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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3230_Библиотеки_им_академика_М_И_Перельмана
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CHAPTER 6 Cardiovascular symptoms
132
Severe lower chest or upper abdominal
pain
Upper abdominal pain may also be difficult for the patient to separate
from lower chest pain, so the causes of chest pain have to be borne in
mind as well.
Some differential diagnoses and typical outline evidence
Gastroesophageal
reflux/gastritis
Suggested by: central or epigastric burning pain, onset
over hours, dyspepsia, worse lying flat, worsened by
food, alcohol, nonsteroidal anti-inflammatory drugs
(NSAIDs)
Confirmed by: esophagogastroduodenoscopy (EGD)
showing inflamed mucosa
Biliary colic Suggested by: postprandial pain, severe and “gripping”
or colicky, usually in right upper quadrant (RUQ) and
that can radiate to right scapula. Onset over hours
Confirmed by: ultrasound showing gallstones and
biliary dilatation or characteristic findings on endo-
scopic retrograde cholangiopancreatography (ERCP)
Pancreatitis
(often due to
gallstone
impacted
in common
bile duct)
associated with nausea and vomiting, gallstones.
Onset over hours.
Confirmed by: iserum amylase to 5 times normal,
iserum lipase
Myocardial
infarction
(often inferior)
Suggested by: continuous pain, usually over 30 minutes,
not relieved by rest or (antianginal) medication.
Onset over minutes to hours
Confirmed by: T wave inversion ± ST elevation of
1 mm in limb leads or 2 mm in chest leads on serial
ECGs or itroponin
ORTHOPNEA AND PAROXYSMAL NOCTURNAL DYSPNEA (PND)1
133
Orthopnea and paroxysmal nocturnal
dyspnea (PND)
Orthopnea is shortness of breath when lying flat. (Try to confirm by
observing what happens when patient lies flat.) It is most often associated
with congestive heart failure (CHF) when pulmonary venous pressure
and alveolar edema, especially in the upper lung fields, are increased in
the recumbent position.
Less frequently it occurs with pulmonary disease such as chronic
obstructive pulmonary disease (COPD) associated with abdominal obesity
when abdominal contents press up on the diaphragm in the recumbent
position. PND can occur when the patient slides down in bed at night or
by bronchospasm due to nighttime asthma.
Some differential diagnoses and typical outline evidence
Pulmonary
edema
due to
congestive
(chronic) left
ventricular failure
(due to ischemic
heart disease,
valvular disease)
Suggested by: dyspnea, displaced apex beat, third heart
sound, bilateral basal fine crackles
Confirmed by: CXR appearances. Impaired left ventricu-
lar (LV) function on echocardiogram. Abnormal ECG
reflecting underlying heart disease
COPD Suggested by: smoking history, cough and sputum.
Pursed lip breathing, use of accessory muscles, reduced
breath sounds, wheezes. Chest hyperinflation. Reduced
peak flow rate
Confirmed by: CXR: radiolucent lungs. Spirometry:
reduced FEV
1
, reduced FEV
1
/FVC ratio, <12% reversi-
bility, hypoxia ± i arterial PCO
2
(rarely, reduced
A
1
-antitrypsin levels)
Asthma Suggested by: wheeze or dry cough. Other specific
triggers to breathlessness. Other allergies. Past history
of similar attacks unless first
presentation
Confirmed by: reversibility of spirometric abnormalities
with bronchodilator treatment, and symptomatic
response to treatment
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CHAPTER 6 Cardiovascular symptoms
134
Palpitations
These are very subjective and nonspecific unless forceful, fast, and associ-
ated with dizziness or loss of consciousness.
Some differential diagnoses and typical outline evidence
Runs of supraven-
tricular tachycardia
(SVT)
Suggested by: abrupt onset, sweats and sustained
dizziness.
Confirmed by: baseline ECG or 24-hour ECG show-
ing tachycardia with normal QRS complexes with
absent or abnormal P waves >140/min. Exercise
ECG to see if precipitated by exercise (and due
to IHD)
Episodic heart block
Second-degree
or third-degree
atrioventricular
(AV) block
Suggested by: onset over minutes or hours, slow
and forceful beats. Loss of consciousness, pallor if
significant loss of cardiac output
Confirmed by: nonconducted P waves associated
with conducted P waves with fixed or progressive
prolonged PR interval, P–R dissociation, and slow
QRS rate on 12-lead or 24-hour ECG
Sinus tachycardia
(anxiety, pain, fever,
caffeine, hypovolemia,
pulmonary embolism,
hyperventilation, etc.)
Suggested by: gradual onset over minutes of
regular palpitations and pulse. History of
precipitating cause (usually)
Confirmed by: 12 lead ECG or monitor strip and
resolution by stopping precipitating factors or
resolution of potential cause
Atrial fibrillation Suggested by: onset over seconds, irregularly
irregular radial and apex pulse, apical–radial pulse
deficit, and variable BP
Confirmed by: ECG showing no P waves and
irregularly irregular QRS complexes
Ventricular ectopy
unifocal (benign) or
multifocal (may have
underlying pathology)
Suggested by: palpitations felt as early or skipped
beats occurring one at a time or in short bursts,
noted over hours or days, sometimes associated
with anxiety
Confirmed by: premature wide QRS complexes
without preceding P waves on 12 lead ECG or
24-hour ECG
PALPITATIONS1
135
Menopause Suggested by: sweats, mood changes, irregular or
no more periods, getting worse over weeks or
months
Confirmed by: dserum estrogen, iFSH
/LH,
and response to hormone replacement therapy
Thyrotoxicosis Suggested by: anxiety, irritability, weight loss,
sweating, loose frequent stools, lid retraction and
lag, proptosis, brisk reflexes, other signs and
symptoms of hyperthyroidism. Onset over weeks
or months. 12 lead ECG may show sinus tachy-
cardia, atrial fibrillation, or ventricular arrhythmias
Confirmed by: iFT4, and/or iFT3 and dTSH
Pheochromocytoma
(rare)
Suggested by: abrupt episodes of anxiety, fear,
chest tightness, sweating, headaches, and marked
rises in BP
Confirmed by: catecholamines
(VMA, HMMA) or
free metanephrine i in urine and blood soon
after episode
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CHAPTER 6 Cardiovascular symptoms
136
Cough and pink frothy sputum
This is due to a combination of frothy sputum of pulmonary edema
tinged with blood.
Some differential diagnoses and typical outline evidence
Acute
pulmonary
edema
Suggested by: onset over minutes or hours of short-
ness of breath, orthopnea, displaced apex, loud third
heart sound, fine crackles at lung base
Confirmed by: CXR
appearance (see Fig. 19.13, though
19.14 is more typical), poor LV function on echocar-
diogram
Mitral stenosis
causing
pulmonary
edema
Suggested by: months or years of orthopnea, tapping,
displaced apex, loud first
heart sound, diastolic murmur,
fine crackles at lung bases. Enlarged left atrial shadow
(behind heart) and splayed carina on CXR
Confirmed by: large left atrium and mitral stenosis on
echocardiogram
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CHAPTER 6 Cardiovascular symptoms
138
Syncope
This is sudden loss of consciousness over seconds. Think of abnormal
cardiac or CNS “electrical” activity or a temporary drop in cardiac out-
put and BP that improves as soon as the patient is in a prone position.
Seizures can occur from a profound fall in BP, so they are not specific for
epilepsy.
Some differential diagnoses and typical outline evidence
Vasovagal
attack—simple
faint
Suggested by: seconds or minutes of preceding
emotion, pain, fear, urination, or prolonged standing—
with nausea, sweating and darkening of vision.
Recovery within minutes. Incontinence is rare.
Confirmed by: history, positive upright tilt test
Postural
hypotension
often due to
antihypertensive
drugs, dehydra-
tion, anemia, or
blood loss
Suggested by: dizziness or sudden loss of consciousness
within minutes after getting up from sitting or lying
position
Confirmed by: fall in BP
and rise in heart rate (HR)
from reclining to standing, confirmation of a causal
diagnosis
Stokes–Adams
attack
due to a variety
of cardiogenic
causes, e.g.,
syncope caused
by AV conduc-
tion block
Suggested by: recurrent episodes of sudden loss of
consciousness with no warning. Pallor, then recovery
within seconds or minutes.
Confirmed by: 24-hour ECG showing episodes of
asystole or heart block, SVT, or ventricular
tachycardia (VT)
Aortic stenosis Suggested by: syncope on exercise. Cool extremities,
slowly rising carotid arterial pulse, low BP and pulse
pressure and heaving apex. Mid-systolic murmur
radiating to carotids. ECG showing left ventricular
hypertrophy (LVH)
Confirmed by: Echocardiogram and cardiac
catheterization: stenosed aortic valve
Hypertrophic
cardiomyopathy
Suggested by: syncope on exercise. FH of sudden death
or hypertrophic cardiomyopathy. Angina, breathless,
jerky pulse, high JVP with “a” wave, double apex beat,
thrill and murmur best at left sternal edge
Confirmed by: characteristic echocardiogram showing
increased left ventricular wall thickness, small,
well-contracting left ventricle
SYNCOPE1
139
Micturition
syncope
Suggested by: sudden loss of consciousness after
urination, usually in a man at night. Often history of
prostatism
Confirmed by: history and examination not indica
t
ive of
other causes of syncope
Cough syncope Suggested by: sudden loss of consciousness after
severe bout of coughing
Confirmed by: history and examination not indicative of
other causes of syncope
Carotid sinus
syncope
Suggested by: sudden loss of consciousness after
turning head, e.g., while shaving. More likely with
tight collars
Confirmed by: history and onset of symptoms on
careful repeat of movement. Excessive sinus
bradycardia with carotid sinus massage
Hypoglycemia Suggested by: preceded by seconds or minutes by
hunger, sweating, and darkening of vision. Usually in
diabetic on insulin.
Confirmed by: blood sugar <50 mg/dL and exclusion of
associated cardiac condition
Epilepsy
(may be due to
profound fall
in BP)
Suggested by: preceding aura for a few minutes then
tonic phase with cyanosis, clonic jerks of limbs,
incontinence of urine and/or feces
Confirmed by: history from witness. EEG changes, e.g.,
spike and wave
Pulmonary
embolus (PE)
or infarct
due to embolus
arising from DVT
in leg, silent
pelvic vein
thrombosis,
silent right atrial
thrombus
Suggested by: sudden shortness of breath, pleural rub,
cyanosis, tachycardia, loud P2, associated DVT, or risk
factors such as recent surgery, childbirth, immobility, etc.
Confirmed by: V/Q scan mismatch, spiral CT showing
clot in pulmonary artery
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CHAPTER 6 Cardiovascular symptoms
140
Leg pain on walking—intermittent
claudication
This is analogous to the more familiar angina but pain comes on in the
legs instead of the chest on exercise. Quantify the effect on daily activity
(especially distance walked) and ability to cope at home, work, recreation,
and rest.
Some differential diagnoses and typical outline evidence
Arterial disease
in legs
Suggested by: predictable leg, calf, thigh, or but
t
ock pain
(worse on hills, better downhill) that is better with rest
(if also present at rest, this implies incipient gangrene).
Patient sleeps with leg hanging down, e.g., over edge of
bed or in chair. Abnormal pulses, poor perfusion of skin
and toes
Confirmed by: Doppler ultrasound or arteriogram or
magnetic resonance angiogram (MRA) showing
stenosis and poor flow
Aortoiliac
occlusive
arterial disease
associated with
erectile
dysfunction =
Leriche’s
syndrome
Suggested by: predictable buttock, hip, or thigh pain on
exertion and male erectile dysfunction (impotence)
Confirmed by: arteriogram or MRA showing stenosis
and poor flow in the distal aortic or iliac arteries
Neurogenic
claudication
Suggested by: weakness and pain in leg, calf, thigh, or
buttock and pain improving slowly with rest but
variable. Worse downhill. No cold toes, normal pulses
Confirmed by: MRI showing neurospinal canal stenosis
or disc compression of cord or cauda equina
LEG PAIN ON STANDING—RELIEVED BY LYING DOWN1
141
Leg pain on standing—relieved by lying
down
Think of something relieved by reducing pressure on lying down. Two
possibilities are relief of the pressure transmitted down to leg tissues by
incompetent venous valves, or relief of pressure by the spinal column on
a damaged disc, aggravating its protrusion and pressure on adjacent nerve
roots.
Some differential diagnoses and typical outline evidence
Peripheral
venous
disease and
varicose veins
Suggested by: generalized ache, associated itching,
varicose veins, and venous eczema ± ulcers. Cough
impulse felt and Trendelenberg test shows filling down
along extent of communicating valve leaks.
Confirmed by: clinical findings or Doppler ultrasound
probe to confirm whether or not incompetence is
present in the saphenofemoral junction or the short
saphenous vein
Disc
protrusion
(slipped disc)
Suggested by: severe referred ache or shooting pains,
affected by position. Neurological deficit in root
distribution
Confirmed by: MRI of sacral and dorsal spine showing
disc impinging on nerve roots (but may be less obvious
as patient lies down in scanner)
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