1. Proses Diagnostik_kuliah

7/29/2019 1. Proses Diagnostik_kuliah

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Diagnostic process in

Cardiovascular DiseaseFaculty of MedicineUniversity of Brawijaya


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Doctor-Patient relationship:

Empathy : the ability to recognize and to some extent share theemotions and states of mind of another and to understand the

meaning and significance of that person's behavior.

Empathy is different from sympathy in that to be empathetic one

understands how the person feels rather than actually

experiencing those feelings, as in sympathy.

Patient: human being mimics

feelings

Appreciate or honor each other

honest

may be positive / Negative


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Doctor-Patient Relationship

Interaction

My feelings

affect my

behaviour

My behaviours

affect patients

feelings

Patients behaviour

affect my feelings

Patients feelingsaffect their

diseases


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Examination of patient the central point needs scientific background

Phase I : - Anamnesis

- Physical notes- Data recording

Needs patience, discipline, sensitive, curious

Phase II : - Data analysis

- Integrating dataDiagnosis, Prognosis, Process, Diagnosis

Phase III : -M anagement

- TreatmentConsideration, experience, advice

Primum Non Nocere

Do No Harm (=Pertama jangan melakukan tindakan yang merugikan).


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The Cardiovascular Data Base

1. Patient history

2. Physical examination

3. Electrocardiogram

4. Chest X-ray

5. Routine blood exams

6. Additional Tests:

1. Two-dimensional echocardiography with Dopplerstudies

2. Exercise treadmil ECG test

3. Ambulatory Holter Monitoring

4. Nuclear imaging

5. Cardiac catheterization


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Classification of Common Heart Disease

(according to the causes)

Cardiovascular malformations (congenital heart

disease)

Involving the valve, heart structure, and other large vessels,

etc.

Acquired heart disease Artery thrombosis disease : leading to ischemia or

infarction, such as coronary heart disease

Rheumatic heart disease: heart inflammation, valvular

disease

Hypertension: primary, secondary, hypertensive

heart disease


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(according to the causes)

Acquired heart disease pulmonary and pulmonary-vascular heart disease:

pulmonary heart disease, pulmonary

hypertension, pulmonary embolism, etc.

Infection: bacteria, viruses invade the heart

Diseases of other systems involve the

heart: hyperthyroidism, anemia, malnutrition,

immune abnormalities, physical and chemicaldamage, mental factors, etc.


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(according to pathology )

Endocardial disease Endocarditis, valvular disease, etc.

Myocardial disease Inflammation, ischemia or necrosis, hypertrophy,

fibrosis, damage, etc. Great vascular diseases

Atherosclerosis, dissection, inflammation,thrombosis, angioma, embolism, etc.

Pericardium disease Inflammation, plot (gas, water, blood, pus, etc),

coarctation, etc.


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(according to pathophysiology )

Heart Failure Left heart, right heart; acute, chronic;

systolic, diastolic

Shock Dysfunction of coronary circulation

Papillary muscle dysfunction

Arrhythmia

Cardiac tamponade Others: high or low blood pressure (of

systemic or pulmonary vascular), shunt, etc.


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Format of Heart Disease Diagnosis

Etiological diagnosis Such as rheumatic heart disease, coronary

artery disease

Pathological or anatomical diagnosis Such as mitral stenosis

Pathophysiology diagnosis

Such as heart failure, atrial fibrillation,pulmonary hypertension


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Methods of Cardiovascular Disease

Diagnosis

Patient history present history, past history, personal history,

the history of surgery, vaccination history,marriage and procreation, family history, etc.

Physical examination Symptoms and signs Laboratoryexamination

Blood, urine, faeces, serous effusions (frompericardial effusion), sputum, biopsy, etc.

Equipment inspection X-ray, ultrasound (echocardiography),

electrocardiography, radionuclide,angiography, etc.


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Evaluation of the Methods in

Cardiovascular Disease Diagnosis

History and physical examination

basic skills, first-hand information, many

diseases can be diagnosed through this

Laboratoryexamination

Most supportive, but some can be used to

make a definite diagnosis, such as

myocardial necrosis marker, BNP (brainnatriuretic peptide), etc.


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Evaluation of the Methods in

Cardiovascular Disease Diagnosis

Equipment inspection

Major method for cardiovascular disease

diagnosis, Divided into invasive and non-invasive

method. non-invasive method can easily be accepted by

patients, and is safe, however, the information

may be limited (eg. ECG, echocardiography)

Invasive method: the opposite to non-invasiveones (eg. Cardiac catheterization)

Semi-invasive examinationsuch as those via theesophagus (eg. Trans-esophageal echocardiography)


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Basic skillInspection: Skin, mucosae(cyanosis?,pale?),

movement of

chest wall,

Palpation : - Sensitivity of the hands/fingers

- Muscle tone

- TumorPercussion : Sonor, dulness, timpanic

Auscultation : Sounds/Voices

- Breath

- Friction- Heart sounds

- Additional sounds: gallop, murmurs


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Problem Oriented Medical Record

POMR is oriented to problem

1.Baseline data

2.Problem list3.Problem oriented medical record

4.Summary of problem


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Common symptoms and signs related toCardiovascular problem

1. Chest pain2. Dyspnea3. Syncope4. Palpitations

5. Lower extremity edema6. Heart murmur7. Hypertension8. Fever associated with cardiac

symptoms and signs


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Chest Pain


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Differential diagnosis of chest pain

System involved Pathology

Cardiac Myocardial infarction

Angina pectorisPericarditis

Prolapse of the mitral valve

Tamponade

Vascular Aortic dissection

Respiratory (all tend to give rise topleuritic pain)

Pulmonary embolusPneumonia

Pneumothorax

Pulmonary neoplasm

Gastrointestinal Esophagitis due to gastric reflux

Esophageal tear

Peptic ulcer

Biliary disease

Pancreatitis


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Differential diagnosis of chest pain


Musculoskeletal Cervical nerve root compression by

cervical discCostocandritis

Fractured rib

Neurological Herpes zoster

Respiratory (all tend to give rise to

pleuritic pain)

Pulmonary embolus

PneumoniaPneumothorax

Pulmonary neoplasm

Psychogenic Anxiety

Panic disorder

Conversion disorder

Malingering


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Dyspnea


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Differential diagnosis of dyspnea:


Cardiac Cardiac failure

Coronary artery disease

Valvular heart disease aortic

stenosis, aortic regurgitation. Mitral

stenosis/regurgitation, pulmonary

stenosis

Cardiac arrhythmias

Respiratory Pulmonary embolus

Airway obstruction-COPD, asthma

Pneumothorax

Pulmonary parenchymal disease (eg.

Pneumonia, interstitial lung disease,

lung neoplasm)Pleural effusion

Chest wall limitation-myopathy,

neuropathy (eg Guillain-Barre

disease), rib fracture,

kyphoscoliosis

ff f


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Differential diagnosis of dyspnea:


Other Obesity (limiting chest wall movement

or sleep apnea)

Anemia

Psychogenic hyperventilation, panic

attack, anxiety.

Acidosis (eg aspirin overdose,

diabetic ketoacidosis)


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Syncope

Diff i l di i f


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Differential diagnosis of syncope :


Cardiac Tachyarrhyhtmias- supraventricular or ventricularBradyarrhythmia- sinus bradycardia, complete or

second-degree heart block, sinus arrest

Stokes-Adam attack- syncope due to transient asystole

Left ventricular outflow tract obstruction- aortic

stenosis, HOCM (hypertrophic obstructive

cardiomypathy)

Pulmonary hypertension

Vasovagal After carotid sinus massage and also precipitated by

pain (simple faint), micturition, anxiety; these result in

hyperstimulation by vagus nerve, which leads to AV

node block (and therefore bradycardia, hypotensionand syncope)

Diff ti l di i f


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Differential diagnosis of syncope :


Circulatory Postural hypotension usually due to antihypertensivedrugs or diuretics; also caused by autonomic

neuropathy as in diabetes

Pulmonary embolus may or may not preceded by

chest pain

Septic shock severe peripheral vasodilatation results

in hypotension

Cerebravascular Transient ischemic attack

Vertebrobasilar attack

Neurological Epilepsy

Metabolic Hypoglycemia


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Palpitations

l i i


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Palpitations :

Palpitations may be caused by anydisorder causing a change in cardiacrhythm or rate and any disordercausing increased stroke volume

P l i i


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Palpitations :

Rapid Palpitations:1. Regular palpitations may be a sign of:

1. Sinus tachycardia2. Atrial flutter3. Atrial tachycardia4. Supraventricular re-entry tachycardia

2. Irregularly irregular palpitations may indicate:1. Atrial fibrillation2. Multiple atrial or ventricular ectopic beats3. Multifocal atrial tachycardia (MAT): usually

found in patients with lung pathology

P l i i


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Palpitations:

Slow palpitations: patients often describe these asmissed beats or forceful beats (after a pause thenext beat is often more forceful due to a longfilling time and therefore a higher stroke volume).

Causes of slow palpitations:

1. Sick sinus syndrome2. Atrioventricular block3. Occasional ectopics with compensatory pauses


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Normal ECG

Rate 90-95 bpm

Regularity regular

P waves normal

PR interval 0.12 s

QRS duration 0.08 s

Interpretation?

Normal Sinus Rhythm


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Sinus Tachycardia

Etiology: SA node is depolarizing faster

than normal, impulse is conducted

normally.

Remember: sinus tachycardia is a

response to physical or psychological

stress, not a primary arrhythmia.


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Atrial Fibrillation

Deviation from NSR

No organized atrial depolarization, so

no normal P waves (impulses are not

originating from the sinus node).

Atrial activity is chaotic (resulting in an

irregularly irregular rate).

Common, affects 2-4%, up to 5-10% if

> 80 years old


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Atrial Flutter

Deviation from NSR

No P waves. Instead flutter waves (notesawtooth pattern) are formed at a rateof 250 - 350 bpm.

Only some impulses conduct throughthe AV node (usually every otherimpulse).


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Lower Extremity Edema


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Differential diagnosis of lower

extremity edema

Pathology Cause

Congestive heart

failure

Myocardial infarction, recurrent tachyarrhythmias

(particularly atrial fibrillation), hypertensive

heart disease, myocarditis, cardiomyopathy due

to drugs and toxins, mitral, aortic or pulmonary

valve disease

Right heart failure

secondary to

pulmonary

hypertension (cor

pulmonale)

Chronic lung disease, primary pulmonary

hypertension

Hypoalbuminemia Excessive protein loss (due to nephritic

syndrome, extensive burns, protein losing

enteropathy), reduced protein production (due

to liver failure), or inadequate protein intake (due

to protein-energy malnutrition)


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extremity edema

Pathology Cause

Renal disease Any cause of renal impairment ( e.g. hypertension,

diabetes mellitus, autoimmune disease, infection)

Liver cirrhosis Alcohol, hepatitis A, B, C, etc, autoimmune

chronic active hepatitis, biliary cirrhosis, Wilsonsdisease, hemochromatosis, drugs

Idiopathic Premenstrual edema

Arteriolar dilatation

(exposing the

capillaries to high

pressure, thus

increasing

intravascular

hydrostatic pressure)

Dihydropyridine calcium channel blockers ( e.g.

nifedipine, amlodipine)


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extremity edema

Pathology Cause

Sodium retention Cushings disease resulting in excessive

mineralocorticoid activity, corticosteroids

Local causes Cellulitis, venous thrombosis, lymphedema


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Heart Murmur


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Differential Diagnosis of Heart MurmurPhase

of

cardiaccycle

Nature of

murmur

Valve lesion Cause of valve lesion

Systolic Ejection

systolic

Aortic stenosis Valvular stenosis,

congenital valvular

abnormality, rheumatic

fever, supravalvularstenosis, senile valvular

calcification

Aortic sclerosis

(murmur that

does not radiate

to the carotids)

Aortic valve roughing

HOCM Left ventricular outflow

tract (sub aortic) stenosis

Increased flow

across normal

valve

High output states (eg

anemia, fever, pregnancy,

thyrotoxicosis)


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of

cardiaccycle

Nature of

murmur


Systolic Holosystolic Mitral

regurgitation

(MR)

Functional MR due to

dilatation of mitral valve

annulus

Valvular MR: rheumatic

fever, infective

endocarditis, mitral valve

prolapse, chordal rupture,

papillary muscle infarct

Tricuspid

regurgitation(TR)

Functional TR

Valvular TR : rheumaticfever, infective

endocarditis

VSD with left-to-

right shunt

Congenital, septal infarct

(acquired)


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of

cardiaccycle

Nature of

murmur


Diastolic Early diastolic Aortic

regurgitation (AR)

Functional AR: dilatation of

valve ring, aortic dissection,

cystic medial necrosis

(Marfan syndrome)

Valvular AR: rheumatic fever,

infective endocarditis,

bicuspid aortic valve

Pulmonary

regurgitation

Functional PR: dilatation of

valve ring, Marfan

syndrome, pulmonaryhypertension

Valvular PR: rheumatic fever,

carcinoid, tetralogy of Fallot


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Differential Diagnosis of Heart MurmurPhase of

cardiac

cycle

Nature of

murmur


Diastolic Mid

diastolic

Mitral stenosis

(MS)

Rheumatic fever, congenital

Tricuspid

stenosis (TS)

Rheumatic fever

Left and rightatrial myxomas

Tumor obstruction of valveorifice in diastole

Continuous PDA

Arteriovenous

fistula

Cervical venous

hum

Congenital


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Hypertension


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Differential diagnosis of

hypertension Systemic hypertension may be classified

as:

Primary (essential) hypertension, for which

there is no identified cause. This accounts for95% of cases.

Secondary hypertension, for which there is a

clear cause


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Blood Pressure Classification

Normal 100

BP Classification SBP mmHg DBP mmHg

JNC VII


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Causes of secondary hypertension

Mechanism PathologyRenal Renal parenchymal disease (e.g.chronic atrophic pyelonephritis,

chronic glomerulonephritis), renal

artery stenosis, renin-producing

tumors, primary sodium retention

Endocrine Acromegaly, hypo- and

hyperthyroidism, hypercalcemia,

adrenal cortex disorders (e.g

Cushings disease, Conns

syndrome, congenital adrenal

hyperplasia), adrenal medulla

disorders (e.g pheochromocytoma)

Vascular disease Coarctation of the aorta

Other Hypertension of pregnancy


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Causes of secondary hypertension

Mechanism Pathology

Increased intravascular volume Polycythemia (primary or

secondary)

Drugs Alcohol, oral contraceptives,

monoamine oxidase inhibitor,

glucocorticoids

Psychogenic Stress

Neurological Increased intracranial pressure


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Fever associated with a

cardiac symptom or sign


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Differential diagnosis of fever

Infective endocarditis (bacterial or fungal

infection within the heart)

Myocarditis (involvement of the myocardum in

an inflammatory proess, which is usually viral)

Pericarditis (inflammation of the pericardiumwhich may be infective, postmyocardial

infarction or autoimmune)

Other rare conditions such as cardiac myxoma


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Summary

1. Clinical diagnosis for patient with

cardiovascular disease needs

comprehensive approach.

2. Cardiovascular data base includes

patient history, physical examination,

electrocardiogram, chest X-ray, Routine

blood exams and additional tests


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Summary

3. Components of a complete cardiac

diagnosis include etiologic diagnosis,

pathologic or anatomical diagnosis, and

pathophysiologic diagnosis.

4. Many of symptoms and signs may lead to

differential diagnosis.

Th k Y


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Thank YouGood luck

1. Proses Diagnostik_kuliah

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