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?
Slide 3
When evaluating symptomatic complaints Site Onset Character
Radiation Alleviating factors Timing Exacerbating factors
Severity
Slide 4
Determine the cause! 4 cardinal features Duration (timing)
Location (site) Quality (character) Precipitating and aggravating
factors
Slide 5
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
Slide 6
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
Slide 7
Pain from acute coronary syndromes (myocardial infarction and
unstable angina) Often comes on at rest Pain present >30min
Slide 8
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
Slide 12
Massive pulmonary embolism Sudden onset May be
retrosternal/angina-like Can be associated with dyspnoea, collapse
and cyanosis
Slide 13
Spontaneous pneumothorax Sharp pain and severe dyspnoea
Localized to one part of chest
Slide 14
Oesophageal disorders Reflux disease can mimic angina
Oesophageal spasm Especially after drinking hot or cold fluid
Associated with dysphagia Relieved by nitrates
Slide 15
Dont forget: Cholecystitis Herpes zoster
Slide 16
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
Slide 18
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
Slide 20
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
Slide 21
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
Slide 22
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
Slide 23
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
Slide 24
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
Slide 25
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
Slide 26
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
Slide 27
Common symptom of cardiac failure Remember other causes Lack of
sleep Anaemia Depression
Slide 28
Previous ischaemic heart disease Hypercholesterolaemia Smoking
Hypertension Family history 1 st degree relatives (parents of
siblings) Especially if