Anamnesi ed esame obiettivo
rodolfo sbrojavacca AOU Udine
SINCOPE
2 0 1 1
The initial evaluation of a patient presenting with
T-LOC consists of careful history, physical
examination, including orthostatic BP
measurements and electrocardiogram (ECG).
measurements,
(ECG)
Based on these findings, additional examinations
may be performed.
Task Force ESC, Guidelines (verison 2009)
European Heart Journal (2009) 30, 2631–2671
SINCOPE
2 0 1 1
Perché ci facciamo i fatti degli altri?
SINCOPE
2 0 1 1
La anamnesi per
definire una probabilità
à
SINCOPE
2 0 1 1
Pretest probability of disease
T-
T+
0%
100%
rule OUT
grey zone
+
rule IN
Worster A CJEM vol.4, n.5, sept 2002
SINCOPE
2 0 1 1
SINCOPE
2 0 1 1
Pretest
Post-test
Probability
Probability
Many tests for syncope have a low
diagnostic yield.
A careful
f l history,
hi t
physical
h i l examination,
i ti
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
SINCOPE
2 0 1 1
di
diagnostic
i yield
i ld
the number of p
pts. with
positive test results divided by
th number
the
b off patients
ti t ttested.
t d
Linzer M et al Ann Intern Med 1997;126:989-96
SINCOPE
2 0 1 1
Generating
gp
pre-test p
probabilities:
a neglected area in clinical decision
making
Attia JR et al
MJA, 2004,;180(9)449-454
SINCOPE
2 0 1 1
Experienced physicians, in response to the same
clinical scenarios, gave a wide range of estimates for
pre-test
pre
test probability.
The
developement
and
dissemination
of
clinical decision rules is needing to support
decision making by practising clinicians.
Attia JR et al
MJA, 2004,;180(9)449-454
SINCOPE
2 0 1 1
Q l lluogo più
Quale
iù adatto,
d tt per una anamnesii attenta
tt t e
dettagliata, di un silenzioso box di PS mentre trenta pazienti
attendono tranquillamente in sala d’ attesa conversando
amabilmente con i loro familiari?
Un q
questionario standardizzato o l’ aiuto del computer
p
sono
un insulto per l’ arte medica?
SINCOPE
2 0 1 1
European Heart Journal (2009) 30, 2631–2671
SINCOPE
2 0 1 1
Ogni uomo racconta una storia.
Ma ha bisogno di tempo.
SINCOPE
2 0 1 1
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%
nell 80% dei casi
casi,
in media dopo 12 secondi.
Resuscitating the physician-patient relationship
Ann Emerg Med 2004;44:262-67
SINCOPE
2 0 1 1
The initial evaluation should answer
three key questions:
(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
cardiovascular events or death?
European Heart Journal (2009) 30, 2631–2671
SINCOPE
2 0 1 1
La
a T-LOC
OC è il p
problema?
ob e a
SINCOPE
2 0 1 1
McDermott Quinn
McDermott,
Quinn, 2011
SINCOPE
2 0 1 1
Fu vera sincope?
Lasciare la sentenza ai posteri può essere pericoloso
SINCOPE
2 0 1 1
European Heart Journal (2009) 30, 2631–2671
SINCOPE
2 0 1 1
Questions about background
Family history of sudden death, congenital arrhythmogenic heart
disease or fainting
Previous cardiac disease
Neurological history (Parkinsonism, epilepsy, narcolepsy)
Metabolic disorders (diabetes, etc.)
Medication (antihypertensive, antianginal, antidepressant agent,
antiarrhythmic, diuretics and QT prolonging agents)
(I case off recurrentt syncope)) Information
(In
I f
ti
on recurrences such
h as
the time from the firstsyncopal episode and on the number of spells
ESC
SINCOPE
2 0 1 1
Tre domande chiave
• Perché sei qui?
• Chi sei?
• Cosa p
possiamo fare p
per te?
SINCOPE
2 0 1 1
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
y
p gradually
g
y increases with
age, and should be considered in the
context of other risk factors,
particularly heart disease.
McDermott, Quinn 2007
SINCOPE
2 0 1 1
SINCOPE
2 0 1 1
Questions about circumstances just
prior to attack
• Position (supine, sitting or standing)
• Activity (rest
(rest, change in posture,
posture during or after exercise,
exercise during or
immediately after urination, defaecation, cough or swallowing)
• Predisposing factors (e.g. crowded or warm places, prolonged standing,
post-prandial
d l period)
d) and
d off precipitating
i i
i
events (e.g.
(
ffear, intense pain,
neck movements);
ESC
SINCOPE
2 0 1 1
In patients with certain or suspected heart
disease the most specific predictors of a
disease,
cardiac cause were syncope
y
p in the supine
p
position or during effort, blurred vision
and convulsive syncope.
Alboni P et al. J Am Coll Cardiol 2001;37:1921-8
SINCOPE
2 0 1 1
The absence of nausea or vomiting before the
syncopal episode was a predictor of higher risk
for
o arrhythmic
a yt
c causes o
of syncope,
sy cope, but no
o other
ot e
symptoms were helpful.
Oh J. Et al Arch Intern Med. 1999;159:375-380.
SINCOPE
2 0 1 1
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 diaphoresis
p
during the recovery phase.
Alboni P et al. J Am Coll Cardiol 2001;37:1921-8
SINCOPE
2 0 1 1
Questions 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
myoclonus,
l
automatism)
t
ti ) and
d their
th i duration,
d
ti
onsett off
movement in relation to fall, tongue biting
ESC
SINCOPE
2 0 1 1
SINCOPE
2 0 1 1
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.
SINCOPE
2 0 1 1
Hoefnagels, WA, Padberg, GW, Overweg, J, et al.
Syncope or seizure? A matter of opinion.
Clin Neurol Neurosurg 1992; 94:153.
SINCOPE
2 0 1 1
SINCOPE
2 0 1 1
Questions about end of attack
Nausea vomiting,
Nausea,
vomiting sweating,
sweating feeling of cold,
cold
confusion, muscle aches, skin colour,
injury, chest
h
pain, palpitations,
l
urinary
i
or
faecal incontinence
Task Force on Syncope, ESC
SINCOPE
2 0 1 1
Symptoms and signs of syncope:
a review of the link between physiology and
clinical clues
Wieling et al
SINCOPE
2 0 1 1
Brain 2009: 132; 2630–2642
Il ritorno dell’ emigrante
SINCOPE
2 0 1 1
Il gioco dell
dell’ indiano
F i ti
Fainting
llark
k
SINCOPE
2 0 1 1
La sincope del Farmacista
(La notte porta consiglio)
SINCOPE
2 0 1 1
Non importa quanto sia stata
accurata la tua anamnesi.
anamnesi
Il paziente terrà sempre in serbo
qualcosa solo per il primario.
SINCOPE
2 0 1 1
Next time take a
better history!
SINCOPE
2 0 1 1
The initial evaluation should answer
three key questions:
(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
cardiovascular events or death?
European Heart Journal (2009) 30, 2631–2671
SINCOPE
2 0 1 1
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?
Brignole
Heart 2007; 93: 130-136.
SINCOPE
2 0 1 1
“ L’ anamnesi è la parte più importante
d ll’ esame obiettivo”
dell’
bi tti ”
SINCOPE
2 0 1 1
L’ esame obiettivo è obiettivo?
SINCOPE
2 0 1 1
Anamnesi ed esame obiettivo sono
metodiche
operatore-dipendente
SINCOPE
2 0 1 1
Il fattore
k
Q
Quante
t volte
lt medici
di i diversi,
di
i visitando
i it d llo stesso
t
paziente,, concordano sulla presenza
p
p
o sulla
assenza di un segno clinico?
• definizione
• modesta
dei segni clinici vaga
capacità del medico
• evanescenza
• mancanza
• bias
d segni
dei
di concentrazione (PS)
Interobserver agreement: physical signs
McGee, EB Phisical Diagnosis, 2002
SINCOPE
2 0 1 1
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
SINCOPE
2 0 1 1
Murmurs indicative of valvular heart disease or
obstruction to flow may prompt further evaluation
ACEP
SINCOPE
2 0 1 1
L’ ECG è parte dell’esame obiettivo
SINCOPE
2 0 1 1
Ip
parametri vitali sono vitali
SINCOPE
2 0 1 1