Family History, Chest Examination, and Cardiac Diseases

NUMERO QUATTRO: HT Family History

Contains the health condition of parents (grandparents), siblings and children of the patient; no wife/husband. Have to note the occurrence of inheritable diseases: haemophilia, spherocytosis, DM, hypertension, cancer, “obesity”?. Draw family tree and mark affected people, we can localize if the disease is dominant, recessive and linked to sex chromosome X. Examination of chest.

INSPECTION:

SHAPE: Barrel chest (expiration prolonged, difficult), Pigeon breast (protruding breast bone, common in rickets), Funnel breast (inward deformity of sternum), Kyphoscoliosis (curvature of the spine, common in childhood rickets, can compromise ventilation), general deformities (due to chronic pulmonary and pleural diseases such as in TB): chest diameters can be shortened due to fibrotic and adhesive changes; patients with heart diseases can have a bulge in heart region; BREAST: shape, size, symmetry. SKIN: are there redness, edema, inflammation, rash? NIPPLE: size, position, color. Look also for lumps, masses and irregularities. PALPATION: Chest palpation is a technique from which can be elicited tenderness, asymmetry, diaphragmatic excursion, crepitus, and vocal fremitus. Local tenderness can indicate trauma or costochondritis. PERCUSSION: used to diagnose pneumothorax, emphysema (in case of this 2 disease we have hyper-resonant), pneumonia (dull, also for cancer), pleural effusion (dull to flat), bronchitis, bronchiectasis (resonant), atelectasis (flat), also can be used to assess the respiratory mobility of the thorax. AUSCULTATION: lungs auscultation can reveal breath sounds such as bronchial (pneumonia), vesicular weak to absent (pleural effusion, pneumothorax), vesicular weak prolonged expiration (emphysema), vesicular prolonged expiration (asthma, bronchitis), vesicular (bronchiectasis) or reduced vesicular to absent (atelectasis) and also abnormal sounds are crackles (pneumonia), friction rub (pleural effusion), whistles (asthma), whistles and wheezes (bronchitis), wet rales (bronchiectasis). Aortic stenosis and regurgitation.

STENOSIS:

Is the narrowing of the aortic valve opening; is often congenital. ETIOLOGY: 60% congenital, 30% degenerative, rheumatoid 10%. Left ventricle has to work harder to force the blood against the resistance of the narrowed aortic outlet; systolic pressure in the ventricle is much higher than in the aorta, thus ventricle is pressure overloaded: this pressure overload gets compensated for by hypertrophy of the ventricular myocardium. TYPES: valvular, subvalvular (hypertrophic obstructive cardiomyopathy). MANIFESTATION: rising apex beat (LV hypertrophy), blunt 1st sound, palpable whirl over the aortic opening, early systolic click, ejection systolic murmur over the aorta, pulse(small and slow pulse). CLINICAL TRIAD: stenocardia, syncope and exertional dyspnea. REGURGITATION is diastolic flow of blood from aorta into LV. ETIOLOGY: dilatation of root of aorta, dissection of the ascending aorta, infectious endocarditis, congenital bicuspid valve, post-rheumatic fever. MANIFESTATION: blowing diastolic murmur over aortic orifice, sometimes Austin Flint’s murmur, diastolic mitral murmur, great systolic-diastolic range of BP, on ECG LV hypertrophy. SYMPTOMS: fatigue, dyspnea.

NUMERO CINQUE: HT Social and Travelling History

OCCUPATION: you have to assess if patient has a tough or strenuous job, if patient is on their feet a lot (edema) or if they inhale any toxic particles (miners, factory workers, painters). FOREIGN TRAVEL: tracking down of certain infectious or parasitic diseases (Salmonellosis, Malaria, Hookworm). LIVING CONDITIONS: how many people live with patient, in what conditions (damp, crowded street, home) cause some disease as TB are spread faster when living in damp conditions) FAMILY LIFE: married, divorced, single (stress). PHYSICAL ACTIVITY: exercise or no? PERSONAL HABITS: smoke, alcohol intake? Examination of abdomen. Let’s divide abdomen in or 4 quadrants, up+low sx and dx or in epigastrium, mesogastrium and hypogastrium via 2 horizontal lines. INSPECTION: location of umbilicus, various protrusions of abdomen (dx: liver enlargement or swelling in gallbladder, sx: spleen enlargement), check abdominal wall during breathing, scars (inguinal hernia, appendectomy, gallbladder surgery), pigmentations (Addison’s disease leads to darkening of linea alba, telangiectases), striae (fast fat accumulation, enlargement of abdomen), hernias. PALPATION: important to palpate the painful or suspected areas first, divided into light and deep palpation, start from hypog. then gradually up; if we encounter “Guarding” or “Defense musculaire” this is essentially increased diffuse of local rigidity of the abdominal muscles, area is hard to penetrate when palpation, classic sign for peritoneal irritation (Blumberg’s sign for check it); in duodenal ulcers pain is located at center of line between gallbladder and umbilicus; in acute appendicitis guarding and pain are at McBurney’s point. PERCUSSION: meteorism has tympanic sound, tumors/ascites have dull one, in urinary bladder we can percuss and diagnose an overfilled bladder. AUSCULTATION: We can auscultate to diagnose the possible increased peristaltic sounds; a stenotic systolic murmur can be heard at times in tumors of pancreas that compress upon the pancreaticoduodenal/splenic arteries; stethoscope over Xiphoid process, scratch skin over the liver, from chest towards abdomen in the midclavicular line, or from light to left over the liver. ECG, basic principles: test which measures the electrical activity of your heart to show whether or not it is working normally; it records rhythm and activity on a moving strip of paper or a line on a screen. RHYTHM: generated by SA node, sign of its healthy functioning is P wave and PQ interval. FREQUENCY: compare 2 QRS complex and measure time interval between their R waves (RR interval). WAVES: P wave (atrial depolarization, 110ms, 0.25mV, positive in I-II, negative in aVR, missing: atrial flutter, fibrillation). PR interval (atrial contraction, 120-200ms, isoelectric), QRS (ventricular depolarization and contraction, Q wave negative, can/can’t be present; R wave, positive; S wave negative; duration of QRS is 120ms), ST (isoelectric line, no activity of heart, 80-120ms), T wave (repolarization of ventricles, 110-125ms). LEADS: I-II-III (bipolar), V1-V6 (unipolar, chest leads), aVR,L,F (unipolar, extremity leads); II-III-aVF: inf. wall of heart, I-aVL,V5,6: lat. wall, V1,2: AV septum, V3,4: ant. wall. AXIS: general direction of depolarization.

NUMERO SEI: Symptoms/signs of Cardiac Diseases

CHEST PAIN, 1st establish correct location: pain in stable angina pectoris will be behind sternum/inside chest bones, burning pain, no stabbing pain; pain in myo. infarction has same location and radiation but is longer; in dysseting aneurysm of aorta is intense, similar location, pain comes on very suddenly, it radiates back or abdomen; in pericarditis is longer than all, relief comes when sitting, stabbing pain, accompanied by dull xicardial pain; in pulmonary embolization pain is not painful but parietal pleuritic may develop over site of lung infarct so pleuritic pain. DYSPNEA (shortness of breath): exertional dyspnea can indicate mitral stenosis; in orthopnea patient sits up to relief their breathlessness; paroxysmal nocturnal dyspnea is a sign of heart disease, especially left heart failure; in pulmonary edema with severe shortness of breath and heavy pulmonary congestion which can be observed if patient has a chronic/dry cough. PALPITATIONS: rapid, strong, irregular heartbeats due to agitation or illness, arrhythmia should be properly identified, also paroxysmal tachycardia which is almost always supraventricular. SYNCOPE: short loss of consciousness due to circulatory disturbances, vasovagal one could be due to patient standing for long time in hot/poorly ventilated areas, exertional one is connected with sudden physical exercise, causes are aortic/pulmonary stenosis. CYANOSIS: blue color of skin (lips, peripheral part of hands), two mechanisms may be responsible: stagnation of blood or fall in O2 saturation of arterial blood (below 85%, normal 96%), it develops if amount of reduced hemoglobin in capillary blood is at least 50 g/l. EDEMA: swelling, unilateral or bilateral but usually asymmetric, most frequently due to decrease in venous pressure (thrombosis or incompetence of venous valves). HEMOPTOE/HEMOPTYSIS.Examination of skin: COLOUR (red/pallor/cyanosis/lack of pigments/jaundice), RASHES (urticaria so eruption of pink/red itchy wheels, lupus erythema with butterfly rash, herpes zoster), LESIONS, SCARS, HEMORRHAGES (haematoma, vascular purpura, haemangioma), MOISTURE (TB, malignant lymphoma), TURGOR (dehydration), EDEMA (local so inflammatory, thromboplebitis, obstruction of lymph drainage or generalized). SKIN APPENDAGES: HAIR (alopecia diffusa loss of total hair, alopecia areata no hairs in few locations, patients with thyroid, ovarian or pituitary glands have it), NAILS (quality, brittleness, shape: flat x iron deficiency, spheric x congenital cyanotic heart diseases, color: white bits in nails x calcium deficiency). Hemoptoe & Hemoptysis: HEMOPTYSIS is the coughing up of blood or blood-stained mucus from the bronchi, larynx, trachea or lungs, it occurs in diseases of pulmonary parenchyma (TB, lung cancer, bronchiectases, lung abscess) and also in pulmonary congestion (particularly in patients with mitral valve diseases), in pulmonary embolism and in pulmonary hypertension. (A rusty sputum indicates the change of erythrocytic hemoglobin to hemosiderin in chronic pulmonary congestion and also in pneumococcal pneumonia). HEMOPTOE is the massive expectoration of blood, is most often the result of bronchopulmonary diseases or in patients with CV diseases (CV: bronchial v. rupture in mitral disease with a high sx atrial pressure or a massive pulmo. infarct.