Cardiac Symptoms 2

8/8/2019 Cardiac Symptoms 2

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CARDIAC

SYMPTOMS


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CHEST PAIN

ANGINA (ISCHEMIC CARDIAC PAIN): Squeezing,crushing, strangling, constricting pain in center of chest.Pain may radiate to left shoulder, left arm, right shoulder,

jaw.

Stable (Typical) Angina: Angina upon effort, or angina

induced by increased blood pressure or increasedheart-rate. Angina is relieved by nitroglycerin, although

nitroglycerin is not specific to this type of angina.

Levine's Sign: Patient makes fist and holds it up to

his chest, to describe the pain.

Second-wind Phenomenon: If patient repeatssame activity after the attack, he may not feel the

attack again the second time.

Walk-through Angina: The pain subsides as patient

continues the activity.


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Atypical Angina:Atypical presentation of typicalangina.

Atypical Symptoms: Sharp or stabbing pain, rather

than crushing pain.

Atypical Causes:Angina with change in position,for example, rather than angina strictly upon effort.

Angina Equivalents: Other symptoms that are

caused by myocardial ischemia.

Exertional dyspnea.

Nausea, indigestion.

Dizziness, sweating.


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Variant Angina (Prinzmetal Angina):Paradoxic angina occurring during rest but usually

not during exercise. It is caused by coronary artery

spasm. It can be hard to spot because it can coexistwith typical angina.

Characteristic ECG findings can help distinguish

variant angina from typical angina.

Nitroglycerin will probably still relieve pain, as it

relaxes coronary arteries.


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Unstable Angina: Angina even at rest, or anginathat has recently gotten worse. It is associated with

sharply increased risk for myocardial infarct within 4

months.

Angina Decubitus is a specific term for anginaoccurring at rest.

Myocardial Infarct: Typical presentation =Unstable angina lasting longer than 15 minutes, that

is not relieved by nitroglycerin.

Silent MI's and MI's with atypical presentation do

occur.


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NON-ISCHEMIC CARDIAC PAIN:Mitral Valve Prolapse: Usually asymptomatic, but may

present with an intermittent, sharp, sticking pain over

left precordium.Pericarditis: The patient feels relief by shallow

breathing and by sitting up and leaning forward.

Dissecting Aneurysm: Sudden, severe tearing pain,

radiating to the abdomen, neck, or back, depending onwhere the aneurysm is going.


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:Pulmonary Embolism: May be asymptomatic, or thepatient may feel a dull tightness if the embolus is large

enough.Paroxysmal Dyspnea is the most common symptom of

pulmonary embolism.

Pleurisy: Pain upon breathing. May be caused bypulmonary embolism, pneumonia, bronchitis, or pleural

effusion.

Pulmonary Hypertension: Dyspnea is a morecommon symptoms than pleuritic pain.

Pneumothorax: Pain may be confused with pain of an

MI.Mediastinal Emphysema: Free air in the mediastinumproduces chest tightness and dyspnea.

Hamman's Sign: Crunching, rasping sound heard

synchronous with the heartbeat, indicative ofmediastinal em h sema.


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GASTROINTESTINAL CHEST PAIN:Esophageal Spasm: Substernal chest pain anddysphagia.

Esophageal Reflux (GERD): Chest pain relievedby antacids.

Gallstone Colic: Colicky RUQ pain radiating to backand to right shoulder. Occasionally it may be confused

with angina.


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CHEST WALL PAIN:TIETZE'S SYNDROME

(COSTOCHONDRITIS): Inflammation ofCostochondral joints. Pain is often localized and can

be elicited by palpating the sternum over the involved

ribs.

HERPES ZOSTER:Pain may precede the

appearance of the rash. Both pain and rash follow

dermatomal distribution.

DACOSTA'S SYNDROME: Psychogenic painusually localized to the cardiac apex. May be

associated with anxiety.May also see palpitations, hyperventilation,

dyspnea, weakness, depression, or other signs of

anxiety.

Vertebral Column Disease: It may occasionallylead to anterior chest ain.


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DYSPNEA


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DyspneaDyspnea is defined as an abnormally uncomfortableawareness of breathing

it should be regarded as abnormal only when it occurs at

rest or at a level of physical activity not expected to cause

this symptom.

The sudden development of dyspnea suggests pulmonaryembolism, pneumothorax, acute pulmonary edema,

pneumonia, or airway obstruction

In contrast, in most forms of chronic heart failure,

dyspnea progresses slowly over weeks or months. Such aprotracted course may also occur in a variety of unrelated

conditions, including obesity, pregnancy, and bilateral

pleural effusion.


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QUANTITATION OF DYSPNEA

- amount of exertion

- condition of individual

SUDDEN UNEXPECTED DYSPNEIC EPISODE ARREST -

Pulmonary Emboli

Spontaneous Pneumothorax

Anxiety

EXERTIONAL DYSPNEA: Dyspnea on exertion is a commonsymptom of mild or severe Congestive Heart Failure.

DYSPNEA at REST:

Pulmonary causes of dyspnea (PE, COPD,

pneumothorax) often occur at rest. With cardiac

problems, dyspnea usually does not occur at rest, or it

is overshadowed by angina.

Anxiety Dyspnea: Difficulty breathing due to anxiety

occurs only at rest.


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ORTHOPNEA: Dyspnea occurring with patient in thesupine position. Orthopnea is a sign ofCongestive Heart

Failure that is more severe than that associated with

exertional dyspnea.CAUSE: Supine position increases pulmonary blood

flow ------> exacerbate pulmonary congestion and

pulmonary edema. The problem is relieved by resuming

a more upright position.

Two-Pillow, Three-Pillow Orthopnea: Terms todescribe the severity of the orthopnea. Three pillow is

worse than two-pillow.

PAROXYSMAL NOCTURNAL DYSPNEA (PND):

Similar to orthopnea, except it has sudden onset and occursonly after the patient has been lying down at rest for at least

an hour.

Unlike orthopnea, It is not relieved immediately by sitting

up.

Patient is usually able to return to sleep, eventually.


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ORTHOPNEA

LV Failure

Asthma

COPD

Dilat. paralysis of diaphragm

TREPOPNEA

Dyspnea in R orL decubitus

Heart Failure

PLATYPNEADyspnea in upright position


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PULMONARY EDEMA: Pulmonary edema is usually a

manifestation of left-ventricular heart failure. Peripheral edema

associated with CHF is a manifestation of right-sided heart

failure (Cor Pulmonale).SYMPTOMS: Severe symptoms. Extreme anxiety, dyspnea,

air hunger, cold sweats, fear of impending death.

SIGNS: Pink, frothy sputum, and bubbly breath sounds.

VALVULAR HEART DISEASE: Mitral Stenosis is associated

with dyspnea.CONGENITAL HEART DISEASES:

Tetralogy of Fallot: Exertional dyspnea is common.

Ventricular Septal Defect: Tachypnea and sweating. Late

cyanosis.

CARDIAC -vs- PULMONARY DYSPNEA:OTHER CAUSES OF SHORTNESS OF BREATH:

Kussmaul Respiration: Intense hyperventilation

(respiratory alkalosis) occurring with Diabetic

Ketoacidosis, as a compensatory mechanism to relieve

the metabolic acidosis.


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DIFFERENTIAL DIAGNOSISINTERSTITIAL OBSTRUCTIVE DISEASE

LARGE EXTRATHORACIC AIRWAY OBSTRUCTION

- ACUTE -

Aspiration of foreign bodyAngioneurotic edema of glottis

- CHRONIC -

Tumors

Fibrotic Stenosis after tracheotomy or intubation

- manifests as stridor & retraction of supraclavicular fossae

with inspiration


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OBSTRUCTION OF INTRATHORACIC AIRWAY

- ACUTE INTERMITTENT WITH WHEEZING - Asthma

- CHRONIC COUGH WITH EXPECTORATION -

Chronic bronchitis - generalized

Bronchiectasis - localized

I. EMPHYSEMA

- diagnosis of exertional dyspnea

- dyspnea at rest


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II. DIFFUSE PARENCHYMAL LUNG DISEASE -

- ACUTE - Pneumonia

- CHRONIC - Sarcoidosis, Pneumoconiosis

- Decreased lung volume

- Decreased lung complianceIII. PULMONARY VASCULAR OCCLUSIVE DISEASE

- Pulmonary Embolism

- Abnormal ABG with normal volumes of lung

IV. DISEASES OF CHEST WALL

- Severe Kyphoscoliosis, Spondylitis- Neuromuscular Disorders


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V. HEART DISEASE

- increased pulmonary capillary pressure, obstructive disease

of pulmonary vein, pulmonary capillary hypertension

- Mechanism:

- increased pulmonary vascular hydrostatic pressure --->Transudation ---> decreased lung compliance ---> stimulation

of J receptor in alveolar interstitial space

- fatigue of respiratory muscles

- metabolic acidosis

- Orthopnea- PND (?)


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DIAGNOSISHEART FAILURE- previous history of heart e.g. AMS

- S3 & S4

- Left ventricular hypertrophy, Jugular venous distention,

Edema

Cardiac Asthma - diaphoresis, more bubbly airway sound,common occurrence of cyanosis

COPD- dyspnea is more gradual than CHF-

Except - with infection, Pneumothorax or exacerbation

of asthma

ANXIETY NEUROSIS- different from pulmonary embolism- - sighing respiration,

bizarre pattern of breathing


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PULMONARY EDEMACARDIOGENIC

- decreased compliance, increased resistance to small airway, increased

lymphatic flow

NONCARDIAC CAUSE- Hypoalbuminemia

- liver disease, NS, protein losing enteropathy

- increased negativity of interstitial

pressure

- sudden massive evacuation of large pneumothorax- lymphatic blockage secondary to fibrotic and inflammatory disease

or lymphangitic carcinomatosis

- disruption of alveolocapillary membrane

- Alloxan administration

- diffuse pulmonary infection, aspiration shock (Gram-

negative infection, sepsis, pancreatitis, cardiopulmonarybypass)

OTHER CAUSES

- narcotic overdose

- exposure to high altitude

- neurogenic pulmonary edema- CNS disorder


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PALPITATIONS:An unpleasant awareness of one'sown heart-beat. Often described as fluttering, or skipping a

beat.

Paroxysmal Atrial Tachycardia: May cause palpitationswith an instantaneous onset.

Premature Ventricular Contractions (PVC's): May be

experienced as palpitations or a skipped beat. The

premature contraction is followed by a compensatory

pause, to allow for ventricular filling.


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FATIGUE: Non-specific finding often found with heart disease.

FATIGUE CAUSED BY HEART DISEASE: It usually occurs

later in the day or in the evening. Fatigue early in the

morning is usually not associated with heart disease, unlessthe patient was aroused from REM sleep.

The heart disease gets worse, as the patient

experiences onset of fatigue earlier in the day.

OTHER CAUSES OF FATIGUE: Lots. Chronic illness of

many types, anemia, psychological causes.


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SYNCOPE: Fainting, transient loss of consciousness.VASOVAGAL EVENTS: Most common cause of

syncope, it is caused by excessive stimulation of the

Vagus nerve ------> excessive bradycardia andreduced blood-flow to the brain.

Anxiety: It is usually associated with acute anxiety

or excessive emotion. The Vagal hyperactivity is

thought to be a hypersensitive response to

sympathetic outflow.

CARDIOVASCULAR CAUSES:

1. Arrhythmias:

STOKES-ADAMS SYNDROME: Syncope

caused by reduced cardiac output secondary toan arrhythmia.

Both severe tachycardia and bradycardia can

reduce cardiac output, leading to syncope.

Severe tachycardia reduces cardiac output by

reducing ventricular filling time.


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2. Cardiac Outflow Tract Obstruction:

Aortic Stenosis may lead to syncope.

Myxomas, benign myocardial tumors, may cause

outflow obstruction and lead to syncope.Tetralogy of Fallot is associated with fainting attacks.

Myocardial Ischemia

3. Carotid Sinus Syncope: Hypersensitivity of the Carotid

Sinus in elderly men is common cause of syncope.

4. Impaired Vasomotor Reflexes: Impairment of

Baroreceptors. Syncope is associated with orthostatic

hypotension.

5. Decreased Blood Volume

FLUID REMOVAL:Micturition Syncope: Syncope occurring with micturition

but at no other time. Associated with removal of fluid from

the body.

POST-TUSSIVE SYNCOPE: Syncope after a bout of coughing, or

after the Valsalva maneuver, may occur in patients with COPD.


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COUGH


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COUGH

DIAGNOSTIC EVALUATION

- Acute or Chronic

- Productive or not

ACUTE - infections

CHRONIC - postnasal drip

CHARACTERISTICS OF COUGH

BARKING - PertussisRELATED TO MEALS -Tracheoesophageal Fistula

Hiatal Hernia,Esophageal Diverticulum

RELATED TO CHANGE IN POSITION

Lung Abscess

Localized BronchiectasisPUTRID SPUTUM - Lung Abscess

PINK FROTHY SPUTUM - Pul. Edema

MUCOID MASSIVE SPUTUM - Alveolar Cell CA


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PHYSICAL EXAMINATION

INSP. STRIDOR & WHEEZING -

Laryngeal Disease

INSP. & EXP. RONCHI - Tracheal & major airway involvement

COARSE INSP. RALES - Interstitial Fibrosis &/or Edema

FINE RALES - Pneumonitis &/or Pulmonary Edema

COMPLICATION

Syncope

Rupture of Emphysematous BlebsRib Fracture


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HEMOPTYSIS

- Recurrent hemoptysis should be managed as if it

were the initial hemoptysisETIOLOGY

1. INFLAMMATORY

Bronchitis

Bronchiectasis

Pulmonary TuberculosisAbscess Pneumonia (Klebsiella)

2. NEOPLASTIC

Lung CA

Bronchial Adenoma

3. OTHERS

Pulmonary Embolism

Left Ventricular Failure

Mitral Stenosis


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TRAUMATIC -

Foreign body

Contussion

Primary Pulmonary HPN

Arteriovenous Malformation (?)Eisenmenger Syndrome

VASCULITIS -

Wegeners Granulomatosis

Goodpastures Syndrome

AMYLOID4. HEMORRHAGIC DIATHESIS


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DIFFERENCE OF HEMOPTYSISWITH HEMATEMESIS

HEMOPTYSIS

- tingling sensation in throat

- bright red

- frothyHEMATEMESIS

- nausea & abdominal discomfort

- magenta-colored

J Rare in Metastatic CancerJ Although it may occur in Viral or Pneumococcal Pneumonia,

still think of other Conditions.


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END OF LECTUREEND OF LECTURE

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Cardiac Symptoms 2

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