280 likes | 508 Views
07/10/2K8. SYMPTOM - ANALYSIS. DR.V.DAYASAGAR RAO DM, FRCP (Ed), FRCP (CAN) KIMS HYDERABAD, A.P. Symptom Analysis. Presence : Severity : Type of Disease : Exertional Syncope Obstructive Lesions Angina CAD Valvular Heart Disease Edema Heart Failure Cyanosis.
E N D
07/10/2K8 SYMPTOM - ANALYSIS DR.V.DAYASAGAR RAO DM, FRCP (Ed), FRCP (CAN) KIMS HYDERABAD, A.P
Symptom Analysis • Presence : • Severity : • Type of Disease : • Exertional Syncope • Obstructive Lesions • Angina • CAD • Valvular Heart Disease • Edema • Heart Failure • Cyanosis
Symptom Analysis • Therapeutic Options: • ACC /AHA : Class III / IV Symptoms, Valvular Heart Diseases C A D (Class I Recommendations) • Effectiveness of Therapy: • Symptoms Relief • Prognosis: • AS : Angina / LVF / Syncope • Heart Failure • CAD : Rest Angina
Symptom Analysis - Severity • NYHA Classification: I - IV • SUBJECTIVE • POOR REPRODUCIBILITY • SPECIFIC Activity Scale: • WORK LOAD : METS • OBJECTIVE : Tread Mill / Bicycle • Daily Activity : Work Load ( mets) • 6 Minute WALK Test: • C H F • P A H
Symptom Analysis • DAILY ACTIVITYWORK LOAD # Dressing (without Stopping) : 2 Mets # Light Domestic Work : 2.5 (Broome, Bringing Grocery Bags) # Descending Steps ( non Stop) : 3 Mets # More Heavy Work : House : 3.25 (Making Bed, Washing, Veg Cutting) # Gardening : 4 - 5 # Fast Walking : 5 # Climbing Steps (With Luggage) : 6 - 7
DYSPNEA • AWARENESS – BREATHING ABNORMAL UNCOMFORTABLE • “SHORTNESS OF BREATH” • SUBJECTIVE MANIFESTATION LEVEL OF ACTIVITY
DYSPNEA GRADING OF SEVERITY : A T S Class I : UNUSUAL PHYSICAL EFFORT II : ORDINARY ACTIVITY III : LESS THAN ORDINARY IV : AT REST
DYSPNEA • PULMONARY VENOUS HYPERTENSION Interstial Fluid Lung Parenchyma LUNG : RIGID / LESS COMPLIANT INCREASES EFFORT Respiratory Muscles • “REFLEXES” initiated vascular distension contributes – SENSATION of DYSPNEA SHALLOW & RAPID BREATHING
DYSPNEA • BRONCHIAL VASCULAR SYSTEM: Pulmonary Veins Bronchial Veins (Dilate) Production of Mucus Rupture Hemoptysis Edema of Bronchial Mucosa Wheeze • ALVEOLAR EDEMA Gas Exchange - Hypoxia P VH
DYSPNEA ORTHOPNEA : Recumbant Posture Number of PILLOWS Increased VENOUS RETURN to HEART Worsening Pulmonary Venous Hypertension
DYSPNEA PAROXYSMAL NOCTURNAL DYSPNEA • Variant Dyspnea / Orthopnea • 2 – 3 Hrs after SLEEP • Nocturnal Evolve Acute Pulmonary Edema • Increased Venous Return Heart • Absorption Edema Fluid Vascular Space Decreased Adrenergic Drive LV Depressed Respiratory Center (Nocturnal)
DYSPNEA – Obstructive Sleep Apnea • EPISODES – HYPOPNEA / APNEA • OBSTRUCTION – SNORING • DAYTIME SLEEPINESS – SOMNOLENCE • RELATION – CARDIAC DYSRHYTHMIAS - PULMONARY ARTERIAL HYPERTENSION • SLEEP LAB DATA
SYNCOPE • TRANSIENT LOSS : CONSCIOUSNESS POSTURAL TONE • PRESYNCOPE : LOSS OF POSTURAL TONE WITHOUT LOSS OF CONSCIOUSNESS Fainting / blackout : Near loss of Consciousness – “GREY” • REST ERRECT POSTURE • EFFORT induced RECUMBANCE STRUCTURAL HEART DISEASE CARDIAC DYSRHYTHMIAS
SYNCOPE • CEREBRAL PERFUSION : • MARKEDLY REDUCED • SYSTEMIC ARTERIAL PRESSURE • CEREBRAL VASCULAR RESISTENCE • MARKED DECREASE in ARTERIAL PRESSURE – DECREASED C B F • PERFUSION PRESSURE : ARTERIAL - VENOUS
SYNCOPE SYSTEMIC PRESSURE – C B F Decreased Cardiac Output : Preload Decreases Decreased S V R : Venous Pooling ARRHYHMIAS LV Dysfunction Tachy & Brady C O Inadequate Vasoconstriction Inappropriate Vasodilatation
SYNCOPE • EFFORT Induced : • Inadequate Cardiac Output • Most C O Exercising Muscles • Inappropriate Vasodilatation • Mechanoreceptors in ventricular wall reflex vasodilatation • Exercise Induced Arrhythmias • OBSTRUCTIVE Lesions: • AS • HOCM • PS
SYNCOPE • Multifactorial Cardiac Output Inappropriate Vascular Response Arrhythmias • Drug Induced / Aggravated • Mechanoreceptors Reflex Effect • Chemoreceptors On Vascular Response
SYNCOPE Confused : Neurological Problems / Disorders History • Patient : Rest / Effort • Bystander : Posture : Circumstances : Tonic – Clonic Movements : Sphincter Incontinence : Post-ictal Neuro status : Persistent Neuro Defecit
EDEMA • Increased Interstitial Fluid • STARLING’S LAW – Fluid Dynamics • Hydrostatic Pressure • Oncotic Pressure • Vascular Permeability • Lymphatic Drainage • Pitting – Dependent areas of body Bilateral • Approximately 5 Lts Fluid (Adults) accumulate before clinically manifest.
FLUID OVERLOAD • ASCITES: • Ascites Precox : Constrictive Pericarditis Tricuspid Valve Disease • HYDROTHORAX: • Pleural Veins Pulmonary Veins & Systemic Veins • Common in COMBINED VENTRICULAR FAILURE • More on RIGHT side • PHANTON tumour
CYANOSIS • Bluish Discoloration : Skin & Mucous Memb. • Excess : Reduced Hemoglobin : Capillaries (>5 G / dl ) • Central / Peripheral : Mechanism – Cyanosis • Normal Arterial Blood : >95% Saturation Reduced Hb% : 0.75 G / dl Venous Blood : 4.75 G / dl, 70% • Central Cyanosis – C H D ; R L Shunt 30% of LV output (Bypassing Lungs)
CYANOSIS • CENTRAL CYANOSIS: • Arterial Oxygen Desaturation • R L Shunt • V / Q Abnormality • PERIPHERAL CYANOSIS: • Increased Extraction of O2 by Tissues (Low C O ) • Superficial areas : Fingers, Cheeks, Nose, Ext. Parts • Occasionally Localized • RAYNAUD’S Phenomenon
CYANOSIS • CENTRAL : Desaturation : < 80% Level of Hb% Often Associated : Clubbing Secondary Erythrocytosis Not Associated with Dyspnea Except : Acute PTE Acute Pulm Edema ( Contrast – Pulmonary Cause) R L Shunt : Pulmonary Stenosis P A H Common Mixing Chamber - Single Ventricle / T A P V C
Onset Location Radiation Quality Severity Duration Precipitating Events Relieving Factors Associated Symptoms Stable / Progressive CHEST PAINIschemic Chest Pain
CHEST PAIN • Classical Angina • Atypical Chest Pain • Non Ischemic Chest Pain Application Baye’s Theorem “ Positive Predictive Value of Test Proportional Prevelence of disease in Population” Pretest Probability Final Diagnosis
CHEST PAIN • Angina : Imbalance : Oxygen Supply / Demand • Coronary Circulation : • % Cardiac Out put • Maximal Oxygen Extraction • Increased Demand Met only with increased Flow • Normal Myocardial Oxygen Consumption • 6 -8 ml / min / 100Gms
CHEST PAIN MYOCARDIAL OXYGEN DETERMINANTS • MAJOR DETERMINANTS : • Heart Rate • Blood Pressure • Contractility • Wall Stress