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Lung congestive symptoms
1. Dyspnea 2. Paroxysmal nocturnal dyspnea 3. Orthopnea 4. Acute pulmonary edema 5. Congestive cough 6. Recurrent winter bronchitis 7. Hemoptysis 8. Cheyne Stokes respiration
Low cardiac output symptoms
1. Exertional fatigue 2. Dizziness and giddiness 3. Fainting and syncope 4. Anginal pain 5. Oliguria if acute
Systemic congestive symptoms
1. Pain right upper abdomen due to hepatic congestion 2. GIT Congestion causing anorexia nausea, vomiting and dyspepsia 3. CNS congestion causing confusion, headache, insomnia, lack of memory
and encephalopathy 4. Edema LL 5. Ascites
Others
1. Chest pain 2. Palpitation 3. Pressure symptoms 4. Cyanosis , jaundice 5. Peripheral vascular disease 6. Systemic embolization 7. Toxic: fever, sweating, weight loss
Cough & Hemoptysis
CVS cause
1. Pulmonary edema 2. Pulmonary congestion 3. Pulmonary infarction 4. CVS drugsà ACEI
5. Compression and irritation of the bronchial tree by
o Aortic aneurysm o Pericardial effusion o Dilated left atrium
Duration If more longer than dyspnea à chest disease If less duration than dyspnea àcardiac disease
Types Dry à it can be from any causes Expectoration à if cardiac with whitish/frothy sputum and increased with pulmonary congestion
Relation to posture
Cough increase on lying flat à LSHF
Precipitate by exertion
LSHF
Time More coughing during night sleep àLSHF More coughing during morning à bronchitis, suppurative lung disease
Correlate with hemoptysis
1. LSHF à MS 2. Pulmonary edema 3. Pulmonary infarction 4. Rupture of aortic aneurysm in the bronchial tree 5. Severe pulmonary hypertension àeg Eisenmenger’s syndrome
DDx Cough due to heart disease o Whitish mucoid/ frothy expectoration o Increase with pulmonary congestion
Cough due to infection o Purulent sputum
Dyspnea Definition Abnormally uncomfortable awareness of breathing or subjective sensation of difficult breathing
Cardiac cause
1. All causes of pulmonary congestion o LVF o MS
2. All causes of low cardiac output o RVF
3. Cyanotic congenital heart disease o Teratology Fallot
4. Pulmonary embolism and pulmonary infarction
Sudden onset
1. Acute pulmonary embolism 2. Pneumothorax 3. Acute bronchial asthma 4. Foreign body inhalation 5. Laryngeal edema
6. Acute pulmonary edema cardiogenic/or non cardiogenic
7. Hemothorax 8. Psychogenic
Rapidly progressive
Over months: CHF Over years: Chronic lung disease
Paroxysmal course
• PND • Bronchial asthma • IHD
• LA Myxoma • Ball Valve thrombus • Some paroxysmal arrhythmia
Regressive course
• With diuretics à HF • With surgical valve procedureà valve disease • With blood transfusion à anemia • With anti – ischemic drugs à angina equivalent (IHD)
Precipitation factor
(exertion)
1. CHD à LSHF 2. Hypoxic heart diseaseà cyanotic congenital heart disease 3. Angina equivalent (IHD) 4. Anemia 5. Thyrotoxicosis 6. Psychological à mental stress
Type Inspiratory dyspnea à cardiac & upper airway obstruction
Expiratory dyspnea à lower airway obstruction
Severity (NYHA) Grade 1 à SOB with > ordinary effort Grade 2 à SOB with ordinary effort Grade 3 à SOB with < ordinary effort Grade 4 à SOB at rest but increase by exertion
Associated symptoms
Cardiac symptoms àchest pain palpitation, systemic congestion symptoms Chest symptoms à hemoptysis, wheezes, expectoration
Related to posture
Orthopnea à indicates advanced LSHF • Pulmonary congestion {MS, LVF} • Massive pericardial effusion
Paroxysmal nocturnal dyspnea • Pulmonary congestion {MS, LVF}
Systemic congestion symptoms
1. Insomnia (due to brain congestion) 2. Dyspepsia (due to stomach congestion) 3. Constipation (due to intestinal congestion) 4. Pain in the right hypochondrium (due to liver
congestion à distended capsule) 5. Ascites 6. Edema lower limb 7. Oliguria (due to renal congestion) 8. Sweating on slight activity
Edema Lower Limb Definition Accumulation of fluids in interstitial tissues of lower limbs
Etiology
Localized (unilateral) Generalized (bilateral) o Venous obstruction
1. DVT 2. Varicose veins 3. Phlebitis
o Lymphatic obstruction
1. Filariasis 2. LN dissection or irradiation
o Inflammatory edema as cellulitis o Allergic
1. Angioedema 2. Insect bite
o Traumatic
o Cardiac o Hepatic o Renal o Nutritional o Idiopathic cyclic edema in females
Cause of generalized edema by mechanism
Increase in capillary pressure
1. HF 2. Constrictive pericarditis 3. Venous obstruction and varicose veins
Decrease oncotic of plasma protein in hypoproteinemia
1. Nutritional edema 2. Nephrotic syndrome 3. Liver cirrhosis and failure
Increase in capillary permeability 1. Angioneurotic edema 2. Edema of infections, trauma, stings, bites, burns
Diminished lymphatic drainage 1. After repeated inflammation 2. Filariasis
Salt and water retention and increased in blood volume
1. Acute nephritis 2. HF 3. Liver cirrhosis 4. Ingestion of liquorice
Drugs 1. Nifedipine
2. Amlodipine Onset o Commonly gradual
o Acute onset in inflammatory condition (cellulitis) Course o Commonly progressive
o Come and go à angioedema, bitting of insects Precipitating
factor Salt intake & long standing
Relieving factor Lying down, therapy, salt restriction
Associated with pain
1. DVT 2. Cellulitis 3. Traumatic
Associated with fever
More in inflammatory conditions
Related to drug intake
Corticosteroids, NSAIDS, contraceptives
Duration
o If edema comes first before ascites à in case of heart failure o If edema comes late after ascites à liver failure, ascites precox {tricuspid valve disease, constrictive
pericarditis} o If edema comes after eyelid puffiness à in case of renal disease
Low cardiac output symptoms
1. Syncope 2. Dizziness, giddiness 3. Exertional blurring of vision 4. Angina 5. Oliguria (only in acute low COP only) 6. Intermittent claudication 7. Exertional fatigue
Fatigue
• Fatigue is due to poor cerebral and peripheral perfusion and poor oxygenation • When severe cardiac disorders are not present, an active infection such as Infective endocarditis may be
responsible. • Drugs prescribed for angina or hypertension, particularly B – blocker may cause fatigue
Syncope Definition Transient loss of consciousness due to temporary cerebral ischemia
Causes of cardiac syncope
1. Resistance to the blood flow à LVOT { AS or HCM} 2. Ball and valve embolus, left atrial myxoma 3. Adam – stokcs 4. Severe bradycardia/ tachycardia à Arrhythmia 5. Acute diminution of venous return
o Hemorrhage o Extensive burns o Extensive peripheral vasodilatation
Arrhythmias Obstruction Situational • Ventricular
tachycardia • Rapid supraventricular
tachycardia • Sinus arrest • AV block • Artificial pacemaker
failure
• Aortic / pulmonary stenosis
• HCOM • Fallot’s tetralogy • Pulmonary
hypertension • Pulmonary embolism • Atrial myxoma • Atrial thrombus • Defective prosthetic
valve
• Neurocardiogenic (vasovagal)
Related to drugs intake
Anti – hypertensive o Diuretics o Beta blocker
Position when syncope happen
Cardiac àsupine Neurological à standing
Premomentary symptoms
Epilepsy o Flashes of light o Flushing of face
Associated symptoms
1. Pallor 2. Sweating
3. Cold extremities 4. Palpitation
Injury during syncope
At head à mostly cardiac due to fall down Tongue bitting, rib fracture à due to epilepsy
Palpitation Causes
1. Increased force of cardiac contraction in case of hyperdynamic circulation and volume overload of the left ventricle
• Aortic regurgitation • Patent ductus • Thyrotoxicosis
2. Increased rate of cardiac action
(tachycardia)
3. Irregular cardiac action in all forms of • Extrasystole • Dropped beats • Irregular tachycardia • Irregular bradycardia
4. Anxiety, emotions, exercise in unaccustomed person, and neurocirculatory asthenia
5. Some drugs • Ephedrine • Salbutamol • Nitrates • Nifedipine
Change in heart rate
Tachyarrhythmia • Sinus tachycardia • Paroxysmal tachycardia
Bradyarrhythmia • Sinus bradycardia • Junctional rhythm • Complete heart block
Change in rhythm 1. Atrial fibrillation 2. Extra systole 3. Sinus arrhythmia 4. Second degree heart block
Change in force
1. Causes of ventricular hypertrophy 2. Causes of ventricular dilatation
• Causes of volume overload • Causes of hyperdynamic circulation
DDx
palpitation Rhythm Rate Onset &
offset ↑ Factor ↓ Factors Associated
symptoms Course
Sinus tachycardia
Regular Rapid Gradual Exertion Emotional stress
B blocker
Paroxysmal tachycardia
Regular
Very rapid
Sudden
Spontaneous
Anti arhythmic drugs
Polyuria Syncope Profuse sweating
Paroxysmal
Brady arrhythmia
Regular Slow but pounding
Spontaneous Sleep
Dizziness
Atrial fibrillation
Markedly irregular
Any
Any
Exertion Emotional stress
B blocker CCB Digitalis
Paroxysmal
Extra systole Occasionally dropped beats
Any
Chest pain
Occasional
Other symptoms
Pressure symptoms (Mediastinal syndrome)
What press What has been pressed? • Left atrial enlargement • Pericardial effusion • Cardiomegaly • Aortic aneurysm
• Esophagus à dysphagia • Left recurrent laryngeal nerve à hoarseness of
voice • Trachea à cough and dyspnea • Spines à backache
Fever
Cardiac causes of fever 1. Rheumatic fever à ask about painful red joint swelling / recurrent tonsillitis/ long acting penicillin 2. Infective endocarditis à ask about minor operations 3. Myocardial infarction à ask about chest pain of pericarditis 4. DVT à ask about lower limb painful swelling 5. Streptococcal nephritis à ask about loin pain and dysuria
Symptoms of systemic
hypertension
• Headache (occipital, in the morning) • Tinnitus • Epistaxis • Blurring of vision
• Flushing • Palpitation • History of treatment (anti – HTN/ SE of
drugs causing HTN)
Symptoms of embolization
1. Sudden hemiplegia à cerebral artery occluded 2. Sudden blindness à central retinal artery occluded 3. Sudden aphasia 4. Painless hematuria à renal artery occluded 5. Acute abdomen àsuperior mesenteric artery occluded 6. Sudden onset of coldness of one limb
Constitutional symptoms
• Fever • Chills
• Prostration • Malaise
• Bony aches • Sweating
Symptoms of peripheral vascular
disease
• Cold extremities • Claudication
• Leg ulcer • DVT
• Cyanosed extremities
Chest pain Cardiac pain Pericarditis Dissecting
aortic aneurysm
Pulmonary embolism
Cardiac neurosis Mitral valve prolapse
Causes /due to
Ischemia of the heart muscle
1. Angina 2. Coronary
insufficiency 3. MI
Site Retrosternal Retrosternal Retosternal Retrosternal Infra mammary Onset Acute Sudden
(acute) Sudden (acute)
Character
Contionous, dull Sharp Throbbing Stabbing
Stabbing Pricking Stabbing Aching
Stitching
Radiation
Jaw, epigastrium, both shoulder and left arm
Left shoulder
Back Apex of left scapula
Associated symptoms
1. Dyspnea 2. Fatigue 3. Palpitation 4. Dizziness
Fever Other signs of psychotic manifestations • Throatling
sensation • Excessive sweating
in palm with cold hand
• Irritability or depression
• Palpitation • Throbbing
headache
Timing / duration
3 – 5 mins up to 20 mins Prolonged Seconds or hours
Exercabation
factor
1. Exertion 2. Emotional
stress 3. Heavy meal 4. Cigarette
smoking 5. Cold weather
Respiration Movement Lying flat
Not precipitated by exertion
Relieving factor
• Rest • Stop the
precipitating factor • Sublingual nitrates
Leaning forward
Not relieved by rest
Cardiac causes of chest pain
1. Pericarditis 2. Pericardial effusion 3. Myocardial infarction 4. Angina 5. Mitral valve prolapse
6. Pulmonary embolism 7. Aortic aneurysm 8. Huge heart 9. Cardiac neurosis