DYSPNEA
Abnormally uncomfortable awareness of breathing.
New York Heart Association IHYHA1—Functional Classification
All patients with dyspnea should be assessed in relationto their functional ability and this is usually graded as per the above classification. This classification is also usedfor fatigue, palpitation and chest pain
Limitations
- Subjective in nature
- Not easily reproducible
- Class 0 is not there.
Hence many people are now using American Thoracic Society scale of dyspnea which has grade 0 as well and also has quantification in terms of length of distance walked.
Etiology of Dyspnea
Cardiac Causes
- Left ventricular failure of any cause
- Mitral stenosis.
Lung Causes
- Asthma
- COPD
- Interstitial lung disease
- Large pleural effusion.
Chest Wall Causes
- Kyphoscoliosis.
Metabolic Causes
- Ketoacidiosis
- Aspirin poisoning.
Other Causes
- Anemia
- Obesity.
Acute Dyspnea
- Acute asthma
- Acute pulmonary edema
- Pulmonary thromboembolism
- Pneumothorax
- Foreign body in the airway.
Paroxysmal nocturnal dyspnea (PND): In this form of dyspnea, the patient develops breathing difficulty 2–5 hours after going to sleep and the patient is forced to get up and seek fresh air.
Mechanism
- Decreased sympathetic drive of the heart during night
- Nocturnal depression of respiratory center.
Orthopnea
This can be defined as dyspnea in the recumbent position which is relieved by elevation of the head. Many patients use several pillows at night to elevate the head to avoid orthopnea. In severe heart failure patient may spend the entirenight in sitting position.
Mechanism
- Redistribution of fluid from abdomen and legs into the chest during recumbency increases the pulmonary capillary pressure
- Elevation of diaphragm in the lying down position.
Trepopnea
Dyspnea in left or right lateral decubitus position.
Platypnea
Dyspnea at upright position
- Left atrial thrombus
- Left atrial tumor
- Pulmonary arteriovenous fistula.
CHEST PAIN
Chest pain is one of the most important manifestations of heart disease. It is important to identify whether the chest pain is due to a cardiac reason or not. In the history, the following points need to be taken into account. One way of remembering is PQRST
- Q—Quality: This is a very important point because since the pain is visceral in nature the pain is felt as pressure, heaviness or squeezing.
- R—Relief: The pain is typically relieved by rest or nitroglycerin.
- S—Site: Usually it is retrosternal in nature, radiating to the neck, jaw, shoulder or arms.
- T—Timing: Usual duration of pain is around 2 to 10 minutes in stable angina. In unstable angina the pain may be as long as 10 to 20 minutes. In patients with myocardial infarction the pain usually last more than 20 minutes.
Causes
The following are the cardiovascular causes of chest pain:
- Stable angina
- Rest/unstable angina
- Myocardial infarction
- Pericarditis
- Dissection of aorta
- Pulmonary embolism
- Pulmonary hypertension.
Angina Equivalent
Some patients with angina do not have chest pain; instead they may have symptoms such as dyspnea on exertion. Other angina equivalents are discomfort seen in areas of secondary radiation without chest pain. For example, patient may have discomfort in the lower jaw or ulnar aspect of left arm or neck.
Features of noncardiac pain:
- Stabbing or shooting pain
- Pain lasting less than 30 seconds
- Well localized, left submammary pain
- Pain that is constantly varying in its location.
SYNCOPE
Syncope is defined as transient loss of consciousness and postural tone due to decreased cerebral blood flow with spontaneous recovery.
A good history with simple tests such as ECG can give a clue to the diagnosis for syncope. In the history, it is important to differentiate between the following:
- Is the sensation described is a “sensation of movement without actual loss of consciousness?” If so, then this is due to vestibular or labyrinthine dysfunction and suggests vertigo.
- Is it a sensation of loss of balance with actual loss of consciousness? This occurs secondary to loss of joint sense, visual disturbances, etc.
- In syncope there is reduced cerebral blood flow leading onto loss of consciousness or a sensation of lightheadedness which may precede the same.
History Taking
The following five points need to be taken in history:
- Preceding events: From the history, you must ask whether syncope happened after prolonged standing or seeing some unusual sight such as an accident, or turning the head, etc.
- Type of onset: The onset is sudden in arrhythmia and in seizures. It is gradual in vasovagal syndrome.
- Position at onset: This history is important because arrhythmia can happen in any position. However, vasovagal syncope occurs on standing for a long time.
- Postsyncopal clearing: Clearing of consciousness is gradual and takes a long time in seizures where as it is very brief in cardiac reasons.
- Associated events: Tongue biting, urinary incontinence are common with seizures.
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PALPITATION
Unpleasant awareness of the beating of the heart.
History Taking
If you can ask the patient to tap out the rate and regularity of the palpitations, it may give you an idea to the etiology. The following items need to be covered in history:
- Is it isolated, occurring as skipped beats? Suggests ventricular ectopic beats
- Is the attacks sudden in onset and sudden in offset? Suggests supraventricular tachycardia
- Is the palpitations regular or irregular? Irregular suggests atrial fibrillation
- Is it related to exercise? Common in atrial fibrillation, thyrotoxicosis
- Is it related to taking any drugs? Such as thyroid tablets, coffee, tea
- Associated flushing and sweating in a middle age women suggests menopausal syndrome.