[os 213] lec 02 cardinal symptoms of heart disease (a)

7/23/2019 [OS 213] LEC 02 Cardinal Symptoms of Heart Disease (a)

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OS 213: Cardiovascular SystemLEC 02: CARDINAL SYMPOMS O! "#AR DIS#AS#

Exam 1 | Dr. Donato Marañon | September 24, 2012

O$LIN#Common Cardiac Symptomatoloy!. C"e#t $ain

1. !ttrib%te# o& $ain2. De'nition#(. C"ronic )ec%rrent C"e#t $ain Syndrome4. !c%te C"e#t $ain Syndrome*. Ca#e Di#c%##ion

+. Dy#pneaC. $alpitat ion#D. EdemaE. Cyano#i#. Syncope--. -mportance o& i#tory and $E

/"e lect%re i# #imilar &rom bloc +# Lect%re b%t e c"aned t"e &ormattin t"o%" a#in an %lo n%n topic. So i& ma# na%l%"an ayo #orry.Some c"ane#:1. !ll t"e #ymptomatoloy are no %nder common cardiac #ymptomatoloy.2. Di3erential# &or c"e#t pain "ae been diided into c"ronic and ac%te.

I% COMMON CARDIAC SYMPOMAOLO&Y

• Sym'toms: complaint# o& t"e patient 5mo#t common complaint: pain67 -ncl%de# c"e#t pain, dy#pnea,

palpitation#, edema, cyano#i#, #yncope

• Si()s: doctor# ob8ectie 'ndin# and ob#eration#

A% C"#S PAIN

• C*est 'ai): mo#t common b%t not ex"a%#tie 9 can be ca%#ed by ot"er &actor# #%c" a# "yperten#ion

ARI+$#S O! PAIN ,PP-RSO.

• Provocative "at prooe#;trier# t"e pain

o -# it precipitated by e3ort 5exertional6<

o !t "at time doe# it appear< ="en yo% are tryin to et %p, moin t"e body, etc>

• Palliative "at reliee#;palliate# t"e pain

o Medication#, t"erapy, etc>

• -uality t"e nat%re o& t"e pain

o S"arp, b%rnin, pricin, #tabbin, #tran%latin, oppre##in, ac"e #imilar to m%#cle ac"e, etc.

• Re(io)/Radiatio) location 5primary reion "ere t"e pain i# &elt6, central reion, "o ide t"e coerae i#

and "ere t"e pain radiate# or i# or#t

o Central precordial pain "ere doe# it radiate< +ac< Le<

o ard to interie ilipino# ?doon, diyan@ a%e de#cription# o& location

• Severity inten#ity: mild, moderate, #eere

o May %#e a #cale &rom 0 to 10 5or#t6

o Aie open9ended B%e#tion#

imi)(

o n#et abr%pt, or#e at #tart, in#idio%#, b%ild# %p;rad%al

Ia)0 Aca0 "a))a* $PCM 21A: -, =alanFapantayG

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o D%ration "o lon doe# it la#t: &e #econd#, min%te#, "o%r#

o reB%ency once eery mont", once eery 2 year#, etc.7 aoid %#in p"ra#e# #%c" a# rarely,

#ometime#

• Ot*er associated sym'toms important to be able to identi&y t"e etioloy

o Ha%#ea and omitin, cold #eat#, palpitation#, co9morbiditie# and ot"er ri# &actor#, etc.

o Always observe while you are examining (these might give you clues on the symptoms of the patient)

D#!INIIONS

From 2015 Bloc B!

• S'o)ta)eous: come# and oe#, not related to e3ort

• Rest: pain rad%ally #%b#ide# "en t"e e3ort i# eliminated

• Nitrates: coronary a#odilator#7 t"i# a# a palliatie &actor i# c"aracteri#tic o& myocardial i#c"emia.

o a#te#t actin9 #%blin%al nitrate#

• Di5use: not more t"an one 'nerbreadt"

• ime: anyt"in exceedin 20 min%te# i# a##ociated it" myocardial in&arction

• Severe: ac%te coronary #yndrome

C"RONIC R#C$RR#N C"#S PAIN SYNDROM#DD6

1% CARDIAC #IOLO&Y: Classic A)(i)aA

ixed arterial #teno#i# ca%#in #ymptom#, %#%ally "ile e7erti)( sel

o I%ality o& c"e#t pain o& aortic #teno#i# i# t"e #ame a# t"at o& anina

o -mbalance in myocardial oxyen demand o%t#trippin t"e #%pply

▪ -n anemic#, t"e #ame amo%nt o& oxyen ill be di#trib%ted to t"e ti##%e# a# normal i& t"ere i# increa#e inCardiac %tp%t or i& t"ere i# increa#e in xyen Extraction )ate in t"e ti##%e#.

o !merican eart !##ociation 5!!6: Ja medical term &or c"e#t pain or di#com&ort d%e to coronary "eart

di#ea#e.J

o C*ro)ic a)(i)a9 myocardial i#c"emia

o Noctur)al a)(i)a9 prooed d%rin #leep

o 2014: c"e#t pain d%e to temporary myocardial i#c"emia, %#%ally #econdary to coronary at"ero#clero#i#

o 2014 tran#: Le## t"an 1*920 min%te# %n#table coronary #yndrome, i& reater t"an (0 min%te#, ac%te


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2% CARDIAC #IOLO&Y: Aty'ical A)(i)a/A)(i)a PectorisA

• t"e c"e#t di#com&ort o& myocardial i#c"emia i# a i#ceral di#com&ort t"at i# %#%ally de#cribed a# a "eaine##,

pre##%re, or #B%eeKin 5arri#on# 1t" Edition pae 6.

o ="ile at re#t or "ile "ain atypical orload

a8le 1% Di5ere)tiati)( t*e 9uality o a)(i)a

/N$-C!L

E!/O)ES

!/N$-C!L

E!/O)ES

D-!+E/-CS

eaine##5a%e ac"e in

t"e c"e#t6

SB%eeKin

Con#trictin

Stranlin

builds up

over time

+%rninStabbin

$in $ricin

May "ae'arest*esia;

c"ane in

#en#ori%m, ill

de#cribe t"in#

di3erently

A Coro)ary Artery Diseases ,CAD.

most commo) etiolo(y or coro)ary i)sucie)cy

• commo) sym'tom IS AN&INA% AN&INA is a sym'tom )ot a disease;

5"ttp:;;.n"lbi.ni".o;"ealt";"ealt"9topic#;topic#;anina;6

• /"e a&orementioned &eat%re# are %#%ally t"e ba#i# &or t"e determination o& typical or atypical anina. -n #ome

re&erence# t"i# i# ba#ed on t"ree cla##ic #in#:

o 516 #%b#ternal c"e#t di#com&ort it" a c"aracteri#tic B%ality pre##%re ;#B%eeKin;"eaine## an

d%ration

o 526 prooed by exertion or emotional #tre##

o 5(6 relieed by re#t or nitrolycerin.

o y'ical a)(i)a i it *as all t*ese t*ree si()s a)d aty'ical i it *as t<o%

• A)(i)a sym'toms resem8le t*ose o a *eart attac=% oeer, anina #ymptom# %#%ally la#t only one to

'e min%te#, "ile c"e#t pain &rom a "eart attac may la#t &or "o%r#. !nina #ymptom# normally dimini#" a&ter

re#tin or tain anina medication#. eart attac #ymptom# do not improe it" re#t, and anina medication ill

not red%ce "eart attac c"e#t pain

•

A)(i)a 5de'nition6 ?c"e#t pain ca%#ed by re#tricted blood Po to t"e "eart 5called i#c"emia6. -t o&ten occ%r#"en yo% are %nder emotional or p"y#ical #tre##, #%c" a# exerci#e. ="en t"e "eart doe#nQt et eno%" oxyen &romt"e coronary arterie#, yo% &eel a #B%eeKin c"e#t pain or pre##%re acro## yo%r c"e#t t"at %#%ally oe# aay a&ter yo%#top t"e actiity. /"e mo#t common ca%#e o& anina i# "ardenin o& t"e arterie# 5at"ero#clero#i#6.@ 5.%mm.ed%6

$sual Distri8utio) o Myocardial Isc*emia

• )etro#ternal c"e#t pain


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• Central c"e#t radiate# to nec and 8a 5anina denti#9 dental pain67 more commonly don t"e le&t arm

5&olloin dermatomal di#trib%tion6

• Can al#o radiate to ri"t arm 5&or ri"t coronary problem#6, epia#tri%m, or bac.

• Dermatomal oriin o& "eart inoled 5"ence di3erent area# o& re&erred pain

• /oot" !c"e and t"roat ac"e can al#o be a #in o& M- ?%p to t"e nec and into t"e 8a.

!i(ure 1% $sual Distri8utio) o isc*emic c*est 'ai): dermatomal distri8utio) o t*e *eart"epigastrium! may suggest right coronary artery involvement

3% CARDIAC #IOLO&Y: Mitral >alve Prola'se

• !n abnormal #y#tolic balloonin o& part o& t"e mitral ale into t"e le&t atri%m, re#%ltin in a Poppy leay ale.

o You)(er 'atie)ts %#%ally "ae t"i# in#tead o& coronary in#%Rciency

o O#%ally #tay# a# it i#, it"o%t "emodynamic deterioration o& t"e ale or #troe

o 29* o& people, e#pecially t"e &emale# commonly #een in t"e clinic#

o Hot ery li&e t"reatenin, b%t i# a##ociated it" mitral re%ritation in t"e Onited State#.

a8le 2% C*ro)ic Recurre)t C*est Pai) Sy)dromes: Cardiac Di5ere)tials?

Classic A)(i)aAty'ical A)(i)a s*ould 8edisti)(uis*ed rom )o)@cardiac c*est 'ai)??

Mitral >alve Prola'se a5ects B o emales

P

D%rin e3ort; exertion5e..alin or d%rin very *ot orvery cold <eat*er67 d%e todemand &or oxyen 5dema)dty'e6

Spontaneo%#;coldeat"er5mec"ani#m i#a#ocontriction; coronarya#o#pa#m T su''ly ty'e o&anina rat"er t"an demand type6,pain at ni"t

Spontaneo%#

P)e#t ; nitrate#5diano#tic i& c"e#tpain oe# aay in a &e min%te#6

Hitrate# Spontaneo%# 5can beincapacitatinneed to %#e a +9

blocer6

-

ariable 5/N$-C!L: SB%eeKin,con#trictin, pin pricin,#tabbin ti"tne##, pre##%re,"eaine##, #tranlin,a%ec"e#t di#com&ort6#basta mabigat$ %&'&&! parang may hollowblocs sa chest

ariable5b%rnin, pricin,#tabbin pain7 &o%nd in diabetic#and t"e elderly7 iti# not li&et"reatenin6

ariable5diano#i# i# ba#ed onec"ocardiorap"y6


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Classic A)(i)aAty'ical A)(i)a s*ould 8edisti)(uis*ed rom )o)@cardiac c*est 'ai)??

Mitral >alve Prola'se a5ects B o emales

R)etro#ternal; precordial5di3%#epain, more centrallylocated6

)etro#ternal 5not typical 7 maybedi3erent in location67 e#pecially

it" diabetic#, t"ey %#%allypre#ent it" atypical anina

Le&t anterior, ariable5can be%nder t"e brea#t6

SMild to moderateUUU 5#table T#ame leel o& inten#ity &or #ometime no6

Mild to moderate Mild #eere5not li&e t"reateninb%t pain i# incapacitating6

19(0 minypically *15+20 mins-& V 20 min#. T Myocardial-n&arction 5M-6

19(0 min#,aybe 2+- mins

Min# "o%r#

O

)i# &actor# 5i.e. !e: MV**;4*U,VW*;**U, * mo#t common ri#&actor#: Smoin, DM,"yperten#ion, dy#lipidemia,enetic predi#po#ition6!##ociated &actor#: obe#ity,

#tre##

!l#o ; CS!$5C"ronic Stable !nina $ectori#7"i"er ri# in diabetic patient#and in omen, pre#ence o& atlea#t 1 ri# &actor &or coronarydi#ea#e6

No%n &emale5o&tentime# t"ecomplication i# benin6

U/"e#e are 8%#t common di#ea#e# 5ot"er di#ea#e# may pre#ent it" #imilar pain;#ymptom#6UU=e #"o%ld not di#mi## t"e complaint 8%#t beca%#e it i# atypicalUUU/"e Canadian Cardioa#c%lar Society 5CCS6 radin o& anina pectori# a# de#cribed in t"e medical literat%re in1XW. /"i# radin #y#tem o& t"e #eerity o& e3ort anina "a# been accepted t"ro%"o%t t"e orld oer t"e pa#t (0year#.

a8le 3% Ca)adia) Cardiovascular Society &radi)( o A)(i)a Pectoris

&rade Descri'tio)

&rade I rdinary p"y#ical actiity doe# not ca%#e anina, #%c" a# alin and climbin #tair#. !nina it" #tren%o%# or rapid or prolonedexertion at or or recreation. (leastbothersome)

&rade II

S

li"t limitation o& ordinary actiity. =alinor climbin #tair# rapidly, alin %p"ill,alin or #tair climbin a&ter meal#, or incold, or in ind, or %nder emotional #tre##, oronly d%rin t"e &e "o%r# a&ter aaenin.=alin more t"an to bloc# on t"e leeland climbin more t"an one Pi"t o& ordinary#tair# at a normal pace and in normalcondition# (provoe. by more than usual tousual activities)

&rade III

Mared limitation o& ordinary p"y#ical actiity.=alinone or to bloc# on t"e leel and climbin one Pi"t o& #tair# in normal condition# and atnormal pace (provoe. by less than usualactivities)

&rade I>

-nability to carry on any p"y#ical actiity it"o%t di#com&ort,aninal #yndrome may be pre#ent at re#t (.isabling or severe/ pain at rest)

)e&erence#:Campea% L%cien. Aradin o& anina pectori#. Circ%lation 1XWY*4:*22( "ttp:;;.cc#.ca;donload;po#itionZ#tatement#;Aradin20o&20!nina.pd&

4% &I #IOLO&Y: #SOP"A&#AL0 &ASRIC0 +ILIARY

a8le 4% C*ro)ic Recurre)t C*est Pai) Sy)dromes: &I di5ere)tials


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http://www.ccs.ca/download/position_statements/Grading%20of%20Angina.pdf









#so'*a(eal

!cid )eP%x Di#ea#e

&astric

Aa#tric;$eptic Olcer

+iliary

Aallbladder #tone#

P eed 5a common prooin &actor60 exerci#e,

#%pine;lyin don a&ter a meal 5d%e to reP%x7e#pecially i& patient "a# "iatal "ernia or eaA- #p"incter7 Aa#troe#op"aeal reP%x:?E!)/+O)H@6

a#tin5or 2"r# a&ter eatin67

e.. peptic %lcer

eedin 5precipitated

by "i" &at meal#7#pa#tic6

P Drinin, proton p%mp in"ibitor#, antacid#,b%rpin,52 blocer;proton p%mp in"ibitor#decrea#e acidity o& a#tric #ecretion#6 paini# d%e to acid oin bac to t"e e#op"a%#,SLH

eedin, )x 5antacid#: 2 blocer#, proton p%mpin"ibitor#6

Spontaneo%#,)x5anti#pa#modic#,antipara#ympat"omimetic aent#6

- ariable 5b%rnin, loer part o& t"e c"e#t7anina9lie6

ariable 5"%ner9 lie pain7nain pain;di#com&ort6

Colicy, crampy or#pa#tic;pain&%l

R S%b#ternal5may radiate to t"e epia#tri%m7i#ceral ac"e6

Epia#tri%m; loer #tern%m )i"t %pper B%adrantb%t can radiate toc"e#t and #"o%lder

S Mild 9 #eere Mild moderate7 #eere5mayimply per#i#tence o& aper&oration i& #eere6

Mild, #eere

*9W0 min 5%#%ally not relieedearlier6

o%r#51.* "r# or loner a&ter ameal7 antacid# &or immediaterelie&6

Min9"r#

O !nina9lie5e#op"aeal #pa#m# al#omani&e#ted b%t not relieed by nitrate#6

Epia#tric pain 4 # 5ri# &actor# o&all#tone#: &at,&emale, &ertile, &orty6,na%#ea and omitin

No%r note# "ere:

B% O"#R #IOLO&Y: PL#$RAL0 MS0 !$NCIONAL

a8le B% C*ro)ic Recurre)t C*est Pai) Sy)dromes: Other diferentialsPleural 5more di3%#e6 or

Pulmo)ary 5ac%te pericarditi#,pne%monia6

Musculos=eletal 5&elt almo#t byeeryone %nle## #edentary6

!u)ctio)al? 5p#yc"o#omatic6

P )e#piration 5deep breat"#67co%"in7 ple%ralinPammation5ac%te ple%riti#,a#t"ma6

C"ane in $o#ition, %ponapplication o& pre##%re, %ponmotion7 elicit tenderne##7 may berec%rrent7 may al#o be a##ociatedit" co%"

S%pratentorial7 Stre##: ?all in t"e"ead@ no oranic ba#i#7p#yc"iatric 5e#pecially +orderline$er#onality6

P !nale#ic# 5anti9inPammatory,narcotic#6

)e#t, )x 5anale#ic# and;or non9#teroidal# beca%#e it# aninPammation6

)elaxation7 p#yc"iatric interention7exten#ie or%p7 deliberate t"o%"ton diano#i#really depend# on"i#tory

- ariable 5sharp, more localiKedpain6

ariable 5d%ll m%#cle typepain, depend# on po#ition andmotion6

ariable 5b%t can be di#tre##ine#pecially i& %nnon etioloy6

R ariable 5"ereer pat"oloyi#, e#p. Le&t; )i"t c"e#t, bac6

ariable S%b#ternal

S Mild #eere 5%neB%albreat"in7 leanin on one #ide

to protect t"e "%rtin area dependent i& ac%te6

Mild #eere Mild #eere

ariable5%ntil inPammationabate#6

ariable o%r#

O Co%" [ &eer 5beca%#einPammation inoled6, co%"a##ociated pain

/ietKe# Syndrome ac%teco#toc"ondriti#7 inPammation o&co#tal cartilae# 5co#toc"ondraland #ternoco#tal 8%nction6,tenderne## and #"arp localiKed

Da Co#ta#5sol.iers heart 6 mo#t#eere7 in #oldier# #ent to ar patient it" pro&o%nd p#yc"o#omatiKation# 5lo## o& motiation,enery lac, c"e#t pain#, a%e


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Pleural 5more di3%#e6 orPulmo)ary 5ac%te pericarditi#,

pne%monia6

Musculos=eletal 5&elt almo#t byeeryone %nle## #edentary6

!u)ctio)al? 5p#yc"o#omatic6

pain 5a &e point# in t"e c"e#t6

9 more common in &emale# beyond&orty7 $E eoe tenderne## byto%c"in c"e#t pain

#ymptom#6

9may reB%ire p#yc"iatric care7circ%latory ne%ra#temia

U%nctional aa #%pratentorial 5its all in the min.$)! but its symptoms is as real as those with organic symptoms No%r note# "ere:

a8le % C*ro)ic Recurre)t C*est Pai) Sy)dromes: Summary Di5ere)tial Provocative Palliative Ot*er

A)(i)a D%rin e3ort )e#t, #%blin%al nitrate# Min# Coronary di#ea#eri# &actor#

#so'*a(eal eedin, exerci#e,#%pine po#ition

+%rpin, drinin, SLH Min# !nina lie

&I a#tin ood, !ntacid# Min# Epia#tric pain

+iliary eedin Spontaneo%#, )x Min# Crampy, colicy

Pleural0 Pulmo)ary )e#piration, co%" !nale#ic# ar. !##oc.

it" co%" and

&eer

Musculo@s=eletal $o#ition, motion,pre##%re

!nale#ic#, 5m%#clerelaxant#6

ar. /ietKe# #yndrome

!u)ctio)al Stre## )elaxation ar. Da Co#ta##yndrome

?e modern doctor# are eB%ipped to reconiKe t"e #%btle ca#e# o& anina, larely beca%#e t"ey are inorant o& t"e#e

detail# or %nillin to ine#t time in "i#tory tain>@?& t"e million coronary anioram# done in 1XX(, 200,000

reealed normal coronary arterie#>ad Leine# teac"in# been "eeded, &e i& any o& t"e patient# o%ld "ae been

#%b8ected to #%c" a co#tly and ina#ie proced%re>@

?reB%ent reliance on a #o9called or9%p>-# te#timony to lac o& clinical #ill#>@

9+ernard Lon, MD 51X* Hobel $eace $riKe6

•

Poi)t o #m'*asis: i#tory and $E matter.

AC$# C"#S PAIN SYNDROM# DD6

a8le E% Acute C*est Pai) Sy)dromes

Commo)

CausesCli)ical Clues

ACS: AcuteMI?

$rior anina, ri# &actor#,V20min%te#, cre#cendoACS:

$)sta8leA)(i)a?

AcutePulmo)ary#m8olism?

Dy#pnea, clear l%n 'eld# (this is nota pulmonary problem/ its a vascular problem), Deep ein /"rombo#i# i# ari# &actor#

Dissecti)(aortica)eurysm?

OneB%al p"a#e#9 radial, brac"ial,&emoral

ou can hear regurgitations


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Commo)

CausesCli)ical Clues

!c%te$ericarditi#

$le%ritic 5araated "en leanin&orard or tain deep breat"#6,

central c"e#t, anterior &riction r%b

!c%te$ne%monia

$le%ritic, co%"

!c%te Aa#triti#

Ha%#ea andomitin

!&ter alco"ol,nain

!c%te$ancreatiti#

!&ter alco"ol,all#tone#

!c%teC"olecy#titi#

\a%ndice

!c%te i#ceral

problem#5abdomen6

Ha%#ea, omitin, cold #eat

U/"ree di#ea#e# a##ociated it" c"e#t pain t"at o%ld reB%ire immediate attention (life threatening) /"e#e ?+i

/"ree@ di#ea#e# can be r%led o%t by C anioram 5"oeer relyin on t"i# te#t can mae yo%r mental capacitie#

deteriorate 5Maranon, 20117 ba#in &rom Lon6

UU!c%te Coronary Syndrome 5!CS6: !c%te M- and On#table !nina. On#table !nina i# it"o%t necro#i# 5t"%# i#

diano#ed a&ter M- i# r%led o%t6

UUUSometime# na%#ea and omitin toet"er it" di3%#ed pain can be a mani&e#tation o& ac%te M- (respect these

symptoms3)

• ixed ob#tr%ction ind can re#%lt to %n#table anina.

o -nten#ity

o reB%ency

o ="at prooe# it

• Acute coro)ary sy)drome re#%lt# &rom plaB%e r%pt%re

o Hecro#i# i# pre#ent in ac%te M-. !c%te t"rombo#i# occ%r#.

o Diano#tic o& necro#i#: EnKyme#.

o !c%te M- i# r%led o%t i& t"ere i# no eidence o& myocardial necro#i#, neatie &or EFA c"ane#, and no

c"aracteri#tic pain. -& enKyme te#t# neatie, t"en it i# %n#table anina.

Let*al

o !c%te M-, On#table !nina, !c%te $%lmonary Emboli#m, Di##ectin !ortic !ne%ry#m

$)sta8le A)(i)a

o more #eere, more &reB%ent, need# -CO con'nement7 cre#cendo anina 5increa#in inten#ity;

or#enin pattern, %nlie in cla##ic and atypical anina6, m%#t monitor anina it"in t"e 'r#t mont" beca%#e itcan ?"ead #o%t"@ to t"i#

Dissecti)( Aortic A)eurysm

o aorta tear#7 aortic in#%Rciency m%rm%r# are "eard on $E7 t"e pain i# more #eere at t"e o%t#et and it

radiate# to t"e bac and t"e b%tt 5dependin on t"e extent o& t"e ane%ry#m6


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o patient# &eel lie t"eyre oin to die 520 die at initial pain67 %neB%al p%l#e# dependin on t"e leel#

o& compromi#e o& aortic branc"e#

Pro7imal aortic dissectio)

o mani&e#t# a# c"e#t pain

• Acute 'ulmo)ary em8olism

o #"ortne## o& breat", clear l%n 'eld# 5a problem o& per&%#ion, not entilation6, oxyen de#at%ration;

"ypoxemia, ple%ritic, p%lmonary "yperten#ion9 related, ) cannot compen#ate: )i"t "eart &ail%re. $ne%moniaT

cracle#,

• Acute 'ericarditis@ pericardial r%b

• Acute ')eumo)ia

o &ebrile epi#ode it" ple%ritic pain7 in#piratory ple%ritic r%b

CAS# DISC$SSION

• -n t"i# ca#e: Do not %#e endo#copy %nle## t"e patient doe#

not re#pond to medication#; treatment

+% DYSPN#A

•

DeG)itio): /"e patient i# not nece##arily in di#tre## b%t i##%3erin &rom #"ortne## o& breat"

HO MAIN YP#S O! DYSPN#A: CARDIAC ANDP$LMONARY

a8le F% Di5ere)tiati)( cardiac a)d 'ulmo)ary dys')eaCardiac Pulmo)ary

O#%ally &rom cone#tie "eart &ail%re oranina, b%t t"e#e do not incl%de edema

b#tr%ctie p%lmonary airay#yndrome#, e.. a#t"ma

O) e7ertio)

$rore##ie and occ%r# on exertion

• $rore##ie: tae# more e3ort at t"e o%t#et,t"en le## and le## in time %ntil it occ%r# atre#t

•

201*: )D, M- or cardiomealy

$rore##ie 5c"ronic: C$D or end #tael%n di#ea#e6

epi#odic 5bronc"ial a#t"ma, "ic" "a#reer#ible, intermittent ca%#e#6

Ort*o')ea

Late•%nle## in ca#e# o& ac%te mitral ale

re%ritation

-mmediate, can "appen earlier on

PND?? 5$aroxy#malHoct%rnal Dy#pnea6?Cardiac !#t"ma@

)elieed by #ittin or#tandin• red%ction o& central eno%# poolin

•201*: "en patient i# #%pine, t"ere i#p%lmonary cone#tion d%e to increa#edblood Po to t"e l%n#

Expectorate:• relieed by #p%t%m prod%ction [ co%"

•201*:expectoratin p"lem, blood

Cou(* Late #ymptom Early prominent #ymptom

#dema!#cendin 5&rom t"e &eet %p6+ientric%lar9 &rom Le&t "eart &ail%re 5C!D6

!#cendin5only in a )9#ided &ail%re or )"eart &ail%re &rom p%lmonary"yperten#ion ?core p%lmonare@6

U/o di3erentiate t"e di3erent &orm# o& dy#pnea, be detailed a# po##ible, #ince #ymptom# are #imilar &or bot" t"e

cardiac and p%lmonary type#

O"#R YP#S O! DYSPN#A SYNDROM#S

• Ort*o')ea 9 dy#pnea "en in #%pine7 diRc%lty breat"in in #%pine po#ition, late #in

• Paro7ymal )octur)al dys')ea?? 9 epi#ode# o& #%dden dy#pnea and ort"opnea t"at aaen t"e patient &rom #leep,%#%ally one or to "o%r# a&ter oin to bed, ?"en yo% #leep, et %p and yo%re o%t o& breat"@

• re'o')ea dy#pnea "en lyin on #ide;lateral dec%bit%# po#ition, can occ%r d%e to "eart &ail%re or p%lmonarycondition# or di#ea#e #tate#


o 14

Case 2 ?/"e pain %#%ally occ%r#d%rin exertion b%t#ometime# at re#t or a&ter&atty meal#. -t i# relieedby nitrate# or re#t or#ometime# by belc"in>@

Diano#i#

m%ltiple etioloie#: biliary, e#op"aeal,atypical anina (Be open min.e. of other

possible etiologies 4o not be limite. towhat is being .iscusse. )

Caeat /"e concept o& par#imony: #imple#t ay toexplain 5only one di#ea#e6

Case 1 ?/"e patient i# a 40 it"c"e#t pain on exertion,%#%ally a&ter a#"inclot"e#>@

Diano#i#

Opper extremity e3ort 5m%#c%lo#eletalpain67 can al#o be d%e to anina +O/ t"etype o& e3ort i# important.

Caeat -n anina, e3ort a# li"t a# alin canca%#e t"e pain. /"e ind o& e3ort illc"aracteriKe t"e pain.





• Platy')ea dy#pnea "en %pri"t %#%ally d%e to a diap"ramatic problem7 di3erential#: "epatop%lmonary #yndromed%e to p%lmonary #"%ntin, diap"ramatic mi#matc"

• /reponea and $latypnea are i##%e# it" c"anin per&%#ion9entilation ratio# and conenital diap"ram problem#

• No) cardiac causes o dys')ea: Dy#pnea may be ca%#ed by #eere anemia and "ypoxia, "ic" are not excl%#ielycardiac or p%lmonary ca%#e#

Caveat

Case 1?4oc/ ma.ali po aong mapago.>@

Diano#i#

ea#y &ati%e #. exertional dy#pneadi3erence in ernac%lar: tire ea#ily 5ea#y&ati%e6 er#%# o%t o& breat" 5exertionaldy#pnea6

Caeat Di3erentiate beteen pat"oloic andp"y#ioloic• Ea#y &ati%e: e3ort intolerance d%e to

lo cardiac o%tp%t• Exertionaldy#pnea: cone#tie "eart

&ail%re

• $at"oloic i& t"e #ymptom i# not ae;>appropriate

Case 2 #4oc/ hinihingal po ao ahit walangginagawa/ saa mayroon ho aong aba/nahihilo ao/ at nanlalamig/ at lagi aonghinang+hina$

Diano#i#

"yperentilation #yndrome

Caeat /"e ca#e may appear non9#peci'c b%tt"e#e #in# are c"aracteri#tic o&"yperentilation #yndrome, "ic" may bea normal t"in and o%ld reB%ire patientto blo into rebreat"in ba

• Dy#pnea may be normal or abnormal dependin %pon t"e #it%ation. /"ere&ore, e need to elicit more in&ormation &romt"e patient d%rin t"e "i#tory tain. Remem8er t*at cardiac a)d 'ulmo)ary sym'toms may al<ays 8e'rese)t o) e7ertio)0 ort*o')ea0 PND0 cou(*0 a)d edema. $roper diano#i# entail# a ood "i#tory tain "ic"inole# t"e clear c"aracteriKation o& t"e #ymptom# and correct %nder#tandin o& t"e patient# de#critption o& cardio9p%lmonary #ymptom#.

C% PALPIAION

• DeG)itio): !arene##;#en#ation o& one# "eartbeat

• Can be:o Sinlet 5#ipped beat#6o )apid #%cce##ion o& palpitation# 5tac"yarr"yt"mia6o o to di3erentiate< !# t"e patient to tap on t"e table &olloin t"e r"yt"m o& "i#;"er perceied "eartbeat

•

Can deelop d%rin exerci#e• Hot alay# tac"ycardia or bradycardia

a8le % Di5ere)tiati)( u)ctio)al a)d or(a)ic 'al'itatio)s!u)ctio)al Or(a)ic/ Pat*olo(ic

Start Arad%al S%dden#)d Arad%al S%ddenri((er Stre## HoneRate ]]100 VV100 5t"ey can "ae

#%praentric%lar or entric%lartac"ycardia# occ%rrin andbeca%#e o& t"at, extremely rapidrate6

201*: alt"o%" t"ere are #omebradycardic palpitation#6

Ot*er Sym'toms !nxiety 5a little bit o& trem%lo%#ne##, #tae &ri"t6U Many complain abo%t t"i#G

C"e#t ti"tne##, #"ortne## o&breat", #yncope

Caveat

Case 1 ?4oc/ lagi po aong inaabahan >@Diano

#i# No% can only come to a diano#i# i& yo% a# t"epatient &%rt"er. !#: Ano pong ibig niyong sabiinginaabahan6^Do not #%e#t an an#er. -& yo%


1 o 14





are prone to #%e#t, ie m%ltiple c"oice#.Caeat Let t"e patient explain "at #;"e mean#

D% &#N#RALIJ#D #D#MA

• c"aracteriKed by an 5abnormal6 acc%m%lation o& ater 5act%ally an acc%m%lationo& #alt, "ic"brin#aterit" it6

•

enerally PAINL#SS

a8le 1% Di5ere)tiati)( t*e di5ere)t ty'es o edema

Cause Descri'tio)Re)al De#cendin

• ypoalb%minic #tate#: p%3y eyelid# 5periorbital edema6 and &ace,e#pecially in nep"rotic #yndrome

• yperolemia, ac%te renal &ail%re

• /o type#: !c%te renal &ail%re and nep"rotic #yndrome"e'atic0 systemic Centri&%al

• Start# in t"e abdomen 5a#cite#6 d%e to portal "yperten#ion

• !# #econdary compen#atory mec"ani#m, yo% et it in yo%r &eetnext

Cardiac a)d Pulmo)ary

5Dependent edema6

!#cendin

• eet 'r#t, bilateral t"en %pard, may eole to ana#arca5eneraliKed edema6

• eart &ail%re 5L[) &or cardiac, ) #ided &or p%lmonary6

Caveat

Case 1 ?/"i# 4 "a# been "ain bilateral anle #ellin&or t"e pa#t mont", #"e can "ardly al>@

Diano#i#

!nle !rt"riti#

Caeat C"ec 'r#t i& t"ere i# pain #ince art"riti# and o%tare %#%ally pain&%l. Edema i# painle##.

#% CYANOSIS

• DeG)itio): bl%i#" color o& t"e #in and m%co%# membrane# re#%ltin &rom an increa#ed B%antity o& red%ced"emolobin 5i.e., deoxyenated "emolobin6 or o& "emolobin deriatie# 5e.., met"emolobin or #%l&"emolobin6

in t"e #mall blood e##el# o& t"o#e ti##%e#. 5arri#on# 1 t"ed6• Commo) locatio)s: in t"e m%co%# membrane# 5o& t"e mo%t"6, nail bed#, con8%nctiae

Pat*o'*ysiolo(y:o -ncrea#e in t"e B%antity o& eno%# blood a# a re#%lt o& dilation o& t"e en%le# and eno%# end# o& t"e capillarie#

_)_o )ed%ction in t"e #at%ration o& arterial blood 5Sa26 in t"e capillary bloodo Lead# to increa#e in t"e B%antity o& red%ced "emolobin in m%coc%taneo%# e##el#

• Cyano#i# become# apparent "en concencentration# o& red%ced "emolobin in capillary blood e7ceeds 4(/L 54;dL6

At least B (rams 'er cell or (reater ,o desaturatio).:

o -t i# t"e a8solute, rat"er t"an t"e relative, B%antity o& red%ced "emolobin t"at i# important in prod%cincyano#i# 57arrisons/ 1t" ed6

• /"%#, cyano#i# i# more appreciated in a polycyt"emic per#on rat"er t"an an anemic per#on

!nemic patient "emolobin at , 2 #at%ration o& * d%e to p%lmonary di#ea#e de#at%ration i# ` o& T 2

not cyanotic beca%#e deree o& deoxy"emolobin i# only 2o $atient it" "emolobin o& 1W, * #at%rated ` or 4 i# not yet cyanotic 5yo% need more de#at%ration &or

cyano#i# to mani&e#t6

It is easier to see desaturatio) or cya)osisKo -n a polycyt"emic per#ono -n &air #inned people t"an dar #inned 5?#in color matter#@6o +etter detected in nail bed# and malar prominence# in &airer #inned per#on#o -n m%co%# membrane# t"an nail bed#

a8le 11% Deo7y"8 Co)ce)tratio) t*at cause Cya)osisDeo7y"8 Co)ce)tratio)

Normal B (/dlMet "8a)emia 5!bnormal b6Uconenital or acB%ired, &rom abnormal or dr%# 5nitrate#6

U%#%ally in toxic concentration# and "emolobinopat"ie#

1%B (/dl

Sul "8 5!bnormal b6 %B (/dl

• Met9b and S%l&9b ari#e &rom "emolobin conenital problem# and toxicitie# 5nitrate poi#onin6

• Can be conenital or acB%ired

PA#RNS O! CYANOSIS: C#NRAL ORP#RIP"#RAL

a8le 12% Di5ere)tiati)( ce)tral a)d 'eri'*eral cya)osisCe)tral Peri'*eral


11 o 14





%irs wor.s!De#at%rated centrally2 #at%ration i# lo d%eto a cardiac p%lmonarycondition

%irs wor.s!Ca%#ed by #omet"inin t"e perip"ery5a#ocon#triction, coldeat"er6

/"e arterial blood "a# looxyen leel 5"ypoxemialeadin to arterialoxyende#at%ration &romt"e aorta9deoxy"emolobin6.

Cyano#i# i# ob#ered bot"in m%co%# membrane#5mo%t", lip#, palpebralcon8%nctia ande#pecially %nder t"eton%e6 and nailbed#

appen# it" conenital

"eart di#ea#e, "eart&ail%re, p%lmonary edema

/"ere i#a#ocon#triction5demon#trated byto%c"in ice6, arterialeno%# occl%#ion#,"emo#ta#i# and arterialblood "a# normaloxyen leel 5normal#at%ration6

+%t &or #ome rea#on,c%taneo%# blood Po#lo# don anddecrea#e#, and t"eti##%e# extract more

oxyen &rom t"e blood

/"ere i# an increa#e ineno%# deoxyenatedblood in t"e capillarie#,and only t"e nailbed#are cyanotic

*is '*e)ome)o) ca) 8e attri8uted to:

• a#o#pa#m 5Ray)auds '*e)ome)o)@ c"aracteriKed by t"e &ocal a#ocon#tricted #tate o& t"earterie#6, ex. Diital arterie#

• ! t"romb%#, embol%# or a normal re#pon#e to a cold enironment or anxiety

• -t co%ld al#o be $D!: $atent D%ct%# !rterio#%# "erein t"e deoxyenated blood Po# to t"e loerextremitie# 5only t"e loer extremitie# are cyanotic, t"e %pper extremitie# and oral m%co#a loo normal6

• $olycyt"emic 5it" b]206 et cyanotic earlier t"an anemic.

Caveat

Case 1 ?/"e toe# ere cyanotic b%t "er 'ner#ere not>@

Dia()osis

Di5ere)tial cya)osis &rom $D!Reverse PDA

• /"ere i# a ri"t to le&t #"%ntin o& bloodpa#t t"e #%bclaian artery, and t"e%pper extremitie# are #pared

• Hote t"at $D! i# a le&t to ri"t #"%ntRevie<: Pate)t Ductus Arteriosus

• Ductus Arteriosus: Comm%nication beteen t"e aorta and t"e p%lmonary artery liament%m arterio#%m

• Pate)t DA: /"e d%ct%# arterio#%# #till per#i#t# a# a e##el leadin &rom t"e bi&%rcation o& t"e p%lmonary artery to t"eaorta 8%#t di#tal to t"e le&t #%bclaian artery i)stead o closi)( ater 8irt*

•-n ad%lt patient# it" $D!, p%lmonary pre##%re# are normal and a radient and #"%nt &rom aorta to p%lmonary arteryper#i#t t"ro%"o%t t"e cardiac cycle.

•$%lmonary pre##%re i# 1/ o& t"e #y#temic circ%lation. +lood &rom t"e le&t "eart oe# %pard 5'ner#6, mixed bloodoe# donard 5&eet6.

Di5ere)tial cya)osis rom PDAo May be d%e to 'reere)tial s*u)ti)( o 8lood to t*e eet ia t"e patent d%ct%# arterio#%# 5$D!6.o Di3erential diano#i# incl%de:

Dia8etes a)d #ise)me)(er sy)drome@ patient# it" a lare comm%nication beteen t"e to circ%lation# att"e aortop%lmonary, entric%lar or atrial leel# and directional or predominantly ri"t to le&t #"%nt# beca%#e o& "i" re#i#tance and ob#tr%ctie p%lmonary "yperten#ion

Severe 'ulmo)ary vascular disease re#%lt# in reer#al o& Po t"ro%" t"e d%ct%#, %noxyenated blood i##"%nted to t"e de#cendin aorta, and t"e toe#, b%t not t"e 'ner#, become cyanotic and cl%bbed termed

di3erential cyano#i#.

!% SYNCOP#

• Syncope i# t"e relatiely abr%pt loss o co)scious)ess5201*: brie&, #econd# to a &e min%te# and d%e to decrea#edblood Po in t"e brain6, it" or it"o%t a #"ort prodrome.

• Presy)co'e dii)ess

• Some people deelop #yncope a&ter diKKine##

• ?Doc na"i"ilo ao@"at type< 8haracteri9e an. .escribe3


12 o 14

a8le 13% es o Dii)ess





y'es a)d causes o cardio(e)ic sy)co'e

• Sto=es@Adams/ cardiac ,sy)co'e.@ #%dden ce##ation o& cardiac &%nction and e3ectie C, complete "eart bloc7bradycardia5&rom complete "eart bloc6ca%#in lo## o&

con#cio%#ne##• >asova(al/Commo) ai)t9 aa )eurocardio(e)ic

sy)co'e5201*: He%roloic ca%#e it" prodrome5Pa#"e# o& li"t, eane## and cold clammy #eat6, more benin7interaction o& cardiac mec"anoreceptor# a# ell a# para9and #ympat"etic receptor#7 a#odepre##or or in"ibitor. Canbe preented beca%#e t"ere are arnin #in#6

a8le 14% -ualities o sy)co'eSto=es Adams >asova(al5t"e common &aint e.. in t"e "eat6

O)set S%dden =it" #"ort prodrome 5#tomac"ac"e, dimmin o& i#ion,

li"t"eadedne##67 clo#e to "yperentilation7 po#ition

dependent, aa common &aint

#)d !#ymptomatic, 5201*: no po#t ict%#,

pt "a# no memory o& occ%rrence6

O#%ally no po#t ict%# 5po#t #eiK%re6 except &or a &e

brie& 8er# #ometime#

Duratio) Second# 5or el#e t"e patient ill be

dead6

Min%te# to "o%r#, relieed by lyin don 5blood oe#

to "ead6

a8le 1B% Ot*er Causes o Sy)co'e@li=e #'isodes ,DD7.!b#ence #eiK%re# Sit%ational5201*: pre9

and po#t9ictal #tae#,ea and #leepy %ponreial, non con%l#ie#eiK%re#6

Co%" #yncope Sit%ational 5201*: beninand common in elderly,lo## o& con#cio%#ne##a&ter co%"in bo%t d%eto increa#ed aal#tim%lation6

$o#t mict%rition#yndrome

Sit%ational 5201*: beninand common in elderly,pt i# oen %p by an %reto %rinate and lo##e#con#cio%#ne## %ponmict%rition6

Carotid #in%#"yper#en#itiity

$a##in o%t "en #"ain5201*: "en t"e patientt%rn# "i# "eador ear# a

ti"t collared #"irt6yperentilation#yndrome

201*: D%e to "ypocapnialeadin to lo## o&con#cio%#ne##

ypolycemia 201*: t"ro%" intae o&oral "ypolycemic# #%c"a# libenclamide,met&ormin, in#%lin andcomi#tamil

Caveat:

Case 1 Doc0 )a*i*ilo'o a=oK t"en lo#e# con#cio%#ne## Diano#i# /ra%ma Caeat Determine t"e di3erential# 5t"i# patient "ad tra%ma 5"ead in8%ry66

/emporal order i# important 5"ittin "ead t"en ettin %p and &aintin # &aintin and t"en &allin and"ittin "ead6

--. -M$)/!HCE -S/)N !HD $Ea8le 1% Im'orta)ce o "7 a)d P#8rombie, 1XW( i#tory and $E acco%nt# &or o& patient diano#i#7ampton, 1X* i#toryTF2 $ET X%aun.ler , 1X0 i#toryT*W $ET 1*%apira, 1XX0 i#toryT $ET X


13 o 14

>erti(o Dise9uili8rium Sy)co'e/ NearSy)co'e

#en#ationo&#pinnin

or t"eroom i##pinnin

le## t"an ertio,may be ear problem#;e#tib%lar or t"e CHS;

central connection# int"e brain 5201*:#en#e o& imbalance7mild ind o& ertio7problem it"proprioceptor#,#tereono#i#7%n#teady ait6

pa##in o%t5201*: near&aintne##, abo%t

to pa## o%t,li"t"eadedne##6,metabolic#ometime#5"ypolycemia> b%t t"at# noto%r topic #incet"i# i# cardio6





• Looin at t"e more recent al%e#, e can #ee t"at e can #till arrie at a diano#i# it" "i#tory and $E. +eteen t"e

to, "i#tory i# importantG

• )emember t"e importance o& "i#tory tain 5and $E6 #o e can proe t"i# %y ron: J4octors pour drugs o&

"ic" they now little, to cure di#ea#e# o& "ic" they now le##, into "%man bein# o& "om they now not"inJ.

Voltaire

#ND O! RANSCRIPION -an: i bloc !G ne la#t mod%le, t"en SEM+)E!F naG Ne"eyG :6!ca: !ca: 7eaven in a wil. :ower . !l#o, -m c%rrently in a po#t9!ard 5#ea#on 26 "i". Matty plea#e, plea#e be the oneG ^cc: DMS /"ey ont et toread t"i#, b%t "appy "appy birt"day to my beloed batc"mate, +le##ieG - loe yo%, #i# !l#o to t"e #iKKlin "ot and ae#ome $atric 5#%per mi## na ita6 and la#tly, belated "appy birt"day to one o& t"e #a%#ae ma#ter#, LeeG Fein, ae#ome 8ob, man. Sexy moG i #i##e# and brod#, !/AG -: =alanFapantayG i yo%G@anna": Fam%#tam%# Falaba#a naman #a minireetin#<G a"a"aG Sorry %y#G =e did o%r be#t b%t e %e## o%r be#t a# t"e be#t.5anaaboomboomanpaalaapeG6


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[os 213] lec 02 cardinal symptoms of heart disease (a)

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