CCCS2 Cardiac HE Troponin in the Diagnosis of MI PDF

Clinical chemistry case study History and examination: general History and examination: cardiac Cardiac Troponin: Clinical Role in the Diagnosis of Myocardial Infarction History and examination Symptoms and Signs Components of a case report: Case history Physical ex...

Clinical chemistry case study History and examination: general History and examination: cardiac Cardiac Troponin: Clinical Role in the Diagnosis of Myocardial Infarction History and examination Symptoms and Signs Components of a case report: Case history Physical examination The important aspects of body systems history and examination Symptoms and signs Symptoms are disease features which patients report. For example pain, itching, and dyspnea Physical signs disease features which are observed or elicited by the clinician at the bedside. For example: Swelling in in fractures or Trousseau sign in hypocalcemia Together, they constitute the features of the condition in that patient. Their evolution over time and interaction with the physical, psychological, and Medical history (case history) Medical History: is the information gained by a physician by asking specific questions, either to the patient or to other people who know the patient and can give suitable information, the aim is obtaining information useful in formulating a diagnosis and a treatment plan Components of a case history (standardized format for the history) Identification and demographics: name, age, gender, and ethnicity Presenting complaint: sometimes called the chief complaint why is the patient in the clinic or hospital? It defines the major health problem or concern, and its time course Usually recorded as the patient’s own words rather than medical terms. Components of a case history (standardized format for the history) History of presenting complaint (or illness): details about the chief complaints, When did it start? What was the first thing noticed? Progress since then. Ever had it before? Pain: ‘SOCRATES’: Site; Onset (gradual, sudden); Character; Radiation; Associations (eg nausea, sweating); Timing of pain/duration; Exacerbating and alleviating factors; Severity (eg scale of 1–10, compared Components of a case history (standardized format for the history) History of presenting complaint (contd.): Specific or ‘closed’ questions about: the differential diagnoses you have in mind risk factors, eg travel in jaundice or smoking in chest pain), and a review of the relevant system. Components of a case history (standardized format for the history) Past medical history: Ever in hospital? Previous Illnesses Any current ongoing illness Previous surgery/operations sometimes distinguished as "Past Surgical History", Specifically about: MI, jaundice, Tuberculosis, hypertension, rheumatic fever, epilepsy, asthma, diabetes, stroke, anaesthetic problems. Components of a case history (standardized format for the history) Drug history:, Any tablets, injections, ‘over-the- counter’ drugs, herbal remedies, oral contraceptives? Allergies and what the patient experienced, may appear as an intolerance (nausea, diarrhea), or may have been a minor reaction of sensitization (eg rash and wheeze), or Components of a case history (standardized format for the history) Social history: Job, marital status. Housing Mobility—any walking aids needed? What can the patient not do because of the illness? Alcohol, tobacco & recreational drugs. How much? How long? When stopped? Components of a case history (standardized format for the history) Family history:, determine if there is a significant family history of diseases such as heart disease, DM, malignancy, inherited diseases or other relevant diseases Example: heart disease; health of the patient’s grandfathers and male siblings, tendency to hypertension, hyperlipidaemia, and claudication before they were 60 years old, as well as ascertaining the cause of death. Components of a case history (standardized format for the history) General enquiry, Constitutional or general symptoms are those related to the systemic effects of a disease. They affect the entire body rather than a specific organ or location. Include: Fevers, weight loss, night sweats, fatigue/lethargy, anorexia, lymphadenopathy Itch or rash Components of a case history (standardized format for the history) General enquiry, Constitutional symptoms are not disease-specific but have to be considered in the differential diagnosis of a disease or infections. the most significant to know in e.g. TB, endocrine problems, or cancer: Components of a case history (standardized format for the history) Review of systems, Systematic questioning about different organ systems Helps uncover undeclared symptoms. Some of this may already have been incorporated into the history. See later for different systems Physical examination The process by which a medical professional investigates the body of a patient for signs of disease Also known as medical examination, or clinical examination (more popularly known as a check-up Physical examination General examination: Physical appearance Well or ill in pain pattern of breathing: labored, rapid, shallow, irregular facial Undernorished, and body obese or appearance may suggest cachectic a particular diseases, eg acromegaly, thyrotoxicosis, or Cushing’s syndrome  Signs and symptoms of Cushing's syndrome thyrotoxicosis due to Graves' disease  butterfly rash Physical examination General examination: Physical appearance abnormal distribution of body hair (eg bearded females, or hairless males) suggestive of endocrine disease Facial skin rashes, eg the malar flush of mitral disease and the butterfly Mental rash ofstate: SLE anxious, malar flush distressed, confused, or unconscious Unusual or abnormal smell, eg uremia, ketones, hepatic Physical examination General examination: Skin color: Blue/purple = cyanosis Yellow = jaundice (yellow skin can also be caused by uremia, pernicious anemia, carotenaemia check the sclera: if they are also yellow it is jaundice. Pallor: this is non-specific; anemia is assessed from the palmar skin creases (when spread) and conjunctivae, you cannot conclude anything from normal  brownish bronze or, at times, slate gr Physical examination General examination: Skin color: haemochromatosis Hyperpigmentation: Addison’s, haemochromatosis and amiodarone and minocycline therapy. Amiodarone Rx Minocycline Rx Addison’s disease Dark brown or black blue‐grey or purple blue-black Physical examination General examination: Hands Finger clubbing: Fingernails have increased curvature in all directions and loss of the angle between nail and mechanism nail fold. Theofnail clubbing fold is unclear; feels Causes boggy.include: Tuberculosis, chronic The exact lung diseases, Inflammatory bowel disease (especially Crohn’s),  Palmar erythema Physical examination General examination: Hands Skin changes for example Palmar erythema is associated with cirrhosis Pallor of the palmar Pigmentation of the creases suggests anemia. is palmar creases normal in people of African-Caribbean or Asian origin but is also seen in Addison’s disease  koilonychias Physical examination General examination: Nail abnormalities: Koilonychias (spoon-shaped nails) suggests iron deficiency, haemochromatosis, endocrine disorders (eg acromegaly, hypothyroidism), Onycholysis or malnutrition Onycholysis (detachment of the nail from the nailbed) is seen with hyperthyroidism,  Physical examination General examination: Beau’s lines: are Beau’s lines, here due transverse furrows from to chemotherapy, a temporary arrest of nail new line is seen with each cycle. stress: severe infection, growth at times of eg malaria, rheumatic fever, MI, chemotherapy, biological severe trauma. Nail-fold infarcts are embolic phenomena characteristically seen in vasculitic  Physical examination General examination: Splinter haemorrhages are fine longitudinal haemorrhagic streaks (under the nails), which in the febrile patient may suggest infective endocarditis. They may be microemboli, normal—being or be caused, by, for example, gardening.  Physical examination General examination: Hands Contractures and nodules Dupuytren’s contracture: fibrosis and contracture of Heberden’s palmar fascia,(DIP) is seen and in liver disease, Bouchard’s (PIP) trauma, ageing, DM ‘nodes’—osteophytes (bone over-growth at a Heberden’s node joint) seen with  Physical examination subcutaneous nodules in General examination: rheumatoid Hands Contractures and nodules (contd.) subcutaneous nodules in rheumatoid Muscles: muscle wasting indicates nerve lesions Joints: Swollen, red joints: acute inflammation Deformities: chronic Physical examination General examination: Hands Power, function, sensation Tenderness: pain induced by pressing the area Charts: Temperature: fever or hypothermia Blood pressure and pulse Urine analysis and input/output charts if available. Physical examination General examination: Fluid status Signs of dehydration, Decreased skin turgor and dry mucous membranes, sunken eyes Increased capillary refill time (if well perfused 0.5h), dull, The cardiovascular system: history Chest pain: Radiation: To shoulder, either or both arms, or neck/jaw suggests cardiac ischaemia. The pain of aortic dissection is classically instantaneous, tearing, and interscapular, but may be retrosternal. Epigastric pain may be cardiac. Precipitants: Pain associated with cold, exercise, palpitations, or emotion suggests cardiac pain or anxiety; if brought on by food, lying flat, hot drinks, or alcohol, consider oesophageal The cardiovascular system: history Chest pain: Relieving factors: If pain is relieved within minutes by rest or glyceryl trinitrate (GTN), suspect angina (GTN relieves oesophageal spasm more slowly). If antacids help, suspect GI causes. Pericarditic pain improves on leaning forward. Associations: Dyspnoea occurs with cardiac pain, pulmonary emboli, pleurisy, or anxiety. MI may cause nausea, vomiting, or sweating. The cardiovascular system: history Chest pain: Associations (contd.): Angina is caused by coronary artery disease—and also by aortic stenosis, hypertrophic cardiomyopathy (HCM)—and can be exacerbated by anaemia. Chest pain with tenderness suggests musculoskeletal origins Pleuritic pain (ie exacerbated by inspiration) implies inflammation of the pleura from pulmonary infection, inflammation, or infarction. Or The cardiovascular system: history Dyspnoea breathlessness may be from LVF, pulmonary embolism, any respiratory cause, or anxiety. Exertional dyspnea: Shortness of breath on exertion is a term used to describe difficulty breathing when engaged in a simple activity like walking up stairs one of the dominant symptoms in patients with chronic heart failure) Orthopnoea, ie breathlessness on lying The cardiovascular system: history Palpitations An awareness of the heartbeat. (rate and rhythm of the palpitations) Irregular fast palpitations are likely to be paroxysmal AF, or atrial flutter with variable block. Regular fast palpitations may reflect paroxysmal supraventricular tachycardia (SVT) or ventricular tachycardia (VT). Dropped or missed beats related to rest or eating are likely to be atrial or ventricular The cardiovascular system: history Palpitations Regular pounding may be due to anxiety. Slow palpitations are likely to be due to drugs such as beta blockers Claudication: a cramping leg pain that develops when walking and is relieved with rest. The most common cause is peripheral artery disease. The cardiovascular system: history Dizziness Dizziness is a loose term, patient may mean: Vertigo, the illusion of rotation of either the patient or their surroundings +/- difficulty walking/standing, patients may fall over. Imbalance, a difficulty in walking straight but without vertigo, from peripheral nerve, cerebellar, or other central pathway failure Faintness, ie ‘light-headedness’, seen in anaemia, decreased BP, postural hypotension, hypoglycaemia, carotid sinus The cardiovascular system: history Past history angina, any previous heart attack or stroke, rheumatic fever, diabetes, hypertension, hypercholesterolaemia, previous tests/procedures (ECG, angiograms, angioplasty/stents, echocardiogram, coronary artery bypass grafts (CABG)). Drug history Particularly aspirin/GTN/ beta blocker /diuretic/ ACEi/ digoxin/statin use. The cardiovascular system: history Family history if any 1st degree relatives having cardiovascular events (especially if 100bpm) or slow (