CARDO VASCULAR HISTORY TAKING BY Dr. SUBRAMANYAM1-03. · Occurs in sleep 2 to 3 hours after going...
Transcript of CARDO VASCULAR HISTORY TAKING BY Dr. SUBRAMANYAM1-03. · Occurs in sleep 2 to 3 hours after going...
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PRESENTED BY
Dr . G . Subrahmanyam M.D., D.M.,Professor of CardiologyDirector of Narayana Medical InstitutionsyEx-Professor of Cardiology SVMC &SVRRHEx Asst. Professor of Medicine, SVMC &Ex Asst. Professor of Medicine, SVMC &
SVRRH
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S C SS S GGS.
CLASS RANKS BAGGED DURING 2010
1 FIRST M.B.B.S 1ST, 2ND, 3RD & 5TH
2 SECOND M B B S 4TH 5TH 6TH & 10TH2 SECOND M.B.B.S 4TH, 5TH, 6TH & 10TH
3 THIRD PART-I 1ST & 9TH
4 THRID PART-II 5th, 8th, 10TH
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NARAYANA NURSING INSTITUTIONNARAYANA NURSING INSTITUTION
S.NO RANKS OBTAINED IN M.Sc(Nursing) during 2010
1 1st, 2nd,3rd, 4th,5th, 6th,7th, 8th
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NARAYANA PHARMACY COLLEGE
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NARAYANA DENTAL COLLEGE
• In MDS results, 27 out of 28 students passed psuccessfully.
• MDS(Prostodontics)MDS(Prostodontics) is the topper in the University wideUniversity wide during 2010.
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• The only centre in AP with all thewith all the Superspecialities like M CH( Surgical gastroM.CH( Surgical gastro enterology).
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History will give you likely diagnosis over 75% of• History will give you likely diagnosis over 75% of the time
• DO NOT SKIP IT in favour of tests
• History will help you immediately –T t ill t k ti t b k d ltTests will take time to come back and may result in more questions than answers.
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Best in the physician’s Quer
History is the richest source of information
Patient spouse gives good information (ChynePatient spouse gives good information (Chynestokes respiration)
Hi t 1 G l M di l Hi tHistory : 1. General Medical History2. Personal and past history3. Occupational history4. Nutritional history
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DYSPNOEA
• Dyspnoea on Exercise
• Dyspnoea on deconditioning Normal person. But moderate exerciseperson. But moderate exercise unaccumastomed causes Dyspnoea
• Interstial and alveolar oedemastretches ‘J’ receptors in the lung (CCF) ↓cardiac output (TOF) without lung↓cardiac output (TOF) without lung congestion.
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Inspiratory Dyspnoea : Obstructive airway diseaseInspiratory Dyspnoea : Obstructive airway disease.
Expiratory Dyspnoea: Obstruction to lower airwaysExpiratory Dyspnoea: Obstruction to lower airways
Exertional Dyspnoea : COPD, Cardiac failure
Dyspnoea developing at rest PheumothoraxP l b liPul.embolism
Dyspnoea occuring at rest and absent on exertion :Dyspnoea occuring at rest and absent on exertion : Functional
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DYSPNOEA
Cardiac, Renal, Ovarian, Bronchial, Psychogenic
Postural – Myxoma
Squatting ↓ TofSquatting ↓ Tof
Trepopnea : Lateral position occurs eg. CCF
Platypnea : Standing causes Dyspnoea eg.PFO, ASD
Orthopnea : Dyspnoea on supine position
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• Orthopnea :
Heart failure
Emphysema
A itAscites
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PAROXYSMAL NOCTURNAL DYSPNOEA
Occurs in sleep 2 to 3 hours after going to Bed
Relieved on up right position
Increased venous return
Diaphragm Elevated (Ascites)
Gravitational force
Sleep depresses Resp centre
Anoxia
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PLATYPNEA ORTHODEOXIA SYNDROMEPLATYPNEA ORTHODEOXIA SYNDROME
• Dyspnoea and arterial desaturation in the upright• Dyspnoea and arterial desaturation in the upright position which improves
on standing ORTHODEOXIA occurs in PFO, ASD
On lying down decreases
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CHEYNE STOKES RESPIRATION
Heart failure
CNS disorders
During sleep without awareness
Ch t k i ti i f f i diCheyne strokes respiration is a form of periodic breathing characterised by Hyperpnoea and apnoea
Apnoea may lossed for 15 seconds are longer
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ANGINA
1. Stable Angina (william Heberden 1772)
2. Walk through phenomenon: Angina will dissipate despite continued exercise.
3. Warm up phenomenon: Angina will not occur when a second exercise effort is under taken that previously produced discomfort No.2 & 3 are due to opening of functioning p g gcollaterals.
4. Levine sign.4. Levine sign.Stable Angina : Characters are un changes in the last 60 days.
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Canadian CVS functional classification of Anginag
Class – I - Cordinary physical activity does not cause anginaangina
Class – II - Slight limitation of ordinary activity
Class – III - Marked limitation of ordinary activity
Class –IV - Inability to carry on physical activity without discomfort
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TYPES OF ANGINA• Unstable Angina / Rest Angina
• Nocturnal angina / Decubitus Angina,Hypercapnia, Acidosis, g g , yp p , ,Rapid Eye movements sympathetic discharge vasoconstriction.
Inverse Angina
Status Anginosis
Un stable Angina: 1. Rest Angina 2. Severe new onset of Angina 3. Prior angina increasing in severity
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• Angina equivalent :Dyspnoea, Fatigue
• Linked up Angina : Associated with GI factors not related to an increased in cardiac work, occurs after eating, mimicked by esophageal acid stimulation which can reduce coronary blood flow
• Microvascular Angina (Syndrome X) : Normal coronary Heart g ( y ) ydisease and vascular & smooth muscle hypersensitive constrictor response
• Linked up Angina : Eosphageal acid stimulation after eating• Linked up Angina : Eosphageal acid stimulation after eating reduces the coronary flow
• Post Prandial Angina• Prinz metal Angina
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AORTIC DISSECTION
• Pain is excruciating
• Tearing Quality
• Commonly localised to inter scapular area radiates to Neck, Back, Abdomen and Flanks
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RELIEF OF CHEST PAIN
• Nitrates - Angina
• Placebo - Dacosta’s syndrome
• Changing Position in bed - Congenital absence of pericardium
• Leaning for ward - Pericarditis
• Food and antacids - peptic ulcer syndrome• Food and antacids - peptic ulcer syndrome
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PSYCHOGENICPSYCHOGENIC
• Dacosta’s Syndrome (Neuro Circulatory Asthenia)
• Sharp Stabbling left inframammay areaSharp, Stabbling left inframammay area multiple complaints, Breathlessness, Palpitation, Giddiness
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FATIGUE & WEAKNESSFATIGUE & WEAKNESSNon specific for heart disease
Anxiety, depression, Anaemia, Thyrotoxicosis
Heart failure Low CoHeart failure – Low Co
Hypotension, Hypokalemia = Diureties
Hypovolemia : A.C inhibitors
Angina Equivalent : fatigue
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SYNCOPESYNCOPE
Near Syncope patient dizzy & weak tendsNear Syncope patient dizzy & weak tendsloose postunal tone but does not looseconsciousness
Causes Vasovagal, Hypersensitive carotid,Miturition, Cough Syncope, postural syncope.
Classification : 1. Non Cardiac2. Cardiac3. Underterminated cause
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NON CARDIAC SYNCOPE• Neuro Cardiogenic• Neuro Cardiogenic• Orthostatic• Cerebrovascular• Seizure disorders
C t id i h iti it• Cartoid sinus hypersensitivity• Situational
CoughSwallowing ValsalvaMicturitionDefecationDiver’sPostpradial
Metabolic, drugsHypoxiaHypoglycemiaHypoglycemiaHyperventilation, Panic attacksEthanol, other drugs
Otherfomrs of syncope or conditions mimicking syncope‘ VertigoVertigo
MigrainePsychiatric
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FEVERFEVERChills and sweating : SBEg
Fever. (Immunuological : MI)
Fever. Intracardiac tumour
Low grade fever. Pulmonoryembolismembolism
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CHANGE IN VOICECHANGE IN VOICE
Aortic aneurysm
M.S, PAH
Pericardial Effusion (Myxodema)
DYSPHAGIA
Mitral StenosisMitral StenosisCoarctation of AortaRt Suberavian OriginDistal to Coarctation and press behind Esophagus
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HISTORY CONTINUED
• Past Historyy
• Family History
• Personal History
• Occupational History
• Neutritional History
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Radiation : Pericarditis CardiomyopathyRadiation : Pericarditis, CardiomyopathyLead Industry: 1: Hypertension
2: Conduction Disturbances2: Conduction DisturbancesTobacco industry : CVS, Lung DisordersCarbon Monoxide Exposure: CADCarbon monoxide reduces oxygen transport byHaemoglobin and inhibits mitochondrial metabolismand aggrevates CADMethylene chloride nickel paints is converted tocarbonmono idecarbonmonoxide.Exposure to Carbon di-sulfide used in Ryon
production accelerates Arheroselerosis Plaqueproduction accelerates Arheroselerosis Plaque.
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Thiamine Deficiency : High output Cardiac failure
Extreme underweight, infection : CAD
Overweight : Obesity, CAD, Hypertension
Low level of folate, B 12 : Homocystine, CAD
Antioxidants, Vitamin E ,C, Selenium : CAD
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Con: togetherGenitus : BornPain on right side of chest (Angina) : Dextro cardia situs
inversus
Left handedness : Dextro cardia situs inversus.
Recurrent Respiratory Infection : L to R stunt Kartageners Syndromeg y
Syncope : RV(O) obstruction
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FEMALES COMMON MALES COMMON
Congenital Complete Heart break Aoritic Valvular Stenosis
Mitral Stenosis AR
ASD - 2:1 Coarctation of Aorta
PPH TGA
PDA Hypertension
Lutembachers Syndrome Coronary Artery Disease
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1. HOCM2. Long QT Syndromeg y3. Complete Heart Block (CHB)4. Maternal Lupus – CHB5. ASD = Holt Oram Syndrome
Scimitar Syndrome6 VSD 3 3 % f l ti6. VSD = 3.3 % of relatives
twins 30%7 Rheumatic fever = Genetic predisposition7. Rheumatic fever = Genetic predisposition
1. Specific B cell allo antigen 99:142. High incidence of Class II HLA antigeng c de ce o C ass a t ge
1,2,3,4
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RHD in west is less
Hypertension I HD – Urban population increase incidence
High altitude : PDA
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Congenital : ASPDAASDVSDVSD
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LOW BIRTH WEIGHT LARGE BIRTH WEIGHTVSD TGATOG
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If in doubt take the history !
If still in doubt take it again !
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References:
1 DR BRAUN WALD: HEART DISESEASE
References:
1. DR .BRAUN WALD: HEART DISESEASE6TH EDITION
2. DR.HURST: THE HEART 10TH EDITION3.DR.HARRISON: 17TH EDITION4.DR.PERLOFF: THE CLINICAL
RECOGNITION OF CONGENITAL HEART DISEASE 3RD EDITIONDISEASE – 3RD EDITION
5. DR. AARON SVERDLOV -
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