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SYMPTOM - ANALYSIS

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.

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SYMPTOM - ANALYSIS

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  1. 07/10/2K8 SYMPTOM - ANALYSIS DR.V.DAYASAGAR RAO DM, FRCP (Ed), FRCP (CAN) KIMS HYDERABAD, A.P

  2. Symptom Analysis • Presence : • Severity : • Type of Disease : • Exertional Syncope  • Obstructive Lesions • Angina  • CAD • Valvular Heart Disease • Edema  • Heart Failure • Cyanosis

  3. 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

  4. 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

  5. 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

  6. DYSPNEA • AWARENESS – BREATHING ABNORMAL UNCOMFORTABLE • “SHORTNESS OF BREATH” • SUBJECTIVE MANIFESTATION LEVEL OF ACTIVITY

  7. DYSPNEA GRADING OF SEVERITY : A T S Class I : UNUSUAL PHYSICAL EFFORT II : ORDINARY ACTIVITY III : LESS THAN ORDINARY IV : AT REST

  8. 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

  9. 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

  10. DYSPNEA ORTHOPNEA : Recumbant Posture Number of PILLOWS Increased VENOUS RETURN to HEART Worsening Pulmonary Venous Hypertension

  11. 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)

  12. DYSPNEA – Obstructive Sleep Apnea • EPISODES – HYPOPNEA / APNEA • OBSTRUCTION – SNORING • DAYTIME SLEEPINESS – SOMNOLENCE • RELATION – CARDIAC DYSRHYTHMIAS - PULMONARY ARTERIAL HYPERTENSION • SLEEP LAB DATA

  13. 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

  14. SYNCOPE • CEREBRAL PERFUSION : • MARKEDLY REDUCED • SYSTEMIC ARTERIAL PRESSURE • CEREBRAL VASCULAR RESISTENCE • MARKED DECREASE in ARTERIAL PRESSURE – DECREASED C B F • PERFUSION PRESSURE : ARTERIAL - VENOUS

  15. 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

  16. 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

  17. SYNCOPE • Multifactorial  Cardiac Output  Inappropriate Vascular Response  Arrhythmias • Drug Induced / Aggravated • Mechanoreceptors Reflex Effect • Chemoreceptors On Vascular Response

  18. SYNCOPE Confused : Neurological Problems / Disorders History • Patient : Rest / Effort • Bystander : Posture : Circumstances : Tonic – Clonic Movements : Sphincter Incontinence : Post-ictal Neuro status : Persistent Neuro Defecit

  19. 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.

  20. 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

  21. 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)

  22. 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

  23. 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

  24. Onset Location Radiation Quality Severity Duration Precipitating Events Relieving Factors Associated Symptoms Stable / Progressive CHEST PAINIschemic Chest Pain

  25. 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

  26. 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

  27. CHEST PAIN MYOCARDIAL OXYGEN DETERMINANTS • MAJOR DETERMINANTS : • Heart Rate • Blood Pressure • Contractility • Wall Stress

  28. Thank you

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