HISTORY TAKING OF CARDIAC PATIENTS DR. MOHAMMED FAKHRY, MD, FACC CARDINAL SYMPTOMS IN HEART DISEASE: Dyspnea ..

respiratory & cardiac Chest pain e.g. coronary heart , myalgic pain..etc Cyanosis Syncope Palpitation Edema Cough .. respiratory & cardiac Hemoptysis ..respiratory & cardiac Fatigue Intermittent Claudication

DYSPNEA: Unpleasant Awareness of Breathing. 1) Pulmonary COPD Restrictive L. Disease Br. Asthma Cardiac congestive heart failure CHF (mitral stenosis, mitral regurgitation, aortic stenosis, acute myocardial infarction, aortic regurgitation, dilated cardiaomyopathy, restrictive cardiomyopathy) 2) Anemia : if hemoglobin is deficient O2 saturation relative hypoxia trigger respiratory center Major 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 & left atrium 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 muscle of 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. Mild symptoms and slight limitation during regular activity. Comfortable at rest. Noticeable limitation due to symptoms, even during minimal activity. Comfortable only at rest. at rest -2 subtypes PND & Orthopnea ( dyspena while laying on bed ) no dyspnea

Class II Class III Class IV * Zero

CHEST PAIN OR DISCOMFORT : Common Causes: 1) CAD - Angina Pectoris - Unstable Angina. - Acute Myocardial Infarction Mitral Valve Prolapse (MVP) Pericarditis GERD. Peptic Ulcer Disease ( PUD ) All of this presentation is due to atherosclerosis

2) 3) 4) 5)

CHRONIC STABLE ANGINA:TYPICAL ANGINAL PAIN coronary artery is stenosed blood supply is severely diminished + exercise accumulation of metabolites (lactic acid) due to anaerobic metabolism ( no creb cycle \ TCA cycle ) cardiac muscle pain . (pain on exertion ) Site retrosternal , left side above the nipple ( inframammary is not typical but above is ) Quality of pain constricting, burning, squeezing, and colicky pain or a sense of pressure and heaviness but bricking (needles) sensation is not typical unless it has a cutting sensation. Duration is limited (few minutes) 1 10 min Radiation typical left shoulder, left arm 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 symptoms dyspena, sweating, palpitation, dizziness, nausea Risk Factors - mainly 45 yrs, after menopause 55 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 TNG need 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 angina A 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 angina A 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 angina A 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 unstable duration, relation to rest, frequency, relation to nitrates Stable 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

ACUTE MYOCARDIAL INFARCTION PAIN Site same as stable an unstable but wider and starts retrosternaly as a fire Quality - squeezing, pressure, heaviness, constricting, colicky Radiation - both shoulders and both arms Duration > 30min- 2 hours Associated Symptoms sweating, pale, server dizziness, syncope, palpitation, dyspena due to edema, cardiogenic shock Response to S. L. TNG no response so we need to inject the patient with IV CYANOSIS
Bluish 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 the cardiovascular or respiratory system.

Central.
Central cyanosis means that there is an abnormal amount of hemoglobin in the arterial blood without oxygen and the 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 middle air 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 he will 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 syncope When 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 the parasympathetic stimulation is out of proportion so this will lead to vagus over tune or parasympathetic drive hypotension & bradycardia Also 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 Arrhythmia If the heart rate is > 200 or < 40 the cardiac output will diminish presyncope & Syncope 4) Cardiac Lesions (AS, MS, PS) cardiac output

PALPITATION Unpleasant Awareness of Forceful or Rapid Heart Beating. Main Cause: Cardiac Arrhythmias Description: Fast or slow Regular or irregular Duration Associated symptoms dizziness, polyuria (frequent micturition) ,cheast pain, nausea & vomiting
EDEMA OF THE LOWER LIMBS

Edema is excessive fluid accumulation in the interstitial spaces

CAUSES: 1) Cardiac edema - pitting lower limbs edema bilateral due to Rt. sided heart failure 2) Renal nephritoc 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 of veins valves by time it will get varicose veins and edema - Long standing posture e.g. teacher, surgeon, traffic police. TYPES Grades:
Around ankle = 1+ edema ascends below the knee = 2+ edema higher the then the knee (thighs) = 3+ edema ascends 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 reflex cough, and sometimes hemoptysis (rupture of capillaries due to pressure or pulmonary infarction by embolus) & dyspnea (associated symptoms of CHF)
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 Pulmonary stenosis Pulmonary hypertension Mitral regurgitation Aortic regurgitation

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 meters SO 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