Clinical Assessmentpart 2

Dr Doha RasheedyLecturer of Geriatric Medicine

Department of Geriatric and GerontologyAin Shams University

REVIEW OF SYSTEMS

• With all symptoms obtain the following details:• Duration• onset —sudden or gradual• what has happened since:• constant or periodic• Frequency• getting worse or better• General Procedures• precipitating or relieving factors• associated symptoms

CARDIAC

PVC

Symptoms of pulmonary venous Congestion:

• It is due to stagnation of blood in the pulmonary veins of the lung due to failure of the left ventricle or mitral stenosis.

• Lung congestion can manifest itself as:Dyspnea on exertion (ask about its grades),

Dyspnea at rest (severe cases)Orthopnoea (The patient trying to lie propped up

e.g. using extrapillows). P.NDCough and expectoration - Haemoptysis.Acute pulmonary oedema.

DYSPNEA• an uncomfortable subjective awareness of

one’s own breathing.

• Are they sure that they stop due to breathlessness or is it some other reason (arthritic knees for example)?

1. How long have you been short of breath?2. Did the shortness of breath occur suddenly

or gradually?3. Do you ever wake up at night feeling short

of breath (paroxysmal nocturnal dyspnea)?4. How many pillows do you sleep on at night?5. How far can you walk before you become

short of breath?6. Have you notice swelling in your legs

associated with your shortness of breath?7. Have you had any chest pain associated

with your shortness of breath?

Causes: • Cardiac, respiratory, metabolic,

neuromuscular, toxin, anxiety • Exertional dyspnea can be an anginal

equivalent also relieved with nitrates.For more classification:• Acute: pul embolism, pneumothorax, GBS,

Foreign body, tamponade, pulmonary edema, MI.

• Chronic: COPD, LVF, EMPHYSEMA, IPF.• Intermittent: BA, MYASTHENIA, CARDIAC

Asthma, Carcinoid S, recurrent pul embolism

Grading: NYHA Functional Classification

Orthopnea:• Dyspnea on lying flat which is partially relieved by

sitting, severity can be determined by number of pillows used by night.

• Cause PVC: MS, LVF• Orthopnea may occur due to a chest disease e.g.: severe asthmatic attack

or increased intra-abdominal pressure e.g. tense ascites.

• Mechanism:1. Increased venous return, which increases pulmonary venous

congestion.2. Elevation of the diaphragm by viscera.3. Interference with mobility of the respiratory muscles.So in laying flat the pulmonary venous congestion is increased ~

activation of Hering Breuer reflex.

Paroxysmal Nocturnal Dyspnea( P.N.D)

• It is a Paroxysmal attacks of dyspnea that wakes the patient from sleep.

• Dyspnea, cough + wheeze developed 1-2 hours after sleep Spontaneously resolved called the Cardiac Asthma

• Associated with: cyanosis, rapid pulse, sweating, cough expecturation (frothy, blood tinged)

• But we have to exclude B.A.

• Mechanism of PND1. Increased V.R. during sleep leading to

aggravation of pulmonary congestion.2. Absorption of oedema fluid into the

circulation causing further increase in V.R.3. Diminished Sympathetic activity during

sleep causing reduction of cardiac contractility

Platypnea • Shortness of breath in erect position• Usually with deoxygenation (Platypnea orthodeoxia

syndrome)• To occur must have anatomical (in the form of an interatrial

communication) + functional shunt.• Anatomical shunts e.g. atrial septal defect, a patent foramen

ovale, or a fenestrated atrial septal aneurysm.• The functional shunt may be cardiac, such as pericardial

effusion or constrictive pericarditis; pulmonary, such as emphysema, arteriovenous malformation, pneumonectomy, or amiodarone toxicity; abdominal, such as cirrhosis of the liver or ileus; or vascular, such as aortic aneurysm or elongation

Acute pulmonary edema

• Severe dyspnea +cough (frothy blood tinged) expecturation +crepitation + tachcardia + tachypnea.

Cardiac disorders manifesting as PE:Atrial outflow obstruction: • due to mitral stenosis or, in rare cases, atrial myxoma, thrombosis of a prosthetic

valve• Mitral stenosis may gradually cause pulmonary edema. Other causes of CPE often

accompany mitral stenosis in acute CPE; an example is decreased LV filling because of tachycardia in arrhythmia (eg, atrial fibrillation) or fever.

New-onset rapid atrial fibrillation and ventricular tachycardiaAcute volume overload: Ventricular septal rupture, aortic insufficiency, and

mitral regurgitation following MI

Acute exacerbation of LV systolic dysfunction:myocardial infarction (MI)Patient noncompliance with dietary restrictions (eg, dietary salt restrictions)Patient noncompliance with medications (eg, diuretics)Severe anemiaSepsisThyrotoxicosisMyocarditisMyocardial toxins (eg, alcohol, cocaine, chemotherapeutic agents such as Adriamycin]

Hemoptysis• Causes: Congestive heart failure, left ventricular

dysfunction, mitral valve stenosis• How long have you been coughing up blood?

duration• How often do you cough up blood? frequency• Do you have chest pain when you cough up

blood? Other associated symptoms• How much blood do you cough up? amount• Anticoagulant use???

Cough expectoration

• Cough is a pulmonary rather than cardiac cause but can be due to PVC

• Frothy, blood tinged• Dry cough: ACEIs

SVC

Systemic congestion• In right ventricular failure.• Manifestations:

1. Oedema L.L. usually before ascites2. Hepatic congestion: Pain in right hypochondrium +

Jaundice. 3. G.I.T congestion = Dyspepsia.

• Ascites precox = ascites before LL oedema in cases of pericardial & tricuspid diseases.

• Cardiac edema: bilateral pitting painless dependent.• If JVP not elevated : it is not cardiac edema

• Do you have swelling in your legs?• When did you first notice the swelling?• Did it appear suddenly or gradually?• Is the swelling worse in the morning or evening?• Does the swelling decrease after a night's sleep?• Do you shortness of breath associated with the swelling?• Have you noticed any change in your weight?• Does elevating your feel make the swelling go down?• Do you have pain in your legs associated with the swelling?• Do both legs swell equally?• Are you taking any medications, if so, which ones?

Causes of unilateral LL edema

• DVT• Cellulitis• Trauma• Immobility hemiplegia• lymphedema

Causes of bilateral LL edema

• Most common: chronic venous insufficiency

• Heart failure• Nephrotic, cirrhosis, nutritional

hypoalbuminemia• IVC obstruction• Lymphedema pelvic tumor• immobility

PALPITATION

PALPITATION

• Palpitation is the sensation of the heart beating in the chest.

• Patients often use terms such as thumping, pounding, fluttering, jumping, racing and skipping a beat.

• Ask patients to tap out, with their fingers, the pattern of palpitation they experience. This helps to clarify the rate and rhythm.

Ask about• Regular or not• At rest / exercise• Onset offset duration• specific triggers of exercise, alcohol, caffeine• Relieving factors: vagal stimulation, exercise• Associated symptoms:

– Dizziness– Syncope– Sweating, flushing– chest pain,

• Etiology: thyroid illness, anxiety, heart disease, medications

example:

• Rapid heart rate. e.g.: Sinus or paroxysmal tachycardia.

• Forcible heart contraction (volume overload).e.g.: A.I or M.I

• Irregular heart. e.g.: extrasystole or A.F

CHEST PAIN

Chest Pain

cardiac Non cardiac

Ask about• Where is the pain?• When did the pain first start? How long does it last ?• Does the pain radiate, if so where?• How often do you have the pain?• How would you describe the pain - burning, pressing, stabbing,

crushing, dull, aching, throbbing, sharp, constricting?• Does the pain occur at rest, with exertion, with stress, after eating,

when moving your arms?• How was the pain relieved?• Do you have any other symptoms with the pain such as shortness of

breath, palpitations, nausea, vomiting, coughing, fever, leg pain ?

Angina pectoris:• Site: retrosternal central , radiates to arm,

epigastrium, neck• tightness or heaviness and it is usually not

severe• Precipitated by exercise, walking uphill, lifting

heavy object, cold weather, heavy meal or emotion

• Relieved by rest, nitrates• 2-10 minutes• Associated with dyspnea

Radiation of anngina

Myocardial infarction• Site, radiation as angina• More severe and prolonged• Often no obvious precipitant• Not relieved by rest, nitrates• Associated with Increased sympathetic

activity, sense of impending death, Nausea and vomiting, sweating, pallor

• Pain absent in 30% of cases

Pericardial pain• Retrosternal, may radiate to left shoulder or back• May be preceded by a flu like illness (prodrome), gradual

onset• May be stabbing, stitching or sharp, rarely as tight or heavy• Made worse by changes in posture (leaning forward),

respiration• Helped by Analgesics, especially non-steroidal anti-

inflammatory drugs • Accompanied by Pericardial rub• Causes: pericarditis (MI, viral infection, autoimmune,

radiotherapy, after surgery, catheter ablation, angiography)

Aortic dissection • sudden • first felt between shoulder blades, and/or behind the

sternum• Very severe pain, often described as 'tearing‘ associated

with autonomic stimulation and syncope• Risk factors: Hypertension, age, smoking, marfan.• major branches may also be involved leading to MI,

stroke, MVO, renal infarction, LL ischemia, UL asymmetrical pulse,ischemia

Oesophageal pain• Causes:Spasm, GERD, HH• Retrosternal or epigastric, sometimes radiates to

arm or back• Burning• Often wakes patient from sleep• Sometimes related to heartburn• Often relieved by nitrates but not rest• Variable duration• More at night

LOW COP

Causes of low COP

Stenotic valve lesions (MS, AS, TS, PS)

Pulmonary embolism, pulmonary hypertension

↓cariac filling dt ↓VR e.g hypovolemia

↓cariac filling dt diastolic relaxation constrictive pericarditis, restrictive

cardiomyopathy

arrhythmia

Heart failure

Manifest as• Easy fatigue• Claudication• Oliguria• Dizziness• Syncope• Anginal pain• Lack of concentration• Headache• Blurring of vision

Fatigue

• How long have you felt fatigued?• Did the fatigue come on suddenly or

gradually?• Do you feel tired all day or only in the

morning and/or evening?• Do you feel more tired at home or at work?• Is your fatigue relieved by rest?• When do you feel least tired?

syncope• How often do you faint (or feel like you are going to

faint)?• What are you doing when you faint (or feel like you are

going to faint)?• Have you ever lost consciousness?• Does the fainting (of feeling like you are going to faint)

occur suddenly?• In what position were you when you fainted (or felt like

you were going to faint)?• Have you noticed anything that seem to be associated

with the fainting (feeling like you are going to faint), for example, chest pain, irregular heart beat, nausea, confusion, hunger, tingling, or numbness?

CYANOSIS

Cyanosis• Cyanosis is bluish discoloration of lips, finger

tips and mucous membranes due to increased levels of deoxygenated hemoglobin in the capillary blood above 5 g/dL

• Cyanosis is manifested from birth in conditions like transposition of great vessels and tricuspid atresia.

• Cyanosis setting in after six months of age is the picture in tetralogy of Fallot (TOF).

• Onset of cyanosis between 5 and 20 years is suggestive of Eisenmenger’s reaction. When patent ductus arteriosus (PDA) goes in for Eisenmenger’s reaction,

• Where is the bluish color skin?• How long have you noticed it?• Did it seem to happen suddenly or gradually?• What type of work do you do?• Does anyone else in your family has this condition?• What makes the bluish skin color better or worse?

(exertional, at rest, spells)• Have you had any chest pain, cough, or bleeding

associated with the bluish color skin?

• Differential central cyanosis: in the lower half of the body only

• PDA with reversed shunt.• PDA with coarctation of aorta.

JAUNDICE

Jaundice in a Cardiac Case1. Hemolytic:In case of pulmonary infarction or due to mechanical haemolysis

of RBCs on artificial valves.2. Hepatocellular:Due to marked congestion of the liver, also late with cardiac

cirrhosis.3. Obstructive:Compression of bile canaliculi by the congested liver leading to

cholestasis.4. Associated:

The commonest (e.g. viral hepatitis).

FEVER

Fever in a Cardiac Case– Endocardium:

• Rh fever or Rh activity. • Infective endocarditis

– Myocardium:• Myocardial infarction.• Myocarditis

– pericardium• Acute pericarditis.• Pericardial effusion

– Vessels:• Deep venous thrombosis.• Thrombophelebitis

– Associated conditions• Pulmonary infarction.• Chest infection• Pulmonary embolism

EMBOLIC MANIFESTATIONS

source

• Left atrium : MS, AF• Left ventricle: MI• Prosthetic valve: IEC• Aorta: athermatous plaque

effects

• Hemiplegia• Blindness• Painless heamaturia• IO acute abdomen• Limb ischemia

HYPERTENSION

hypertension• No symptoms suggest the diagnosis of

hypertension, only history of regular use of anti hypertensive drug.

• Asymptomatic• Headache.• Blurring of vision.• Tinnitus.• Epistaxis.

PRESSURE MANIFESTATIONS

Causes in cardiac case

• Enlarged LA due to MS or MRManifest as:• Dysphagia: esophagus• Dyspnea: bronchi• Brassy cough: trachea• Hoarseness of voice: Lt recurrent

laryngeal N • Facial , UL edema, Cyanosis: SVC