Clinical Examination Dr Osama Mahmoud

Cardlao 'heet

2. Withdrawal of adrenergic help: (Sympathetic drive)

This occurs during sleep due to vagal predominance, and causes further weakness of the force of left ventricular contraction.

3. Bad dreams:

Will lead to tachycardia and increase of blood pressure.

4. Slipping of the head from over the pillow 11

Causes of PND, cardiac asthma and pulmonary edema.

is a gradual process, so protective mechanisms will occur as follows:

a. Opening of the anastomosis between pulmonary and bronchial veins, with shunting of the blood from the pulmonary veins to the bronchial veins with formation of bronchial varices which may rupture on coughing or straining ~ haemoptysis. (Pulmonary or bronchial apoplexy)

c.Vasoconstriction of the pulmonary arterioles will decrease pulmonary congestion but leading to pulmonary hypertension (PVC ~ reflex V.C of pulmonary arterioles).

d.Increased thickness of the walls of pulmonary vessels decreasing the

process of transudation.

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Cardiac~~~~~sheet

American functional classification of heart .di

II. Haemopt sis

This is a profuse frank haemoptysis occurring mainly in M.S. due to rupture of bronchial varices with coughing or straining.

2. Chest infection:

This occurs more commonly with M.S. than with L.V.F as there is chronic congestion of the lung leading to decrease the lung defense, irritation and devitalization of bronchial mucosa occurs with super imposed infection with production of mucopurulent sputum streaked or tinged with blood due to rupture of bronchial capillaries.

5. Associated chest conditions.

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Cardiac sheet

III. Cardiac Oedema

Oedema means swelling of the tissues due to an increase in the interstitial fluid.

Causes of cardiac oedema:

Characteristics of Cardiac Oedema:

1.Occurs in the dependent parts of the.body:

*Ankle oedema: in ambulant patients.

*Sacral oedema: in bed ridden patients.

2.Bilateral, but one sides may be affected more due to:

*Deep venous thrombosis.

*Postural, in patients sleeping on one side.

3.It is always pitting oedema.

4.Oedema of lower limbs always precedes appearance of ascites, except cases of "Ascites praecox" where ascites occurs first, causes:

IThe most important cause of ascitis precox is constrictive ericarditis.

5. Other features of cardiac disease.

Differential Diagnosis of Cardiac Oedema:

(1) From other causes of generalized oedema:

. Renal Oedema:

This occurs in nephritic or nephrotic syndromes. Oedema occurs first in the eye lids and is associated with features of renal disease .

. Hepatic oedema:

Oedema of lower limbs and ascites it is also associated with features of liver disease e.g.: cirrhosis, splenomegaly, jaundice.

I~Nutrition_~f~dema:

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Cardiac sheet

2.Local causes of oedema:

a.Angioneurotic oedema (non pitting oedema):

This allergic oedema occurs with relation to certain factors, as eating certain

c. Lymphatic obstruction:

@ Leading to non pitting oedema. d. Venous obstruction:

@Dilated veins will be present over the limb. e.g.: in DVT of lower limb.

e.Orthostatic oedema:

Due to prolonged sitting, or standing up (this may occur in normal persons.)

Pathogenesis of cardiac oedema:

1. Increased venous pressure: (S.V.C.)

Due to accumulation of blood in systemic circulation in the cases of right sided heart failure or pericardial disease causing S.V.C.

2. Salt and water retention: Due to:

3.Hypoalbuminaemia may occur as a result of long standing GIT congestion which leads to decreased intake and absorption, also leading to protein losing enteropathy.

4. Capillary permeability is increased due to tissue hypoxia.

5. Resistance to the action of the atrial natriuretic peptide (ANP)?

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Cardiac sheet

~ Causes of Unilateral Oedema in Cardiac Patient:

1.Positional (patient usually laying on one side).

2.Deep vein thrombosis.

IVLow C.O:P.S mptoms

Easy fatigue - coldness - dizziness - oliguria - sweating - syncopal attacks, anginal pain and claudication pain. The symptoms are usually exertional.

Causes:

~ Stenotic lesion of the heart e.g.: A.S, M.S.

~Heart failure.

~Pericardial effusion or constrictive pericarditis.

(Exertional syncope may be suggestive of stenotic heart lesion especially A.S.)

. S mptoms' of H pertenslon

Usually it is asymptomatic so it is called the silent killer. o Headache usually occipital especially in the morning.

@Blurring of vision:

- These (1,2) symptoms are only suggestive and can occur in low C.O.P. states.

@) Manifestations of the cause or complications of hypertension.

The eye may be affected in various forms of C.V.S. diseases:

1. Sudden unilateral impairment of vision due to retinal haemorrhage in severe hypertension or from embolic manifestations.

2. Disturbance of vision in both eyes may be due to cerebral embolism.

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Cardiac sheet

I. Embolic manifestations

1.Hemiplegia or hemiparesis.

2.Painless Haematuria.

3.Acute abdomen (mesenteric occlusion).

4.Sudden onset of coldness of a limb (acute ischaemia).

Causes: (The heart as a source of embolization)

;,. M.S. with A.F.

Y Infective endocarditis.

,.. Mural thrombosis on top of myocardial infarction. ;,. Artificial valves.

;,. Dilated cardiomyopathy.

II.S ncope

Definition: Sudden transient complete loss of consciousness due to reduced cerebral blood flow. If the ischaemia prolongs convulsions may occur. It is associated with postural collapse with spontaneous recovery.

N.B.: presyncope refers to lack of strength with sensation of impending loss of consciousness (faintness).

Causes:

. Cardiac 5

o Resistance to the blood flow .e.g.: left ventricular outflow tract obstruction. e.g.: A.S. or HOeM. (Exertional syncope)

@ Ball and valve embolus and left atrial myxoma. (Positional syncope). e Adams-stocks, severe bradycardia or tachycardia. (syncope at rest)

e Acute diminution of venous return, as in hemorrhage, extensive burns or excessive peripheral vasodilatation.

~.~~~_~oif!~t~~syncoEi]

o Vasovagal attack: (Simple faints)

Exposure to fear, emotions or bad sights may cause excessive

vagal stimulation leading to marked bradycardia and syncope. The patient will be pale with sweating, marked bradycardia and low BP.

6, arotid sinus syndrome:

Stimulatior (If hypersensitive carotid sinus e.q. during shaving or carotid massaqe causesvaqal stimulation and syncope

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III. Palpitation

Awareness of heart beats, terms such as thumbing, pounding, fluttering, jumping, racing and bumping are often used by the patient

Causes:

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

*

* Arrhythmia means a change of heart rate or rhythm.

* Arrhythmia may be manifested by palpitation, syncope or may be asymptomatic. Marked tachycardia or marked bradycardia usually. leading to low C.O.P.

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Cardiae sheet

IX. Chest Pain

(Cardiovascular causes)

1.Coronary heart disease:

a.Angina pectoris.

b.Myocardial infarction.

2.Pericardial disease:

a.Acute pericarditis.

b.Pericardial effusion.

3.Pulmonary embolism:

a.Massive pulmonary embolism.

b.pulmonary infarction.

4.Aortic aneurysm:

a.Aortalgia: Retrosternal sawing pain due to stretch of sympathetic fibers

around aorta.

b.Neuralgia: Brachial or intercostal pain, due to compression of nerve roots.

5.Dissecting aneurysm of the aorta:

a.Dissection of ascending aorta:

Sudden severe retro - sternal pain similar to myocardial infarction.

6.Mitral valve prolapse (young female)

7.Pain of cardiac neurosis:

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Cardiac sheet

~~Never to be < 30 seconds.

Causes of anginal pain in young person: o Aortic vale disease.

Angina versus myocardial infraction

. Fever in a Cardiac Case

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