CRR Associated Symptoms/Physical Exam

CHEST DISCOMFORT: “Pain” “Heaviness” “Pressure” “Squeezing”

Want to ask YOURSELF four questions:

Could discomfort be due to an acute life-threatening condition? (Acute ischemic heart disease, Aortic
dissection, Pulmonary embolism, or Spontaneous pneumothorax)

If not, could it be due to a chronic condition that may likely lead to serious complications? (Stable
angina, Aortic stenosis, or Pulmonary hypertension)

If not, could it be due to an acute condition requiring treatment specific to the disease? (Pericarditis,
Pneumonia/pleuritis, Herpes zoster)

If not, could it be due to a treatable chronic condition? (Esophageal reflux or spasm, Peptic ulcer
disease, Gallbladder disease or other gastrointestinal disease, Cervical disc disease, Arthritis of shoulder
or spine, Costochondritis or other musculoskeletal problem, Anxiety state)

Want to ask PATIENT questions about quality and location of discomfort, onset and duration.

ACUTE LIFE-THREATENING

Condition Duration Quality Location Associated sx

(Angina)--in this >2 <10 min Pressure, burning, Retrosternal, may Onset w/exertion,
section for tightness, radiate to, or exposure to cold,
comparison; squeezing, isolate to, jaw, psych stress; S4
belongs in chronic heaviness neck, shoulders, gallop or MV regurg
serious arms w/ pain; Nitro/rest
relieves
Unstable angina 10-20 min ~ angina ~ angina ~ angina
Acute MI Often >30 ~ angina ~ angina NOT relieved by
nitro/rest
Aortic dissection Abrupt onset; Tearing/ripping; Anterior chest, Assn w/ HTN and/or
unrelenting knifelike often radiates to connective tissue
back, between disorder e.g.,
scapulae Marfan’s; murmur
AI, loss of periph.
pulses; pericardial
tamponade or rub
Pulmonary Abrupt onset; Pleuritic Often lateral to Dyspnea, low BP,
embolus minutes to hours side of embolism tachypnea,
tachycardia,
Spontaneous Sudden onset; Pleuritic Lateral to side Dyspnea, decreased
pneumothorax many hours involved breath sounds

8/27/10 1
CHRONIC BUT SERIOUS

Condition Duration Quality Location Assoc features

Stable angina As angina above As angina above As angina above As angina above
Aortic stenosis Recurring; as for As for angina As for angina Late-peaking
angina systolic murmur
radiating to
carotid arteries
Pulmonary variable pressure Substernal Dyspnea, signs -
hypertension increased venous
pressure: edema,
Jug Ven Distension

ACUTE, SPECIFIC TREATMENT

Condition Duration Quality Location Assoc features

pericarditis Hours-days; +/- Sharp Retrosternal or May be relieved
episodic toward cardiac by sitting up &
apex; may radiate leaning forward
to left shoulder
Pneumonia/pleuritis Variable Pleuritic Unilateral/local Dyspnea, cough,
fever, rales, occ.
rub
Herpes zoster Variable Sharp or burning Dermatomal Vesicular rash in
distribution area of discomfort

OTHER TREATABLE CHRONIC

Condition Duration Quality Location Assoc features

Esophageal reflux 10-60 min Burning Retrosternal, Worse w/
epigastric postprandial
recumbency;
better w/ antacids
Esophageal spasm 2-30 min Pressure, burning, retrosternal Can mimic angina
tightness
Peptic ulcer Prolonged Burning Epigastric, Relieved w/ foods,
substernal antacids
Gallbladder dz Prolonged Burning, pressure Epigastric, RUQ, May follow a meal
substernal
Musculoskeletal Variable Aching Variable Worse w/
movement;
reproduced by
pressure on exam
Psych Variable; fleeting Variable Variable; Anxiety;
substernal depression on hx

8/27/10 2
PALPITATIONS: Awareness of heart beating.

About 20% of patients have a psych disorder. Must rule out cardiac dysrhythmia. Ask about
onset, duration, circumstances of occurrence, associated symptoms. Ask patient to tap rhythm on table.
Abrupt onset/termination suggests ventricular or supraventricular tachyarrhythmia; gradual
onset/termination suggests sinus tachycardia.

Consider non-cardiac conditions such as thyrotoxicosis, hypoglycemia, fever, or

pheochromocytoma (catecholamine-producing tumor of adrenal).

SYNCOPE: Transient loss of consciousness accompanied by loss of postural tone (fainting).

Consider medication side effects (esp. antihypertensives & antidepressants), orthostatic

hypotension, and bradyarrhythmias. Ask about presence of postural or exertional symptoms, associated
chest pain, shortness of breath, palpitations, and associated situation such as micturition; if focal
neurologic weakness, tongue-biting, uncontrolled extremity movements, postictal state; family history
of syncope or sudden death or known cardiac syndrome.

May be neurally mediated (vasovagal, carotid sinus, or situational—with cough, swallowing,

micturition, defecation), orthostatic (drug-induced, autonomic nervous system failure, or volume
depletion—e.g., with diuretics), cardiac dysrhythmia (slow rate—AV block or sick sinus syndrome; fast
rate—ventricular or supraventricular, inherited—e.g., long QT syndrome), structural cardiopulmonary
(acute MI, aortic stenosis, hypertrophic obstructive cardiomyopathy, pulmonary hypertension),
nonsyncopal loss of consciousness (metabolic, epilepsy, intoxications, psychogenic, falls, transient
ischemic attacks).

CLAUDICATION: Muscle pain associated with decreased blood flow to extremities.

Described as pain or cramping in buttocks, thighs, calf muscles, usually with ambulation and
relieved by rest. Peripheral vascular disease accompanied by decreased or absent peripheral pulses. If
pulses normal, consider lumbar spinal stenosis (usually have paresthesias and relieved by sitting and/or
leaning forward) or arthritis (pain in joint, not muscle). If not relieved by rest and muscle tender to
palpation and decreased muscle strength, consider myalgia.

DYSPNEA: Abnormally uncomfortable awareness of breathing.

Dyspnea may be acute or chronic and may occur at rest, with exertion, during episodes of recumbency
(orthopnea—how many pillows does the patient sleep on?) or awakening the patient from sleep at night
(paroxysmal nocturnal dyspnea [PND]).

Cardiac causes of dyspnea: Valvular disease (e.g., aortic stenosis or regurgitation, mitral stenosis or
regurgitation); Myocardial disease (e.g., hypertensive heart disease; dilated, restrictive, or hypertrophic

8/27/10 3
cardiomyopathy); Pericardial disease (e.g., constrictive pericarditis, pericardial tamponade, pericardial
effusion); Coronary disease (e.g., myocardial ischemia or infarction); Arrhythmia (e.g., ventricular or
supraventricular dysrhythmias, congenital heart disease)

Pulmonary causes of dyspnea: Reactive airway disease, chronic obstructive lung disease, interstitial
lung disease, infection (e.g., acute bronchitis, pneumonia), pulmonary embolism, chest wall disease,
pleural effusion

Other causes of dyspnea: Deconditioning, obesity, malingering, psychogenic (e.g., anxiety, panic
disorder), anemia

Want to ask: Tobacco use; hx of asthma, including use of bronchodilator/inhaler or steroids; wheezing
(if new onset and no prior hx of asthma); chronic cough, if productive (character of sputum) [COPD sx];
fever/chills w/ productive cough [pneumonia, acute bronchitis]; acute onset w/ pleuritic chest pain +/-
leg swelling [pulmonary embolus]; PND, orthopnea, nocturia, weight gain, pedal edema [cardiac cause].

COUGH: Can arise from a large variety of anatomic locations. See website
http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=cm&part=A1188&rendertype=table&id=A1205

Nose and sinuses, pharynx, larynx, trachea/bronchi, pulmonary parenchyma, esophagus, heart and great
blood vessels, mediastinum, pleura, external ear canal/tympanic membrane, and no organic cause.

Can be caused by postnasal drip, infection(s) (pharyngeal or lung), neoplasms, irritation (e.g., chemical),
aspiration, infiltrative lung disease (fibrosis), swallowing disorders, fistulas, heart failure (w/ pulmonary
edema), aortic aneurysms, pulmonary embolus, pleural effusion, foreign body, drugs (esp. Angiotensin
Converting Enzyme Inhibitors), habit, intentional.

Acute (< 3 weeks) or chronic (> 3 weeks)?

Any evidence of factors above? Be sure to ask if on ACE inhibitors—DC’d medication leads to “cure”

HEMOPTYSIS: Make sure coming from lungs and not from upper airway or upper GI tract. Dark red or
brown blood and acid pH suggests UGI origin. Bright red and alkaline pH more compatible with
pulmonary origin. Can be due to chronic bronchitis to tumor to pneumonia to tuberculosis to
pulmonary edema to autoimmune phenomenon e.g., Goodpasture’s syndrome or lupus erythematosus.
Massive hemoptysis is > 100 ml over 24 hours—medical emergency.

CYANOSIS: Bluish color of skin and mucus membranes due to increased amount of reduced
(deoxygenated) hemoglobin in blood. May be central (decreased arterial oxygen saturation or abnormal
hemoglobin) or peripheral (decreased blood flow to extremities).

In cases of central cyanosis can be caused by high altitude (low ambient oxygen), impaired lung function
(e.g., decreased alveolar ventilation with normal blood flow or alveolar hypoventilation), or anatomic

8/27/10 4
shunts (e.g., congenital heart disease). Abnormal hemoglobins, such as methemoglobin or
sulfhemoglobin or carboxyhemoglobin (COHb looks cherry red and not blue, but it doesn’t oxygenate
tissues).

Peripheral cyanosis caused by reduced cardiac function, cold-induced vasoconstriction, arterial or

venous obstruction.

CLUBBING OF THE FINGERS: Bulbous enlargement of fingertips. Can be due to pulmonary disease,
cyanotic heart disease, but can be hereditary or due to gastrointestinal disease (e.g., inflammatory
bowel disease or hepatic cirrhosis).

SIGNS AND SYMPTOMS OF RENAL DISEASE:

Changes in urinary volume, anuria or oliguria. If loss of concentrating ability can have polyuria.

Can have hematuria, cloudy urine, frothy urine, peripheral edema, and, in some cases, hypertension.
May have flank pain with/without costovertebral angle tenderness and pain may radiate to groin (esp.
with passage of a kidney stone).

Best way to diagnose renal disease is with urinalysis with microscopic exam of urine sediment to look for
cellular elements, casts, and crystals, etc.

Other symptoms referable to the urinary tract will be addressed in ERG.

PHYSICAL EXAM

Head-to-Toe checklist items:

Vital Signs: 1 through 6

Lungs and thorax: 49 through 54

Cardiovascular: 61 through 85

Costovertebral angle tenderness: 125

Bates: Chapter 4 (Vital Signs), Chapter 8 (Respiratory), Chapter 9 (Cardiac), Chapter 12 (peripheral
vascular)

8/27/10 5