and briefly compare with the other side.
Temperature (may be cold in congestive heart failure).
Sweat.
Nails: blue discolouration if peripheral blood flow is poor; splinter haemorrhages (small streak-like bleeds in the nail bed) seen especially in bacterial endocarditis but may also be a sign of rheumatoid arthritis, vasculitis, trauma, or sepsis from any source.
Finger clubbing: cardiac causes include infective endocarditis, and cyanotic congenital heart disease.
Xanthomata: raised yellow lesions caused by a build-up of lipids beneath the skin. Often seen on tendons at the wrist.
Osler nodes: rare manifestation of infective endocarditis (a late sign, usually treated before this develops); red, tender nodules on the finger pulps or thenar eminence.
Janeway lesions: non-tender macular-papular erythematous lesions seen on the palm or finger pulps; a rare feature of bacterial endocarditis.
