Clinical Assessment

part 2
Dr Doha Rasheedy
Lecturer of Geriatric Medicine
Department of Geriatric and Gerontology
Ain 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.ND
Cough and expectoration - Haemoptysis.
Acute pulmonary oedema.

DYSPNEA
an uncomfortable subjective awareness of
ones 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 PND
1. 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 tachycardia

Acute 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 anemia
Sepsis
Thyrotoxicosis
Myocarditis
Myocardial 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.
2.
3.

Oedema L.L. usually before ascites

Hepatic congestion: Pain in right hypochondrium +
Jaundice.
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 antiinflammatory 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

Stenotic valve lesions (MS, AS, TS,

PS)
Pulmonary embolism, pulmonary
hypertension
cariac filling dt VR e.g
hypovolemia
Causes of low COP
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 Eisenmengers reaction. When patent
ductus arteriosus (PDA) goes in for Eisenmengers
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 Case

1. 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 MR

Manifest as:
Dysphagia: esophagus
Dyspnea: bronchi
Brassy cough: trachea
Hoarseness of voice: Lt recurrent
laryngeal N
Facial , UL edema, Cyanosis: SVC

THANK YOU