28 Questions
What is the primary focus of detailed history taking in patients with palpitation?
Distinguishing between different types of palpitation
What type of information should be obtained when inquiring about the nature of the palpitation?
Rhythmic pattern and irregularity of the heartbeat
What is the benefit of asking about the nature of the palpitation?
To distinguish between different types of palpitation
Why would you ask the patient to roll onto their left side during an apex beat assessment?
To locate the apex beat more easily
What information should be obtained from the patient to understand the palpitation?
Characteristics of the palpitation, such as rapidity and irregularity
Why is it important to ask about the palpitation's nature?
To accurately diagnose the type of palpitation
What should you do if you are unable to feel the apex beat?
Ask the patient to roll onto their left side
In what direction should your fingers be laid on the chest to locate the apex beat?
Parallel to the rib spaces
What should you assess in addition to the location of the apex beat?
The character of the apex beat
Why is it important to note the position of the apex beat?
To aid in the diagnosis of cardiac conditions
What is a common consequence of trivial injuries in individuals with impaired blood flow?
Ulceration and tissue loss
What is the primary source of thromboembolism in acute limb ischemia?
Left atrium
Which of the following is NOT one of the '6 Ps' of acute limb ischemia?
Polyuria
What is the likely outcome of acute limb ischemia if left untreated?
Amputation and/or death
Which of the following is a symptom of severe ischemia in acute limb ischemia?
Paralysis of the affected limb
What is the likely cause of a 'crunching' noise heard during auscultation?
Pneumopericardium
Which of the following patients are more likely to have an 'innocent' murmur?
A patient with fever
What is the most important step in the examination sequence for auscultation?
Making sure the room is quiet
What is the primary difference between a murmur and a normal heart sound?
The velocity of flow
Which of the following is NOT a cause of an 'innocent' murmur?
Patient with a septal defect
What is the most common symptom of abdominal aortic aneurysm (AAA) prior to rupture?
No symptoms at all
What is the significance of the 'wave sign' in abdominal aortic aneurysm (AAA) patients?
It is a incidental finding in some patients
What is the most common cause of digital ischemia leading to blue toes?
Emboli from abdominal aortic aneurysm (AAA)
What is the primary difference between primary and secondary Raynaud's phenomenon?
Presence of underlying disease
What is the indication for investigating underlying peripheral arterial disease (PAD) in patients with Raynaud's phenomenon?
All of the above
What is the usual finding in patients with digital ischemia?
Full set of pedal pulses
What is the third phase of Raynaud's phenomenon?
Redness
Why is it important to ask about a patient's past medical history in the context of peripheral vascular disease?
To identify if they have established peripheral vascular disease
Study Notes
Palpitation History Taking
- Nature of palpitation: rapid, forceful, or irregular heartbeat
- Locate apex beat by laying fingers on the chest parallel to rib spaces
- Assess character of apex beat and note its position
Auscultation
- Ensure a quiet room for auscultation
- Murmurs: turbulent flow across abnormal valve, septal defect, or outflow obstruction
- 'Innocent' murmurs: increased velocity of flow through a normal valve in pregnancy, athletes, or patients with fever
Acute Limb Ischemia
- Classical features: '6 Ps'
- Pallor
- Pulselessness
- Perishing cold
- Pain (worse when muscle squeezed)
- Paralysis (inability to move toes/fingers) → SEVERE ISCHEMIA
- Paresthesia (numbness or tingling over the forefoot or dorsum of the hand) → SEVERE ISCHEMIA
- Causes: Thromboembolism usually from the LA (in atrial fibrillation → often diagnosed incidentally
Abdominal Aortic Aneurysm (AAA) Rupture
- Classical features: abdominal/back pain, pulsatile abdominal mass, syncope, and shock (hypotension)
- Patients may observe ripples in the water when in the bath (wave sign)
- Most patients are asymptomatic until the aneurysm ruptures
Digital Ischemia
- Blue Toes: patchy bluish discoloration over the toes and forefoot of one or both feet
- Causes: emboli (e.g. from AAA) or alternative proximal embolic source (popliteal aneurysm / atherosclerotic plaque)
- Usually has a full set of pedal pulses
- Should be taken seriously → risk of acute limb ischemia & even limb loss
Vasospastic Symptoms (Raynaud's Phenomenon)
- Digital ischemia induced by cold and emotion
- Primary (Raynaud's disease) or secondary (Raynaud's syndrome) to drugs, connective tissue disease, hyperviscosity syndromes, use of power tools
- Three phases:
- Pallor: due to digital artery spasm and/or obstruction
- Cyanosis: due to deoxygenation of static venous blood (this phase may be absent)
- Redness: due to reactive hyperemia
- Patients over 40 presenting with unilateral Raynaud's phenomenon should be investigated for underlying PAD, especially if they have cardiovascular risk factors, diabetes, or a smoking habit
Test your knowledge on identifying the nature of palpitations and understanding the importance of detailed history taking in cardiology. Questions cover the characteristics of palpitations and their diagnosis.
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