Anamnesi ed esame obiettivo

rodolfo sbrojavacca AOU Udine

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The initial evaluation of a patient presenting with The initial evaluation of a patient presenting with

T-LOC consists of careful history, physical

examination, including orthostatic BP

measurements and electrocardiogram (ECG) measurements, and electrocardiogram (ECG).

Based on these findings, additional examinations

may be performed.

Task Force ESC, Guidelines (verison 2009)European Heart Journal (2009) 30, 2631–2671

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Perché ci facciamo i fatti degli altri?Perché ci facciamo i fatti degli altri?

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La anamnesi per La anamnesi per

àdefinire una probabilità

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Pretest probability of disease

T- T+

0% 100%

grey zone

- +rule OUT rule IN

Worster A CJEM vol.4, n.5, sept 2002

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Pretest Post-test

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Pretest Probability

Post-test Probability

Many tests for syncope have a low diagnostic yield.

A f l hi t h i l i ti A careful history, physical examination, and electrocardiography will provide a diagnosis or determine whether diagnostic testing is necessary in most patients.

Linzer M et al Ann Intern Med 1997;126:989-96

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di i i lddiagnostic yield

the number of pts. with p

positive test results divided by

th b f ti t t t dthe number of patients tested.

Linzer M et al Ann Intern Med 1997;126:989-96

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Generating pre-test probabilities:g p p

a neglected area in clinical decisiona neglected area in clinical decision

makingmaking

Attia JR et alMJA, 2004,;180(9)449-454

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Experienced physicians, in response to the sameExperienced physicians, in response to the sameclinical scenarios, gave a wide range of estimates forpre-test probability.pre test probability.

The developement and dissemination ofclinical decision rules is needing to supportdecision making by practising clinicians.decision making by practising clinicians.

Attia JR et alMJA, 2004,;180(9)449-454

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Q l l iù d tt i tt t Quale luogo più adatto, per una anamnesi attenta e

dettagliata, di un silenzioso box di PS mentre trenta pazienti

attendono tranquillamente in sala d’ attesa conversando

amabilmente con i loro familiari?

Un questionario standardizzato o l’ aiuto del computer sono q p

un insulto per l’ arte medica?

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European Heart Journal (2009) 30, 2631–2671

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Ogni uomo racconta una storia.

Ma ha bisogno di tempo.

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In una videoregistrazione di 93 visite in ED di pazienti

non critici, i 24 medici che hanno partecipato allo

studio hanno interrotto i pazienti prima che finissero di

spiegare il motivo del loro accesso nell’80% dei casi spiegare il motivo del loro accesso nell 80% dei casi,

in media dopo 12 secondi.

Resuscitating the physician-patient relationshipAnn Emerg Med 2004;44:262-67

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The initial evaluation should answer three key questions:

(1) Is it a syncopal episode or not?(1) Is it a syncopal episode or not?

(2) Has the aetiological diagnosis been

determined?

(3) Are there data suggestive of a high risk of (3) Are there data suggestive of a high risk of

cardiovascular events or death?

European Heart Journal (2009) 30, 2631–2671

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La T-LOC è il problema?a OC è p ob e a

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McDermott Quinn 2011McDermott, Quinn, 2011

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Fu vera sincope?Fu vera sincope?

Lasciare la sentenza ai posteri può essere pericoloso

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European Heart Journal (2009) 30, 2631–2671

Questions about backgroundFamily history of sudden death, congenital arrhythmogenic heart disease or faintingPrevious cardiac diseasePrevious cardiac diseaseNeurological history (Parkinsonism, epilepsy, narcolepsy)Metabolic disorders (diabetes, etc.)Medication (antihypertensive, antianginal, antidepressant agent, antiarrhythmic, diuretics and QT prolonging agents)(I f t ) I f ti h (In case of recurrent syncope) Information on recurrences such as the time from the firstsyncopal episode and on the number of spells

ESC

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Tre domande chiave

• Perché sei qui?

• Chi sei?

• Cosa possiamo fare per te?p p

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We feel there is little utility in using any

specific age threshold for increased

risk when assessing patients with

syncope. Risk of adverse outcomes

after syncope gradually increases with y p g y

age, and should be considered in the

context of other risk factors,context of other risk factors,

particularly heart disease.

McDermott, Quinn 2007

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Questions about circumstances just prior to attackprior to attack• Position (supine, sitting or standing)• Activity (rest change in posture during or after exercise during or • Activity (rest, change in posture, during or after exercise, during or immediately after urination, defaecation, cough or swallowing)• Predisposing factors (e.g. crowded or warm places, prolonged standing,

d l d) d f i i i ( fpost-prandial period) and of precipitating events (e.g. fear, intense pain, neck movements);

ESC

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In patients with certain or suspected heart In patients with certain or suspected heart

disease the most specific predictors of a disease, the most specific predictors of a

cardiac cause were syncope in the supine y p p

position or during effort, blurred vision

and convulsive syncope.

Alboni P et al. J Am Coll Cardiol 2001;37:1921-8

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The absence of nausea or vomiting before the

syncopal episode was a predictor of higher risk syncopal episode was a predictor of higher risk

for arrhythmic causes of syncope, but no other o a yt c causes o sy cope, but o ot e

symptoms were helpful.

Oh J. Et al Arch Intern Med. 1999;159:375-380.

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Significant and specific predictors of a neurally

mediated cause were time between the first and

last syncopal episode >4 years,

abdominal discomfort before the loss of

consciousness and nausea and diaphoresisp

during the recovery phase.

Alboni P et al. J Am Coll Cardiol 2001;37:1921-8

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Questions about attackQuestions about attack(eyewitness)Way of falling (slumping or kneeling over), skin colour(pallor, cyanosis, flushing), duration of loss of consciousness, breathing pattern(snoring), movements (tonic, clonic, tonic-clonic or minimal

l t ti ) d th i d ti t f myoclonus, automatism) and their duration, onset of movement in relation to fall, tongue biting

ESC

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Imparare a gestire l’ ansia dei familiari e

a convertirli da nemici ad alleati.

Una testimonianza decisiva può a volte

essere raccolta solo in PS.

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Hoefnagels, WA, Padberg, GW, Overweg, J, et al.

Syncope or seizure? A matter of opinion.Syncope or seizure? A matter of opinion.

Clin Neurol Neurosurg 1992; 94:153.

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Questions about end of attackQuestions about end of attack

Nausea vomiting sweating feeling of cold Nausea, vomiting, sweating, feeling of cold, confusion, muscle aches, skin colour,

h l iinjury, chest pain, palpitations, urinary or faecal incontinence

Task Force on Syncope, ESC

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Symptoms and signs of syncope: Symptoms and signs of syncope:

a review of the link between physiology and

clinical clues

Wieling et al Brain 2009: 132; 2630–2642

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Il ritorno dell’ emigrante

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Il gioco dell’ indianoIl gioco dell indiano

F i ti l kFainting lark

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La sincope del Farmacista

(La notte porta consiglio)

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Non importa quanto sia stata

accurata la tua anamnesiaccurata la tua anamnesi.

Il paziente terrà sempre in serbo

qualcosa solo per il primario.

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Next time take a

better history!better history!

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The initial evaluation should answer three key questions:

(1) Is it a syncopal episode or not?(1) Is it a syncopal episode or not?

(2) Has the aetiological diagnosis been

determined?

(3) Are there data suggestive of a high risk of (3) Are there data suggestive of a high risk of

cardiovascular events or death?

European Heart Journal (2009) 30, 2631–2671

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Three key questions should be addressed during the initial evaluation:

• Is loss of consciousness attributable to syncope or not?

• Are there features in the history that suggest the diagnosis?

• Is heart disease present or absent?

BrignoleHeart 2007; 93: 130-136.

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“ L’ anamnesi è la parte più importante

d ll’ bi tti ”dell’ esame obiettivo”

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L’ esame obiettivo è obiettivo?

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Anamnesi ed esame obiettivo sono

metodiche

operatore-dipendente

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Il fattore kQ t lt di i di i i it d l t Quante volte medici diversi, visitando lo stesso

paziente, concordano sulla presenza o sulla p , p

assenza di un segno clinico?

• definizione dei segni clinici vaga• definizione dei segni clinici vaga

• modesta capacità del medico• modesta capacità del medico

d• evanescenza dei segni

• mancanza di concentrazione (PS)

• bias

Interobserver agreement: physical signs

McGee, EB Phisical Diagnosis, 2002

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Interobserver agreement: diagnostic standards

McGee, EB Phisical Diagnosis

The presence of suspected or certain heart

disease after the initial evaluation is a strong

predictor of a cardiac cause of syncope.p y p

Alboni P et al. J Am Coll Cardiol 2001;37:1921-8

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Murmurs indicative of valvular heart disease or Murmurs indicative of valvular heart disease or

obstruction to flow may prompt further evaluation

ACEP

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L’ ECG è parte dell’esame obiettivo

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I parametri vitali sono vitalip

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