presenting problems in
cardiovascular system
56/M 30 pack years of smoking DM and SHTN not on
regular medication . woke up with severe central chest
pain associated with increased sweating , nausea , non
radiating .pt wife called neighbour doctor who gave
sublingual nitroglycerin pain did not subside
1) Likely diagnosis
2) how will you approach
Chest pain is one of the common presentation in
Medicine OPD, it may be life threating or non life
threatening hence triage is essential
CARDIAC CHEST PAIN
Anginal pain : Stable angina
Unstable angina (ca be ACS)
Nocturnal angina
Prinzmental Angina
Anginal Equivalent
Pericardial Pain
APPROACH TO ANGINA
Resting ECG
Cardiac markers
Stress ECG : Treadmill stress test
Pharmacologic stress ECHO
Gold Standard : Coronary Angiography
ANSWE
Pt was shifted by ambulance to near by hospital
ECG showed ST Elevation of all the precordial leads
Diagnosed with anterior wall MI , Shifted To cath lab
and CAG showed Total occlusion of LMCA and
primary PTCA was done
41/M Central chest pain of one hour duration radiating
to the back , BP - 220/140 mmHg Auscultation
revealed faint EDM in aortic area and diminished
brachial and radial pulses in left arm
Diagnosis and Approach :
40/F came with complaints of chest pain after food
especially on lying down non radiating associated
with burning sensation in the epigastrium cardiac
workup including ecg treadmill , biomarkers were
negative
Likely cause and management
DYSPNEA
Title Approach and Differential Diagnosis
PULMONARY CAUSES
01 AIRWAY DISEASES
Asthma
COPD
02
PARENCHYMAL DISEASE
Interstitial lung disease
03 Chest wall Disease
Kyphoscoliosis
Neuromuscular weakness
CARDIAC CAUSES
01 LEFT HEART FAILURE
Coronary Artery Disease
Cardiomyopathy
02 Pericardial Disease
Restrictive Pericarditis
Cardiac Tamponade
01 Pulmonary and cardiac
Pulmonary Hypertension
02 Others
Anemia
Deconditioning
Psycological
Approach to Dyspnea
Onset and Duration
Minutes to hours (Rapid onset):Pneumnothorax
Acute Asthma
Pulmonary Embolism
Pulmonary edema
Foreign body obstruction
Hours to Days(Gradual Onset) Pneumonia
Pleural Effusion
Anemia
Guillian Barre syndrome
Months to Years(slow onset ): Pulmonary Tuberculosis
COPD
Carcinoma
Fibrosing Alveolitis
NYHA CLASSIFICATION
Aggravating and Releiving factors
Improves on weekend / Holidays: Occupational asthma
Extrinsic allergic alveolitis
Recumbency / sleep: Orthopnea/ Paroxysmal nocturnal
dyspnea
25/M presents with progressive breathlessness over a
period of 24 hrs with no known comorbids to ER.On
Examination his vitals are stable XRAY, ECG , ECHO
were found to be normal his SPO2-98% under Room
air were normal RR-30/min .he had increased rate and
depth of respiration
Likely Dignosis
Kussmaul type of breathing
CBG
ABG to be taken
urine and blood ketones
Dx: Diabetic ketocidosis
18/F came with complaints of acute breathlesssness
after getting scolding from her parents ,She had
numbness and tingling in her hands , pt had anxious
look and shallow breathing , ccarpopedal spasm.
ABG : ph .7.52
pco2 -22
po-94
Hco 3- 25
Diagnosis:
Hyperventilation syndrome
Treatment :
Reassuance
Anxiolytic drugs
Breathing into a Bag / Rebreathing mask.
PALPITATIONS
Palpitations are extremely common among patients
who present to their internists and can best be defined
as a “thumping,” “pounding,” or “fluttering” sensation in
the chest. This sensation can be either intermittent or
sustained and either regular or irregular.
Diagnosis
Approach
ECG
Holter monitoring
Event monitoring
Management of Palpitations
• Most of the causes do not have serious arrythmias o
underlying structural heart disease
• Insymptomatic patients , occasional beningn atrial or
ventricular premature contractions can often b treated by
beta blockers
• Avoid Preecipitation factor , such as alcohol , tobacco , or
illicit dugs.
• If caused by pharmacologic agents : consider alternative
therapies if appropriate or possible
• Psychiatric Causes : By cognitive Therapy or
pharmacotherapy
• Reassurance :After all serious causes have been excluded.
SYNCOPE
Syncope is a transient, self-limited loss of
consciousness due to acute global impairment of
cerebral blood flow.
The onset is rapid, duration brief, and recovery
spontaneous and complete.
A syncopal prodrome (presyncope) is common,
although loss of consciousness may occur without
any warning symptoms.
Typical presyncopal symptoms include
Dizziness,
Lightheadedness or
Faintness,
Weakness,
Fatigue
Visual and auditory disturbances.
The causes of syncope can be divided into three
general categories:
(1) neurally mediated syncope (also called reflex
or vasovagal syncope),
(2) orthostatic hypotension
(3) cardiac syncope.
EVALUATION
CARDIAC
• ECG ,
• Holter monitoring
• Echo
• Treadmill exercise test
• Electrophysiologic studies
• Orthostatic hypotension
• Capillary blood glucose
• EEG
• Baseline blood investigations :Anemia
Other cardiac Manifestations
• Fatigue
• Oliguria
• Pedal edema
Patient presenting to casualty breathlessness difficult
to diffrentiate between cardiac or respiratory cause
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