Intermittentchestpain Causedbycoronaryatherosclerosis,aorticstenosisandHCM

Acutechestpain

Causedbycoronaryatherosclerosisandplaquerupture

Predisposingfactors:HTN&CTD(Marfan'ssyndrome)

Causes:Viralinfection,CTD,MIoraftersurgery/radiotherapy/catheterablation

Mechanisms

AnginaequivalentisSOBcausedbyMI

Presentinelderlyanddiabetic.

Anxiety,anemia,respiratorydisease,andobesity

SymptomatichallmarkofCHF.

InpatientswithHFsignifyingadvanceddiseaseorincipientdecompensation.

Arrhythmias

Tachycardia

Ectopicbeats

Hyperthyroidism,anxiety,anddrugs

Causes:hypovolemia,drugs,autonomicneuropathy,elderly>65

Simplefaint=>Abnormalvasovagalreflexproducingbradycardia+/-vasodilatation.Thereflexcanbeduetostandinglongtimesinawarmenvironmentorapainful/emotionalstimuli

Pressureoverthecarotidsinusmayleadtoreflexbradycardiaandsyncope.

Bradyarrhythmia(MCC) Sinoatrialdisease,AVblocks(Stoke-Adamsattacks),andrate-limitingdrugs.

Supraventriculartachyarrhythmia(atrialfibrillation;rare)

Ventriculararrhythmia

LV=>severeaorticstenosis,HCM//RV=>massivepulmonaryembolism//Atrialmyxoma

Epilepsy,andanxiety

HF,constrictivepericarditis,chronicvenousdisease,vasodilatingCCB(amlodipine)andhypoalbuminemia

DVT

Drugs,immobility,liverdisease,andnephroticsyndrome

Sx:wtloss,nightsweats,fever,fatigue

Sxofstroke,acutelimbormesentericischemia

Sx:abdominaldistension,wtloss,andmusclewasting

HTN,DM,hyperlipidemia=vasculardisease

Rheumaticfeverormurmursduringchildhood

Skininfections,recentdentalwork,IVdruguse,trauma=IE

CTD(pericarditis,Raynaud's),Marfan's(aorticdissection),Myotonicdystrophy(AVblock)

AskaboutprematureCAD,cardiomyopathis,venousthrombosisandfamilialhypercholestrolemia

Askabout,smoking,alcohol,recreationaldrugs(amphetamine,cocaine),dailyactivity,etc.

At45degrees,exposedfromthewaistandup

HR.RR,temp,BMI,O2sat

HTNcanbe:essential,secondary(<1%),orwhite-coatsyndrome

Patient'spositionandobviouscyanosis

Tobaccostain,p.cyanosis,clubbing,splinterhemorrhage

Tendonxanthoma,petechialrash

Palmarerythema,creasepallor,OslernodesandJanewaylesions

IVdruguseandtremor

Temp.,wet/dry

Xanthelasmata(periorbital)

Petechialhemorrhage,pallor,jaundice

Cornealarcus

HTNorDMchangesandRothspots

Malarflush(mitralstenosis)

C.cyanosis,dentalhygiene

-Diffuseinwardmovement-Twowavesperpulse

-Impalpable-Compressattherootoftheneckitwilldisappearwithpressure

-Varieswithrespiration(-withinspiration)-Lyingflat(+)-Abdominojugularreflux(+)

Betweentipofvisiblepulsationandthesternalangle//Unit:cmH2O

Venoushum

45degreeswiththeshouldershorizontal,exposetillthewaist

Chestshape,symmetry,breathingpattern,deformities

Hairdistribution,skinlesions,scars,visibleveins,skinchanges,apexbeatwithatorch

Askthepttorolltotheleftifitcan'tbefelt

Usingtheheelofthehandwhilethepatientholdshisbreathonexpiration

Usingthepadsofthefingers

Aorticarea:R-2ndICS

Pulmonaryarea:L-2ndICS

Mitralarea:apex(5thICS,mid-clavicularline)

Tricuspidarea:L-4thICSclosetotheleftsternalborder

Erb'spoint:L-3rdICSclosetotheleftsternalborder

ClosureofMV&TV,bestheardattheapex

ClosureofAV&PV,bestheardatlowerleftsternalangle

Earlydiastolic:'To-Ron-To',bestheardwiththebellattheapex.

Latediastolic/presystolic:'Ken-Tuck-Ky',bestheardwiththebellattheapex

Suddenopeningofastenosedvalveinearlydiastole(mostlyMS).Itisbestheardwiththediaphragmattheapex.

Suddenopeningofastenosedvalveinearlysystole(congenitalaorticorpulmonarystenosis).BestheardwiththediaphragmattheupperR/Lsternalborders.

Mostlyfrommitralvalveprolapseinlatesystolic.Bestheardwiththediaphragmattheapex.

Pericardialrub(frictionrub)isacoarsescratchingnoisebestheardwiththediaphragmwhileholdingbreathonexpiration.

Pleuropericardialrub

Gasinthepericardium(pneumopericardium)

Metallicsoundatsystole'S1'andaloudopeningsnapatdiastole'S2'.

Metallicsoundatdiastole'S2'andaloudopeningsnapatsystole'S1'.

HeartSoundsAuscultation

Auscultatethe4areas

AuscultatethecarotidbilaterallywhilethepatientholdshisbreathforASejectionsystolicmurmurradiationandcarotidbruits

AuscultatetheleftaxillaforMRradiation

AuscultatethetricuspidareaforTS

AuscultatetheapexforS3,S4andMS

Keepingthebellontheapex,askthepatienttoturntotheleftformid-diastolicMSmurmur

Usingthediaphragm,askthepatienttoholdhisbreathonexpirationandleanforwardwhileauscultatingtheaorticareaandErb'sareaforAR

HeartMurmurs

Determinewhetheritssystolicordiastolic

AR,PR

MS,AR(AustinFlint)

MSinapatientwithsinusrhythm,atrialcontractioncauseapresystolicaccentuationofthemurmur

Patentductusarteriosus

Harsh,blowing,musical,rumbling,high/lowpitched

MRpansystolicmurmurs->leftaxilla

ASmurmur->rtuppersternaledge,suprasternalnotchorcarotidarteries

VSDmurmurs->rightsternaledge

-Pathology:usuallyatherosclerosisaffectinglargeandmediumsizedvessels-ABI:<0.9atrest-Mostpatientsareasymp.,butareatriskofmajorCVeventsandimpairedwoundhealing.

-Paininagroupofmusclesuponwalkingduetoarterialinsufficiency.ItisthemostcommonSxofPAD-Thecalfismostaffected(femoropopliteal),also,thighand/orbuttock(aortoiliacobstruction).

Wakingup1-2hrsaftersleepwithpaininthefoot(instep)duetopoorperfusion.

-Occurswhenbloodflowisinsufficienttomeetthedemandsofthetissueevenatrest-RestornightpainindicatesevereLLPADandisa‘redflagsymptom’requiringurgentactionastheymayleadtotissuelossandamputation

-InsevereLLPAD,tissueloss(gangrene)maydevelopinthedigitsandspreadproximally.-Eventrivialinjuriesdonothealwellformingulcers -Withoutre-vascularization>amputation/death

-Paralysisandparesthesiaarethemostimp.Featuresindicatingischemiaaffectingnerve/musclefx.-Muscletendernessindicatesmuscleinfarction.-AlimbwithALIfeatureswillbecomeIrreversiblydamagedunlesscirculationisrestoredwithinafewhours.

-Increasedpressurewithinthefascialcompartmentsofthelimb,mostcommonlythecalf,whichcompromisesperfusionandviabilityofmuscleandnerves.-Causes:mostcommonlyalowertrauma(e.g.fracturedtibia)orreperfusionfollowingacuteLLITx.-Sx:severepainoftenunrelievedbyopioidsandexacerbatedbyactiveorpassivemovement.Peripheralpulsesareusuallypresent.

Acute -Sx:severeabdominalpain,shock,bloodydiarrhea,andprofoundmetabolicacidosis.-Rarely,renalanglepainoccursfromrenalischaemiaandisassociatedwithhematurea.

Chronic-2/3mustbecriticallystenosed.-Sx:severecentralabdominalpaintypicallydevelops10–15minpost-prandial“scaredofeating”withsignificantwt.loss,also,diarrheamayoccur.

-Abnormalfocaldilatationofaorta(150%)affecting5%ofmenaged>65yrs(3Xmoreinmen)andmostlyasymptomatic.-Riskfactors:smoking,HTN,familial/geneticelement.-Sx:backpainorawarenessofabdominalpulsation+wavesign-RupturedAAASx:abdominal+/-backpain,pulsatileabdominalmass,syncopeandshock(hypotension).

-Patchyblue/purplediscolorationoftoes&forefootofoneorbothfeetduetoathero-embolismfromanAAA,poplitealaneurysm,atheroscleroticplaque.Usuallyfullsetofpedalpulses.-Thereisariskofamajorembolusleadingtoacutelimbischemiaandevenlimbloss.

-Digitalischaemiainducedbycold.-Pts>40YOwithunilateralRaynaud’sphenomenonhaveunderlyingPADunlessprovenotherwise,especiallyiftheyhaveriskfactors(smoking,diabetes).

Afocalneurologicaldeficitthathasavascularcause

Askaboutsmoking,hypercholesterolaemia,HTN,DM(riskfactorsforatheroscleroticconditions)

Anti-platelets,lipid-lowering,anti-hypertensive,etc.

PrematureCADorAAA

Smoking,occupation,anddailyactivity

Dilated,tortuous,sup.veinscausinglegdiscomfort,itchingorswellingandaggravatedbyprolongedstandingwhenuncomplicated

-Affects10%ofpatientswithseverevaricosevein,commonlyduringpregnancy-Recurrencemaybeassociatedwithunderlyingmalignancy-RiskofDVTorPE-Red,painfulskinovertheinvolvedarea

Painandtenderness(usuallyinthecalf)

-70-80%oflowerlimbulcerationisduetovenousdiseases-Usuallyaffectsthemedialaspectoftheleg.-Maybepainlessandrelievedbylimbelevation.It'streatedwithgraduatedcompressionbandaging

-Maybeassociatedwithlowerlimbdisease,enquireaboutDVTriskfactors-UpperlimbDVT:swollenarm,mottledandcyanosedskin,distendedveins.Sxareexacerbatedbyactivityandholdingthearmoverthehead.TheremaybeaHxoftraumaatthethoracicoutlet.

EnquireaboutpreviousvaricoseveinsurgeryandriskfactorsforDVT