Cardiovascular History Taking PDF

Cardiovascular History Taking Dr Khaled Eltamawy Lecturer of Cardiology Faculty Of Medicine Merit University  Objectives At the End of this session: 1. You can Illuminate the history taking steps 2. Enumerate the common...

Cardiovascular History Taking Dr Khaled Eltamawy Lecturer of Cardiology Faculty Of Medicine Merit University  Objectives At the End of this session: 1. You can Illuminate the history taking steps 2. Enumerate the common Cardiovascular Symptoms 3. Can evaluate Chest pain and correlate its cardiac origin 4. Enumerate 5 other causes of Non-cardiac Chest Pain 5. Illustrate causes of Dyspnea in CV disease 6. Analysis dyspnea and enumerate 2 special types 7. Correlate between dyspnea and other related CV symptoms 8. Analysis Palpitation as presenting symptoms 9. Enumerate Causes of Syncope with highlight to cardiac causes 10. Correlate CV symptoms and narrow DD of presenting Complain  Agenda Applied anatomy and physiology Review of general roles in History Taking Common CV symptoms Chest Discomfort Common CV symptoms Dyspnea Common CV symptoms Palpitation Common CV symptoms Edema Common CV symptoms Fatigue Common CV symptoms dizziness and Pre-syncope Other Related Symptoms (Claudication, Hemoptysis, etc.)  Agenda Applied anatomy and physiology Review of general roles in History Taking Common CV symptoms Chest Discomfort Common CV symptoms Dyspnea Common CV symptoms Palpitation Common CV symptoms Edema Common CV symptoms Fatigue Common CV symptoms dizziness and Pre-syncope Other Related Symptoms (Claudication, Hemoptysis, etc.)  Heart The left ventricle lies almost entirely posteriorly and the right anteriorly. The myocardium is arranged in a complex spiral such that a contraction causes the heart to elongate and rotate slightly, hitting the anterior chest wall as it does—this can be felt as the apex beat. All of this movement is lubricated by a double-lined cavity filled with a very small amount of fluid that the heart sits in—the pericardial sac  Arteries & Veins As the ventricle expels blood into the arteries, it sends a pulse wave to the periphery that can be felt. This is not the actual flow of blood from the ventricle at that contraction but a pressure wave Blood flows at a much lower pressure in the veins Above the level of the heart, gravity does most of the work in returning the blood Below, blood return is facilitated by contraction of muscles surrounding the deep veins, helped by numerous one-way valves to prevent backflow  Heart LV constitute the main cardiac muscle bulk and Septum follow LV Blood Supply of the heart through coronary arteries Coronary Blood flow mainly during diastole (LV vs. RV). Oxygen Extraction in Heart Muscle nearly 70% in Skeletal Muscle at rest 25% (Consequences if need more energy) Energy production in Myocardium is O2 dependent Cardiac Blood Flow during Exercise increase 5 fold Nearly all cardiac cells can fire and conduct impulses (Automaticity)  Agenda Applied anatomy and physiology Review of general roles in History Taking Common CV symptoms Chest Discomfort Common CV symptoms Dyspnea Common CV symptoms Palpitation Common CV symptoms Edema Common CV symptoms Fatigue Common CV symptoms dizziness and Pre-syncope Other Related Symptoms (Claudication, Hemoptysis, etc.)  Agenda Applied anatomy and physiology Review of general roles in History Taking Common CV symptoms Chest Discomfort Common CV symptoms Dyspnea Common CV symptoms Palpitation Common CV symptoms Edema Common CV symptoms Fatigue Common CV symptoms dizziness and Pre-syncope Other Related Symptoms (Claudication, Hemoptysis, etc.)  Quiz Your Uncle live nearby you, Your cousin awaken you at 3 Am as his father complain of chest discomfort and asked you to give your medical advice about his chest discomfort How much are you confident? 1. Yes, it`s and easy job I'll be very confident 2. I`ll be some what confident but will take right decision 3. I'll not be sure about my decision 4. I think it`s very difficult and I can`t do this surely  QUIZ Which Anonymous you Prefer? A. Angina Pectoris B. Chest Pain C. Chest discomfort WHY?  General Considerations Cardiac Pain is visceral Pain (deep seated, dull, can`t localized, etc.) It`s important to consider all forms of discomfort, since cardiac problems does not always cause pain The severity of discomfort does not correlate to the severity of the cardiac problem There are many other causes of Chest discomfort  Costo-chondritis Pleurisy Pericarditis Coronary Dissection Tracheitis Pulmonary E Pneumonia Esophagitis  Angina (SOCRATES) Usually possible to determine the probable cause of the pain with a detailed history Distinguishing between serious and benign causes of chest pain is imperative  NAP On Left or Right Side N = Nature A = Associated Symptoms P = Precipitating factors On = Onset Left = Location Right = Radiation & Relieving Factors Side = Severity  Chest Pain Characteristics and Corresponding Causes Nature Angina symptoms are perceived as retrosternal chest discomfort (e.g., pain, discomfort, heaviness, tightness, pressure, constriction, squeezing, Heavy object on my chest, etc.) Sharp chest pain that increases with inspiration and lying supine is unlikely related to ischemic heart disease (e.g., these symptoms usually occur with acute pericarditis).  Chest Pain Characteristics and Corresponding Causes Associated symptoms Common symptoms associated with myocardial ischemia include, but are not limited to, dyspnea, palpitations, diaphoresis, lightheadedness, pre-syncope or syncope, upper abdominal pain, or heartburn unrelated to meals and nausea or vomiting. Atypical Presentation Indigestion, Belching, and Dyspnea may occur in patients with diabetes, women, and elderly patients.  Chest Pain Characteristics and Corresponding Causes Precipitating factors Physical exercise or emotional stress are common triggers of angina symptoms. Occurrence at rest or with minimal exertion associated with angina symptoms usually indicates ACS. Positional chest pain is usually non-ischemic (e.g., musculoskeletal).  Chest Pain Characteristics and Corresponding Causes Onset and duration Angina symptoms gradually build in intensity over a few minutes Sudden onset of ripping chest pain (with radiation to the upper or lower back) is unlikely to be angina and is suspicious of an acute aortic syndrome. Fleeting chest pain—of few seconds’ duration—is unlikely to be related to ischemic heart disease.  Chest Pain Characteristics and Corresponding Causes Location and Radiation It is felt over the central part of the anterior chest and can radiate up to the jaw or shoulder, or down the arms or even to the umbilicus. Patients classically clench their right fist and hold it to their chest when describing the pain (Levine Sign) Pain that can be localized to a very limited area and pain radiating to below the umbilicus or hip are unlikely related to myocardial ischemia  Chest Pain Characteristics and Corresponding Causes Severity The severity of discomfort does not correlate to the severity of the cardiac problem Ripping or Tearing chest pain (“worse chest pain of my life”), especially when sudden in onset and occurring in a hypertensive patient, or with a known bicuspid aortic valve or aortic dilation, is suspicious of an acute aortic syndrome (e.g., aortic dissection).  Chest Pain Characteristics and Corresponding Causes Relieving factors Rest relieves pain within minutes Relief with nitroglycerin is not necessarily diagnostic of myocardial ischemia and should not be used as a diagnostic criterion.  Quiz A 65 Years Old male presenting with 2 hours history of central chest discomfort He describes it as “though an Heavy Stone compressing my chest” He gets similar symptoms when walking 2 blocks and is relieved with rest Today episode began after he walked to the bathroom and was not relieved at rest Cardiac Non-Cardiac Possible Cardiac  Agenda Applied anatomy and physiology Review of general roles in History Taking Common CV symptoms Chest Discomfort Common CV symptoms Dyspnea Common CV symptoms Palpitation Common CV symptoms Edema Common CV symptoms Fatigue Common CV symptoms dizziness and Pre-syncope Other Related Symptoms (Claudication, Hemoptysis, etc.)  Dyspnea (Breathlessness) Shortness Of Breath (SOB) or Dyspnea is the sensation one has when using an abnormal amount of effort to breathe. Patients may describe “breathlessness,” an inability to “get their breath,” or being “short-winded.” “Tightness” ‫مش بقدر اخد نفسي – نفسي ضيق – نفسي بيروح مني‬  QUIZ Breathlessness (Dyspnea) is a Specific Cardiac Symptom A. True B. False  Exertional Dyspnea Shortness Of Breath on Effort or Exertion – Onset (Acute, Rapid, Insidious) – Duration – Severity – Exacerbating Factors (Effort, Emotional Stress, Salt Intake, Drugs, etc.) – Relieving Factors (Rest, Diuretics) – Associated Symptoms (Cough, Dizziness, Wheezes, etc.)  Exertional Dyspnea Shortness Of Breath on Effort or Exertion – Onset (Acute, Rapid, Insidious) – Duration –Severity – Exacerbating Factors (Effort, Emotional Stress, Salt Intake, Drugs etc.) – Relieving Factors (Rest, Diuretics) – Associated Symptoms (Cough, Dizziness, Wheezes, etc.)  Quiz Mr. M. 45 Years Old since 2 weeks he began to feel shortness of breath when climbing 2 flights of stairs (Previously he can climb up to four flights without feeling any discomfort). What the Severity of his dyspnea? NYHA Class I NYHA Class II NYHA Class III NYHA Class IV Common CV symptoms “Dyspnea” Is the Dyspnea Specific for the heart? Enumerate 3 other Causes of Dyspnea  Special Types Of Dyspnea Positional Dyspnea Orthopnea Bendopnea Platypnea Terpopnea Paroxysmal Nocturnal Dyspnea Bendopnea Orthopnea (Latin Ortho =)  Common CV symptoms “Orthopnea” SOB on laying Flat relieved by sitting up Can you prescribe to me how can you sleep? How can you sleep? Your position during sleep? Do you need to raise your back, if do so How many number of pillows used during sleep? Do you sleep in sitting position or can sleep flat?  Orthopnea is a symptom and sign of ------------ Heart Failure a) Mild b) Moderate c) Sever  Paroxysmal Nocturnal Dyspnea PND episodes of breathlessness occurring at night awaken the patient from sleep WHY?  Paroxysmal Nocturnal Dyspnea Patient sit up or stand and many go to the window for “fresh air” in an attempt to regain their normal breathing How Often? “Every Night – frequent - infrequent” Time of occurrence “Mid-night- Early morning” Severity! “Sit-up - Stand - Go to the widow or street” Lasting for “minutes – prolonged” Associated Symptoms “Cough – Frothy sputum – Sweating - Palpitation”  Quiz When you take a detailed history from Mr. M. he reported that he awaken from sleep every night after sleeping by about 2 – 3 hours by breathlessness which lasts for 30 minutes and associated with cough and wheezes The cause of SOB most probably 1. Cardiac “Heart Failure with PND” 2. Bronchial Asthma as there was Wheezes 3. Emotional Stress “Night mares”  Quiz WHY? When you take a detailed history from Mr. M. he reported that he awaken from sleep every night after sleeping by about 2 – 3 hours by breathlessness which lasts for 30 minutes and associated with cough and wheezes The cause of SOB most probably 1. Cardiac “Heart Failure with PND” Cardiac Asthma 2. Bronchial Asthma as there was Wheezes 3. Emotional Stress “Night mares”  Agenda Applied anatomy and physiology Review of general roles in History Taking Common CV symptoms Chest Discomfort Common CV symptoms Dyspnea Common CV symptoms Palpitation Common CV symptoms Edema Common CV symptoms Fatigue Common CV symptoms dizziness and Pre-syncope Other Related Symptoms (Claudication, Hemoptysis, etc.)  Palpitation Definition: Awareness of the heartbeat Normally: Is common during exertion or heightened emotion. A description of the rate and rhythm of the palpitation is essential. Extra systoles: – Are common but rarely signify important heart disease. – They usually are experienced as ‘missed’ or ‘dropped’ beats; the forceful beats that follow may also be noticed. Rapid irregular palpitation is typical of atrial fibrillation. Rapid regular palpitation of abrupt onset occurs in Supraventricular and ventricular tachyarrhythmia.  Agenda Applied anatomy and physiology Review of general roles in History Taking Common CV symptoms Chest Discomfort Common CV symptoms Dyspnea Common CV symptoms Palpitation Common CV symptoms Edema Common CV symptoms Fatigue Common CV symptoms dizziness and Pre-syncope Other Related Symptoms (Claudication, Hemoptysis, etc.)  Swelling of Lower Limbs (LL) Edema refers to fluid accumulation in the subcutaneous tissues  Agenda Applied anatomy and physiology Review of general roles in History Taking Common CV symptoms Chest Discomfort Common CV symptoms Dyspnea Common CV symptoms Palpitation Common CV symptoms Edema Common CV symptoms Fatigue Common CV symptoms dizziness and Pre-syncope Other Related Symptoms (Claudication, Hemoptysis, etc.)  Easy Fatigue Exertional fatigue, an important symptom of heart failure, is particularly troublesome towards the end of the day. Its etiology is complex but is caused partly by: – Deconditioning – Muscular atrophy. As symptoms of Low Cardiac Out Put (COP) As NYHA classification for Dyspnea  Agenda Applied anatomy and physiology Review of general roles in History Taking Common CV symptoms Chest Discomfort Common CV symptoms Dyspnea Common CV symptoms Palpitation Common CV symptoms Edema Common CV symptoms Fatigue Common CV symptoms dizziness and Pre-syncope Other Related Symptoms (Claudication, Hemoptysis, etc.)  Cardiovascular Syncope Cardiovascular disorders produce dizziness and syncope by transient hypotension, resulting in abrupt cerebral hypo-perfusion. For this reason, patients who experience cardiac syncope usually describe either brief lightheadedness or no warning symptoms at all prior to their syncopal attacks. Recovery is usually rapid, unlike with other common causes of syncope (e.g. CV Stroke, epilepsy)  Dizziness, Pre-syncope Dizziness vs. Vertigo  Vasovagal syncope Vasovagal syncope is caused by autonomic over- activity, usually provoked by emotional or painful stimuli, less commonly by coughing or micturition (‘cough syncope’ or ‘micturition syncope’). Vasodilatation and inappropriate slowing of the pulse combine to reduce blood pressure and cerebral perfusion. Recovery is rapid if the patient lies down.  Agenda Applied anatomy and physiology Review of general roles in History Taking Common CV symptoms Chest Discomfort Common CV symptoms Dyspnea Common CV symptoms Palpitation Common CV symptoms Edema Common CV symptoms Fatigue Common CV symptoms dizziness and Pre-syncope Other Related Symptoms (Claudication, Hemoptysis, etc.)  Claudication Calf pain with walking relieved by rest (Claudication) Rest Pain associated with paleness and coldness, OR calf spasm during sleep awaken the patient  Hemoptysis Hemoptysis vs. Hematemesis  References Oxford American Handbook of Clinical Examination and Practical Skills Macleod`s clinical Examination 12th edition 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guideline  Case to solve 19 Year-old man, student, Came C/O of Central Chest Pain 2 days duration, Pain is sharp Stabbing with increasing severity within the last 2 hours to become 6/10 in severity, Pain referred to the left shoulder, increase by lying down relieved partially by leaning forward, there was 1 week history of constitutional symptoms of fever and cough, ICE: he potentially afraid from Heart attack because his father dies by heart attack at the age of 62, No history suggestive of VTE (Prolonged recumbence, Syncope, Wt. loss, …) 1. What is the most likely diagnosis? 2. Mention 3 Differential diagnosis of this pain? 3. Mention 2 key words support your diagnosis? 4. Mention 1 complication for this case?