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Dr. J.A. Coetser GKV 353 CoetserJA@ufs.ac.za 0833542861

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A 56 year old white male presents to casualties at 3h40am, complaining of severe chest pain that started 30min earlier. WHICH IMPORTANT ASPECTS WOULD YOU ELICIT FROM THE HISTORY?

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When evaluating symptomatic complaints Site Onset Character Radiation Alleviating factors Timing Exacerbating factors Severity

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Determine the cause! 4 cardinal features Duration (timing) Location (site) Quality (character) Precipitating and aggravating factors

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Angina Crushing pain, heaviness, discomfort or choking sensation in retrosternal area Central rather than left chest May radiate to jaw and/or arms Rarely below umbilicus Typical vs. atypical angina

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Typical anginaMeets all 3: 1.Characteristic restrosternal chest discomfort typical quality and duration 2.Provoked by exertion or emotion 3.Relieved by rest or GTN or both Atypical anginaMeets 2 of above Non cardiac chest painMeets 1 or none of above

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Pain from acute coronary syndromes (myocardial infarction and unstable angina) Often comes on at rest Pain present >30min

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Clot dissolves Coronary blood flow returns No cardiac muscle damage Clot persists Coronary blood flow cut off Cardiac muscle dies UNSTABLE ANGINAMYOCARDIAL INFARCT Angina Acute coronary syndromes

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Pleuritic pain Due to movement of pleural surfaces on one another Inflammation of pleura or pericardium Viral infection of pleura Pneumonia Pulmonary embolism Made worse by inspiration Often relieved by sitting up and leaning forward

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Dissecting aneurysm 3 features Severe, tearing pain Rapid onset Radiates to back Proximal aorta dissection = anterior chest pain Descending aorta dissection = interscapular pain Hx of HPT, or connective tissue disorder e.g. Marfans syndrome

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Massive pulmonary embolism Sudden onset May be retrosternal/angina-like Can be associated with dyspnoea, collapse and cyanosis

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Spontaneous pneumothorax Sharp pain and severe dyspnoea Localized to one part of chest

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Oesophageal disorders Reflux disease can mimic angina Oesophageal spasm Especially after drinking hot or cold fluid Associated with dysphagia Relieved by nitrates

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Dont forget: Cholecystitis Herpes zoster

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Dyspnoea definition: unexpected awareness of breathing Sensation of increased force needed for work of breathing Need to distinguish between cardiac and respiratory causes

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Cardiac dyspnoea LV output fails to rise during exercise Increased LV end-diastolic pressure Raised pressure in LA Raised pressure in pulmonary venous system Leakage of fluid into interstitial space Decreased lung compliance

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NYHA classification of dyspnoea Class IDisease is present, but no dyspnoea OR Dyspnoea only on heavy exertion Class IIDyspnoea on moderate exertion (climbing stairs) Class IIIDyspnoea on minimal exertion (getting dressed, washing) Class IVDyspnoea at rest

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Orthopnoea Dyspnoea in the supine position In supine position, interstitial oedema distributes to all lung zones, decreasing overall oxygenation In sitting position, oedema redistributes to lower zones, leaving upper zones free for oxygenation Other causes of orthopnoea Massive ascites Pregnancy Bilateral diaphragmatic paralysis Large pleural effusion Severe pneumonia

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Paroxysmal nocturnal dyspnoea (PND) Severe dyspnoea that wakes patient from sleep Has to sit up and gasps for breath Mechanism Sudden failure of LV Reabsorption of peripheral oedema at night while supine with overload of LV Dont forget anxiety as cause of dyspnoea Inability to take deep enough breath to fill lungs in satisfying way

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Ankle oedema of cardiac origin Usually symmetrical Worst in evenings, improves during night As failure progresses, involves legs, thighs, genitalia and abdomen Find out if pt is on a calcium channel blocker, i.e. Adalat XL (nifedipine), amlodipine, etc., which can also cause ankle oedema If oedema also involves face, think of nephrotic syndrome

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Definition palpitations: unexpected awareness of the heartbeat Ask pt to tap out beat with finger Ask if palpitations are slow or fast, regular or irregular, and what the duration is Any fast arrhythmia can produce angina if pt also has ischaemic heart disease

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Atrial fibrillation Completely irregular rhythm Atrial or ventricular ectopic beat Sensation of skipped beat, followed by particularly heavy beat Ventricular tachycardia Rapid palpitations followed by syncope

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Syncope = transient loss of consciousness resulting from cerebral anoxia, usually due to inadequate cerebral blood flow Presyncope = transient sensation of weakness without loss of consciousness (Im about to faint) NB: ask about family history of sudden death Long QT syndrome / Brugada syndrome

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Postural syncope LOC when standing for long periods or standing up suddenly Ask about drugs that can cause postural hypotension Micturition syncope LOC when passing urine Vasovagal syncope LOC with emotional stress Syncope due to arrhythmia LOC regardless of position Exertional syncope Aortic stenosis Hypertrophic cardiomyopathy

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Claudication = pain in one or both calves (thighs or buttocks) on walking more than a certain distance (claudication distance) 6 Ps of peripheral vascular disease Pain Pallor Pulselessness Parasthesiae Perishingly cold Paralysed Lumbar spinal stenosis (pseudo claudication) Pain relieved by flexing spine Exacerbated by walking downhill

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Common symptom of cardiac failure Remember other causes Lack of sleep Anaemia Depression

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Previous ischaemic heart disease Hypercholesterolaemia Smoking Hypertension Family history 1 st degree relatives (parents of siblings) Especially if