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EdemaCough .. respiratory & cardiac

Hemoptysis ..respiratory & cardiac

Fatigue

Intermittent Claudication

HISTORY TAKING

OF CARDIAC PATIENTS

DR. MOHAMMED FAKHRY, MD, FACCCARDINAL SYMPTOMS IN HEART DISEASE:

Dyspnea .. respiratory & cardiac

Chest pain e.g. coronary heart , myalgic pain..etc

Cyanosis

Syncope

Palpitation

DYSPNEA:

Unpleasant Awareness of Breathing.1) Pulmonary

COPD Restrictive L. Disease

Br. Asthma Cardiaccongestive heart failure CHF (mitral stenosis, mitral regurgitation, aortic

stenosis, acute myocardial infarction, aortic regurgitation, dilated cardiaomyopathy,

restrictive cardiomyopathy)

2) Anemia : if hemoglobin is deficient O2saturation relative hypoxia trigger respiratory centerMajor symptom of anima is dyspnea & palpitation

3) Obesity : more weight and less distribution of blood tired heart & not enough cardiac output relative hypoxia trigger respiratory center

Cardiac dyspnea: whenever there is left side heart failure increase pressure in left ventricle & leftatrium increase pressure in pulmonary veins increase pressure in P. capillaries push the fluid to

alveolar spaces ( you need dry environment for good exchange) exchange of gas will alter HYPOXIC respiratory center will suffer(increasing its rate) send messages to accessory muscleof respiration e.g. sterno , trapz (power will increase)

Conclusion is PULMONARY CONJESTION

Mechanism of dyspnea is still respiratory rather than cardiac cause the problem is in the alveoli

FUNCTIONAL CLASSES OF DYSPNEA: (NYHA Classification)

Class I No symptoms at any level of exertion and no limitation in ordinary physical activity.

Class II Mild symptoms and slight limitation during regular activity. Comfortable at rest.

Class III Noticeable limitation due to symptoms, even during minimal activity. Comfortable only at rest.

Class IV at rest -2 subtypes PND & Orthopnea ( dyspena while laying on bed )* Zero no dyspnea

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CHEST PAIN OR DISCOMFORT :

Common Causes:1) CAD - Angina Pectoris

- Unstable Angina.

- Acute Myocardial Infarction

2) Mitral Valve Prolapse (MVP)3) Pericarditis4) GERD.5) Peptic Ulcer Disease ( PUD )

CHRONIC STABLE ANGINA:TYPICAL ANGINAL PAIN

coronary artery is stenosed blood supply is severely diminished + exercise accumulation ofmetabolites (lactic acid) due to anaerobic metabolism ( no creb cycle \ TCA cycle ) cardiac musclepain . (pain on exertion )

Siteretrosternal , left side above the nipple ( inframammary is not typical but above is )Quality of painconstricting, burning, squeezing, and colicky pain or a sense of pressure andheaviness but bricking (needles) sensation is not typical unless it has a cutting sensation.

Duration is limited (few minutes) 110 minRadiationtypical leftshoulder, leftarm and lower jaw while sometimes to the back,epigastrium, right shoulder and right arm .

Provoking factor (Exercise, Emotional excitement and Cold weather.)

Relieving factors (rest & TNG) one tablet of TNGdialate the coronary arteries ( good response)Associated symptomsdyspena, sweating, palpitation, dizziness, nauseaRisk Factors - mainly 45 yrs, after menopause55 yrs , diabetes mellitus , hypertension,

dyslipidemia , HDL ( > 40 / >50 ) , obesity , lack of exercise.

UNSTABLE ANGINA

Duration 10min -30min could be 1 hour

Relation to rest

Response to TNGneed more than one Sb.lingual tablet to relive the pain( moderate response) ( >3 is considered acute MI)

3 types of unstable angina :

- Crescendo () or accelerated angina or progressive anginaA patient has a history with stable angina having a attack every 2 weeks on exertion which

lasts 3-5 min and relives by rest or trinitroglycerin but now the patient is having pain more

frequent 2-3 times a day even at rest for 15-20 min

- New onset frequent anginaA patient has no history of chest pain and over last 2 weeks he had experienced 2 attacks of

chest pain and the majority of them are at rest

- Post myocardial infarction anginaA patient of acute MI was admitted in the hospital coronary care unit (CCU) last week and

after his symptoms got under control and before his discharge he experienced chest pain

again = post MI angina

Deference between stable an unstableduration, relation to rest, frequency, relation to nitratesStable patient goes to the Out Patient Department OPD for further investigation.But unstable angina patient should be admitted in the hospital CCU. So take this in to your consideration or he will die

All of this presentation is

due to atherosclerosis

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ACUTE MYOCARDIAL INFARCTION PAIN

Sitesame as stable an unstable but wider and starts retrosternaly as a fireQuality - squeezing, pressure, heaviness, constricting, colickyRadiation - both shoulders and both arms

Duration > 30min- 2 hoursAssociated Symptomssweating, pale, server dizziness, syncope, palpitation, dyspena due to

edema, cardiogenic shockResponse to S. L. TNGno response so we need to inject the patient with IV

CYANOSISBluish Discoloration of the Skin and Mucous Membranes.Due to O2 pressure &saturation NOT CO2

Peripheral.Peripheral cyanosis occurs when the blood supply to a certain part of the body is reduced e.g. lips in cold weather

are blue but the tongue is spared. If central cyanosis is the problem must consider a problem with thecardiovascular or respiratory system.

Central.Central cyanosis means that there is an abnormal amount of hemoglobin in the arterial blood without oxygen andthe blue discoloration is present in parts of the body with good circulation such as the tongue.Causes : congenital heart disease ( fallot's tetralogy, transposition of great arteries , double outlet

right ventricle) , COPD, sever bronchial asthma, restrictive lung disease due to extensive pulmonary

fibrosis (destruction of alveoli).

DIZZINESS, PRESYNCOPE AND SYNCOPE- Its a sign of low cardiac output (vascular dilation) in main cases while sometimes it is due to middleair disease (deferential)

- Presyncope is server dizziness until the patient feels like he is about to fall down but conscious enough

to support him self.

-Syncope

is transient loss of consciousness and the patient will fall down but when he / she lies flat hewill regain his consciousness because while laying flat the brain will be in the same level of the heart

then it will be easy for the blood supply to reach the brain hence the patient will regain his

consciousness (transient).

Causes:

1) Drugs: V. Dilator Drugs ( vasodilatation hypotension brain blood supply syncope)You should test the first effect of the drug while the hypertensive patient is still in the OPD (first

dose effect will be magnificent or server so you should take care)

2) Vasovagal syncopeWhen the patient is experiencing painful or unpleasant stimuli (bad news) this will summon first the

sympathetic reaction further more the parasympathetic will arise afterwards too. Moreover if theparasympathetic stimulation is out of proportion so this will lead to vagus over tune or

parasympathetic drive hypotension & bradycardiaAlso when a person is experiencing hot weather and tiredness or even sleeplessness he will develop

syncope.

Keep in mind that the patients having carotid sinus hypersensitivity and when the baro recpters is

stimulated it will cause syncope hence Kung Fu fighting techniques 3) Cardiac ArrhythmiaIf the heart rate is > 200 or < 40 the cardiac output will diminish presyncope & Syncope4) Cardiac Lesions (AS, MS, PS) cardiac output

http://www.wrongdiagnosis.com/t/transposition_of_great_arteries/intro.htmhttp://www.wrongdiagnosis.com/t/transposition_of_great_arteries/intro.htm

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- Pulmonary stenosis- Pulmonary hypertension- Mitral regurgitation- Aortic regurgitation

PALPITATION

Unpleasant Awareness of Forceful or Rapid Heart Beating.

Main Cause: Cardiac Arrhythmias

Description:

Fast or slow Regular or irregular

Duration Associated symptomsdizziness, polyuria (frequent micturition) ,cheast pain, nausea & vomiting

EDEMA OF THE LOWER LIMBS

Edema is excessive fluid accumulation in the interstitial spacesCAUSES:

1) Cardiac edema - pitting lower limbs edema bilateraldue to Rt. sided heart failure

2) Renalnephritoc syndrome, chronic renal failure,

3) Hypoalbuminemia due to Liver cirrhosis ( albumin level hydrostatic pressure fluid will go outside)4) Venous Insufficiency

- Esp. pregnancy(uterus compress Venus return from femoral veins torsiousty? and destruction ofveins valves by time it will get varicose veins and edema

- Long standing posturee.g. teacher, surgeon, traffic police.TYPES Grades:Around ankle = 1+ edemaascends below the knee = 2+ edemahigher the then the knee (thighs) = 3+ edemaascends to the abdominal wall and scrotum= 4+ edema

COUGH DUE TO CONGESTIVE HEART FAILURE

It occurs when pulmonary venous pressure with exercise or

even at rest in patients with CHF transudation of fluid or blood into alveolar spaces reflexcough,and sometimeshemoptysis(rupture of capillaries due to pressure or pulmonary infarction by embolus) &dyspnea

(associated symptoms ofCHF)

HEMOPTYSIS

Coughing blood

pulmonary Congestion (CHF) Ruptured pulmonary Capillaries. It occurs in the course of pulmonary. Infarction

heart failure server edema cough +hemoptysis +dyspnea

FATIGUE

It is usually due to low cardiac output

associated symptoms of CO :

- CHF- Myocardial infarction- Aortic stenosis- Mitral stenosis

INTERMITTENT CLAUDICATION Stenosed femoral artery blood supply sever pain due to effort after walking a few distances hence the After that patient is rested and walked again he will be fine until he will feel the pain once again (intermittent)

Intermittent claudication due to peripheral arterial disease or Peripheral Vascular Disease (PVD)

Severity:

- Is high when the pain arouse in short distance e.g. 10 meters

- Is low when the pain arouse in long distance e.g. 500 metersSO when you see a pale leg that means the blood supply to that leg is effected already that need quick iliofemoral

bypass or else it will be gangrenised