Flashcards in Cardiovascular Deck (17)
Key Cardiovascular symptoms to ask?
Chest Pain- SOCRATES
Dyspnoea- exertional/ orthopnea/ paroxysmal nocturnal dysponea
Palpatations- tap out rhythm?
Systemic Systems- fatigue/fever/weightloss
Key Chest Pain Questions to ask?
ONSET- duration? acute/gradual? rest/exertion at onset?
CHARACTER- aching/crushing (ACS), sharp/worse inspiration (pleuritis)
RADIATION- pain move? jaw/arm? (ACS) back?(dissection)
ASSOCIATED Q's: dysponea, sweating/clamminess/nausea, cough (duration/productive/haemoptysis), palpatations, syncope, oedema, fever (pericarditis, costrocondritis, pneumonia)
TIME: duration. worsening/ improving/ fluctating
worse- inspiration (PE/pneumthorax/pneumonia), exertion ( ACS/PE/pneumothorax/ pneumonia), lying flat (pericarditis)
better- GTN spray (ACS/ oesphageal spasm), leaning forward (pericarditis)
SEVERITY- similar in past?
Differentials of chest pain
SOB, Pleuritic chest pain, haemoptysis, dizziness, syncope
RF: immobility, FHx (thrombophillia, anti-phospholipid syndrome), malignancy, pregnancy, contraception
Management: ABCDE modified Well's score >4= CTPA, <4= D-dimer
Bedside- urine (bHCG), obs, ECG, ABG
Bloods- FBC, U&E, clotting, d-dimer
Imaging- CTPA, V/Q ( female of women's bearing age)
Haemodynamically unstable= thrombolyse massive PE (rule out dissection unequal pulses/BP, AV incompetence, inferior MI, limb ischaemia)
Haemodynamically stable: LMWH/unfractionated if renal impairment for 5 days then start DOAC/warfarin
Provoked PE- further investigations
Length of Tx: Provoked 3 months and then reassess risk to benefit profile
Unprovoked PE with no identifiable risk factors >3months
Malignancy- LMWH continue for 6 months or until Malignancy cured
Pregnancy LMWH- till end of pregnancy
What is the modified Well's score?
Clinical Signs and symptoms of a DVT +3
An alternative diagnosis is less likely than a PE +3
Recent Immobilisation +1.5
Previous DVT or PE +1.5
Cancer: active Tx/ within 6/12/ palliative +1
Symptoms: SOB, fever, productive cough, pleuritic chest pain
Signs: Pyrexia, cyanosis, confusion, tachypnoea, tachycardiac, hypotension, consolidation (dull percuss, increased vocal resonance, increased fremitis), pleuritic rub.
Management: ABCDE approch, CURB-65, sepsis 6 pathway if necessary
Bedside- obs eps SpO2, urine (atypical screen legionella//pneumococcal), ABG
Bloods0 FBC, CRP, U&Es
Special- Sputum sample, pleural fluid asp, broncos-copy in immunocompromised patients.
Tx- Supportive- anti-pyretics, fluids, Abx as per guidelines.
Follow up CXR in +/- 6/52
What is CURB-65
Confusion ( abbreviated mental test = 8)
Urea > 7mmol/L
Respiratory Rate >/= 30/min
BP <90 systolic
Age >/= 65
0-1 PO Abx and home Tx
2 Hospital Therapy
3- severe pneumonia 15-40% mortality
May underscore in the young
Symptoms- Sudden onset SOB, pleuritic chest pain
Signs- reduced expansion, hyperresonance, diminshed breath sounds, (tension= deviated trachea)
RF- tall, thin, smoker, asthmatic, COPD, Marfan's
Management- ABCDE: haemodynamically unstable = chest drain
Bedside= ABG (hypoxic/dysponeic), ECG, repeat obs
>50? smoking Hx/ evidence underlying chest pathology on CXR/exam? yes= secondary pneumothorax
1) Primary= >2cm +SOB? yes= needle aspiration.
No/ Successful then discharge and review in OPD in 2-4 weeks.
Not successful chest drain and admit
2) Secondary 1-2 cm?
YES- needle aspiration- under one cm? yes (no= chest drain)
NO- admit + O2 for 24hrs for obs
>2cm + SOB= chestdrain
Causes of Pericarditis
Viral (coxsakie, echovirus, EBV, CMV, adeno, mumps HIV)
Bacterial ( TB, lyme disease, Q fever, pneumonia, rheumatic fever, staphs, streps, legionella)
Autoimmune- SLE/RA, vasculitides, IBS, sarcoid, amyloid, dresslers.
Metabolic- uraemia, hypothyroidism, anorexia
Drugs- procainamide, hydralazine, anorexia
Central chest pain, worse on inspiration and lying flat +/- improves with leaning forward, pericardial rub on auscultation, fever +/- symptoms of pericardial effusion/ cardiac tamponade
Management- ABCDE approach
Bedside- repeat Obs, ECG ( widespread saddle shape ST elevation)
Bloods- FBC, ESR, U&Es Cardiac enzymes ( troponin may be raised.
Imaging- CXR (cardiomegaly might point to effusion), echo if suspected effusions.
Tx- NSAID + gastric protection for 1-2 weeks, colchicine 3/12 to reduced recurrence. Rest and Tx cause
Not improving/ autoimmune= steroids
Pericardial effusion: pericarditis/ myocardial rupture/ aortic dissection/ pus/ malignancy
CF- SOB, Pain, local compression (hiccups,phrenic/ nausea, diaphragm), bronchial breathing in LLL, muffled heart sounds
Bedside- ECG ( reduce voltage QRS comlexes)
Bloods- FBC, U&Es (CKD), CRP, CArdiac Enzymes
Imaging- CXR (>300ml enlarged), Echo
Special- Pericardiocentsis + culture (ZN stain cytology)
Complications of pericarditis?
Heart encased in rigid pericardium
Cause- unknown/ TB/ after any pericarditis
Clinical Features- RHF, increased JVP; Kussmaul's sign; soft diffuse apex beat; quiet HS; S3; diastolic pericardial knock; hepatosplenomegaly; ascites; oedema
Management- ABCDE approach
Imaging CXR- small heart +/- pericardial calcification
CT/MRI distinguish from restrictive cardiomyopathy
Tx- Surgical Excision
medical review to address cause + symptoms
Pericardial effusion that increases intrapericardial pressure, decreases ventricular filling and decreases cardiac output
Signs- Tachycardia, hypotension, pulslus paradoxus, raised JVP, Kussmaul's sign, muffled heart sounds
Management- ABCDE + senior + emergency pericardiocentisis
Bedside- Repeat Obs, ECG (low voltage QRS)
Bloods- FBC, cardiac enzymes
Imaging- Echo= diagnostic ( echo free zone >2cm/>1cm acute around heart +/- diastolic collapse
Special- culture of fluids
What is Ewarts?
Dullness to percuss in LL lung flied from atelectasis caused by a large pericardial effusion compressing the lungs
What is Kussmaul's Sign?
JVP rises paradoxically with inspiration