Course 03: Cardiovascular, Vascular and Hematology
Lesson 1 of 12. Read the diagnostic framework and case, then complete the 10-question practice set. All material is original educational content; high-risk presentations require emergency referral.
Focused history and differential diagnosis
- Define the presenting syndrome: chest discomfort, dyspnea, palpitations, syncope, edema, fatigue or reduced exercise tolerance; establish onset, duration, triggers and associated symptoms.
- Assess immediate instability: airway, breathing, circulation, mental status, vital signs, pulse oximetry and signs of poor tissue perfusion.
- Clarify cardiac risk: prior CAD, hypertension, diabetes, dyslipidemia, smoking, kidney disease, family history, stimulant exposure, pregnancy status and current medication use.
- Separate ischemic, arrhythmic, structural, pulmonary, infectious, gastrointestinal and musculoskeletal causes; normal examination does not exclude life-threatening illness.
Cardiac examination and red flags
- Record bilateral pulses when indicated, jugular venous pressure, cardiac murmurs, gallops, peripheral temperature and edema; listen for lung crackles.
- New severe pressure-like chest pain, syncope during exertion, shock, new focal deficit or acute severe breathlessness warrants immediate emergency assessment.
- A new murmur with fever, embolic features or recent invasive procedures raises concern for infective endocarditis.
- Orthopnea, elevated JVP, crackles and edema support congestion; unilateral leg swelling with sudden dyspnea raises pulmonary embolism concern.
12-lead ECG fundamentals
- Check calibration and acquisition, rate, regularity, P waves, PR interval, QRS duration, axis, QT/QTc and ST-T changes.
- Identify atrial fibrillation by an irregularly irregular rhythm without consistent discrete P waves; consider artifact and other irregular rhythms.
- Recognize STEMI-equivalent and ischemic patterns in the clinical context; a normal or non-diagnostic first ECG does not rule out ACS.
- A wide-complex tachycardia in an ill patient should be treated as ventricular tachycardia until proven otherwise by a trained emergency team.
- Long QT, high-grade AV block, pre-excitation, hyperkalemia changes and Brugada-pattern findings require appropriate urgent evaluation.
Testing and interpretation
- Use serial high-sensitivity troponin with a validated local protocol for suspected ACS; troponin elevation signals myocardial injury, not automatically type 1 infarction.
- BNP/NT-proBNP supports heart failure assessment but may rise with age, renal dysfunction or atrial fibrillation; low values can help make HF less likely.
- Echocardiography evaluates chamber size, ejection fraction, valve disease, wall motion and pericardial effusion; choose it for suspected structural disease.
- Ambulatory ECG monitoring can capture intermittent palpitations or syncope when a resting ECG is unrevealing; choose monitoring duration based on symptom frequency.
- Use clinical pretest probability to select stress testing, coronary CT angiography or specialist referral; avoid indiscriminate testing.
Decision documentation
- Record differential diagnoses and why major emergencies were considered or excluded, including time course and examination findings.
- Use shared decision-making to discuss benefits, limitations, false positives, downstream procedures and urgent return precautions.
- Do not defer emergency referral while waiting for outpatient blood tests or imaging if a patient has concerning symptoms.
Applied clinical case
A 59-year-old with diabetes reports 40 minutes of chest pressure, diaphoresis and nausea. BP 102/70, pulse 108; first ECG is non-diagnostic.
Show model clinical reasoning and disposition
High-risk possible ACS remains the leading concern. Activate emergency transfer and obtain time-sensitive ECG/serial troponin in a monitored setting; do not reassure based on the first ECG.
Clinical self-check
- Which conditions must be excluded first?
- Why is one normal ECG insufficient?
- What changes make an outpatient plan unsafe?
Guidelines and further learning
- AHA/ACC — 2025 Acute Coronary Syndromes Guideline (external)
- Canadian Cardiovascular Society — Guidelines Library (external)