Cardiovascular System
28. Subjective examination of the patient with cardiovascular diseases.
a) Complaints and their characteristics
Dyspnea – sign of developing circulatory insufficiency
Initial stage of heart failure : dyspnoe develops only during exercise, such as ascending
stairs, during fast walk
Second stage : mildly increased physical activity, during talking, after meal, or during
normal walk
In advance case : dyspnoe at rest
Exertional dyspnea:
Elevated left ventricular (LV) pressure:
1. LV systolic dysfunction
2. LV diastolic dysfunction (hypertrophy, fibrosis, pericardial disease)
3. Valvular obstruction
Elevated pulmonary venous pressure
Hypoxia
Pulmonary edema (left atrial hypertension)
Hypoxia (pulmonary edema or intracardiac shunting)
Orthopnea – dyspnea in recumbency
Paroxismal nocturnal dyspnea (30 min. – 2 hours after going to bed, reliaved by sitting up
or standing up)
Asphyxia – cardiac asthma
Arises suddenly, at rest, or soon after physical or emotional stress, sometimes during
night sleep
In paroxysmal attack of cardiac asthma, patient would complain of acute lack of air,
respiration become stertorous, sputum is foamy with traces of blood
Chest pain
Myocardial ischemia – pain short or within 20-30 min.
Sense of anxiety
Retrosternal pain
Radiation to the throat, lower jaw, shoulders, inner arm, upper abdomen, back
1) ischemic cardiac chest pain
Location : central, diffuse
Radiation : jaw, neck, shoulder, left arm, left scapula, back, left sternum
Character : tight, squeezing, catching
Precipitation : by exertion or emotion
Relieving factor : Rest, respond to nitrates
Associated features : breathlessness
Page 1 of 120
, 2) non cardiac chest pain
Location : peripheral, localized
Radiation : other or no radiation,
Character : sharp, stabbing, catching
Precipitation : spontaneous, not related to exertion, provoked by posture, respiration or
palpation
Relieving factor : not relieved by rest, no response to nitrates
Associated symptoms : respiratory, gastrointestinal, locomotor or psychological
Palpitation – accelerated and intensified heart contraction
Its determined by increased excitability of patient nerve’s apparatus that controls the
heart activity
It’s a sign of affection of heart muscles (myocarditis, myocardiac infarction, congenital
heart disease)
Arise as a reflex in diseases of some other organs, in fever, anaemia, neurosis,
hyperthyroidism, after administration of medicinal preparations (atropine sulphate)
Occurs in healthy person under heavy physical load, during running, emotional stress,
smoking or coffee abuse
Palpitation – increased stroke volume or cardiac arrhythmias:
Ventricular extrasystole – “skipped” beat, feeling of sinking, stoppage of heart. Occurs
during exercise or at rest
Supraventricular extrasystole – rapid or irregular palpitation or “fluttering”
Syncope
Syncope – SA node arrest, exit block, AV conduction block (Morgagni-Adams-Stokes
syndrome), ventricular tachycardia or fibrillation; aortic valve disease & hypertrophic
obstructive cardiomyopathy
Fatigue
Cough- congestion in lesser circulations
Usually dry, sometimes small amount of sputum
Haemoptysis : in grave heart disease
Due to congestion in lesser circulations
Mostly occur in patients with mitral heart disease
May occur in embolism of the pulmonary artery
Oedema – venous congestion in greater circulations
Develops only in evening and resolves during night sleep
Occus in malleolus region and on the dorsal side of the foot
Then shins are affected
Heaviness in the abdomen and its enlargement – formation of ascites
Poor apetite – due to disorder of blood circulation in the abdominal organs
Nausea
Vomiting
Page 2 of 120
, Swelling of the abdomen
Deranged sleep
High fever in some diseases such as myocarditis and endocarditis
b) Difference between bronchial and cardiac asthma
Bronchial asthma is another name for the common form of asthma. The term ‘bronchial’
is occasionally used to differentiate it from what doctors sometimes call ‘cardiac’ asthma,
which is not true asthma but breathing difficulties caused by heart failure. Although the
two conditions have similar symptoms, including shortness of breath and wheezing (a
whistling sound in the chest), they have quite different causes.
Cardiac asthma
In cardiac asthma, the reduced pumping efficiency of the left side of the heart leads to a
build up of fluid in the lungs (pulmonary oedema). This fluid build-up can cause
breathlessness and wheezing. Cardiac asthma has very similar symptoms to bronchial
asthma. The main symptoms and signs of cardiac asthma are:
shortness of breath with or without wheezing;
cough;
rapid and shallow breathing;
an increase in blood pressure and heart rate; and
a feeling of apprehension.
The pattern of shortness of breath helps doctors determine which type of asthma you have
— people with bronchial asthma tend to experience shortness of breath early in the
morning, whereas people with heart failure and cardiac asthma often find they wake up
breathless a few hours after going to bed, and have to sit upright to catch their breath.
This is because in people with heart failure, lying down for prolonged periods will cause
fluid to accumulate in the lungs leading to shortness of breath.
Both bronchial and cardiac asthma can make people short of breath when they exert
themselves. In bronchial asthma, symptoms are usually brought on by vigorous exercise
and tend to be worse after the exercise than during it. On the other hand, cardiac asthma
tends to happen during less vigorous exertion — someone with heart failure can find
themselves short of breath while climbing stairs, or in severe cases, while getting dressed.
People with heart failure also often have problems with swollen ankles that worsen
during the course of the day. They may also feel very tired, put on weight and have to
urinate frequently.
Cardiac asthma can be a life-threatening condition
Bronchial asthma
Page 3 of 120
, For most people with bronchial asthma, the pattern is periodic attacks of wheezing
alternating with periods of quite normal breathing. However, some people with bronchial
asthma alternate between chronic (long-term) shortness of breath and episodes in which
they feel even more breathless than usual.
Risks for developing bronchial asthma include being a person who is genetically
susceptible to asthma and being exposed early in life to indoor allergens, such as dust
mites and cockroaches, and having a family history of asthma or allergy. Exposure to the
effects of tobacco smoke before birth or during early childhood also increases the risk of
developing bronchial asthma.
Bronchial asthma attacks can be triggered (precipitated or aggravated) by various factors,
including:
respiratory tract infections;
cold weather;
exercise;
allergens (substances that trigger an allergic reaction) such as pollen and house dust mites;
cigarette smoke and other air pollutants; and
stress.
Some people can develop asthma due to an intolerance that their body develops to aspirin
or other non-steroidal anti-inflammatory drugs (NSAIDs) (in which case exposure to
aspirin or NSAIDs can trigger an asthma attack). Other medicines, such as beta-blockers,
can worsen or unmask bronchial asthma. Other people develop asthma due to an allergy
that they develop to certain chemicals in the workplace (this is called ‘occupational
asthma’, in which case exposure to the chemical triggers an asthma attack).
The symptoms of bronchial asthma include:
a feeling of tightness in the chest;
difficulty in breathing or shortness of breath;
wheezing; and
coughing (particularly at night).
Although there is currently no cure for bronchial asthma, it can be controlled.
c) Difference between neurotic and true angina pectoris
1) neurotic angina pectoris
Seat of pain : left breast nipple (above and below)
Pain character : squeezing, boring, stabbing, intensifying, during breathing
Speed of attack progress : monotonous, slowly increasing and gradually decreasing, in
some cases instantaneous
Pain radiation : Most commonly none, may radiate into left scapula and armpit
Preceding events : Attack develops at rest or in emotional stress
Pain duration : Persist for hour, in some cases instantaneous
Page 4 of 120
28. Subjective examination of the patient with cardiovascular diseases.
a) Complaints and their characteristics
Dyspnea – sign of developing circulatory insufficiency
Initial stage of heart failure : dyspnoe develops only during exercise, such as ascending
stairs, during fast walk
Second stage : mildly increased physical activity, during talking, after meal, or during
normal walk
In advance case : dyspnoe at rest
Exertional dyspnea:
Elevated left ventricular (LV) pressure:
1. LV systolic dysfunction
2. LV diastolic dysfunction (hypertrophy, fibrosis, pericardial disease)
3. Valvular obstruction
Elevated pulmonary venous pressure
Hypoxia
Pulmonary edema (left atrial hypertension)
Hypoxia (pulmonary edema or intracardiac shunting)
Orthopnea – dyspnea in recumbency
Paroxismal nocturnal dyspnea (30 min. – 2 hours after going to bed, reliaved by sitting up
or standing up)
Asphyxia – cardiac asthma
Arises suddenly, at rest, or soon after physical or emotional stress, sometimes during
night sleep
In paroxysmal attack of cardiac asthma, patient would complain of acute lack of air,
respiration become stertorous, sputum is foamy with traces of blood
Chest pain
Myocardial ischemia – pain short or within 20-30 min.
Sense of anxiety
Retrosternal pain
Radiation to the throat, lower jaw, shoulders, inner arm, upper abdomen, back
1) ischemic cardiac chest pain
Location : central, diffuse
Radiation : jaw, neck, shoulder, left arm, left scapula, back, left sternum
Character : tight, squeezing, catching
Precipitation : by exertion or emotion
Relieving factor : Rest, respond to nitrates
Associated features : breathlessness
Page 1 of 120
, 2) non cardiac chest pain
Location : peripheral, localized
Radiation : other or no radiation,
Character : sharp, stabbing, catching
Precipitation : spontaneous, not related to exertion, provoked by posture, respiration or
palpation
Relieving factor : not relieved by rest, no response to nitrates
Associated symptoms : respiratory, gastrointestinal, locomotor or psychological
Palpitation – accelerated and intensified heart contraction
Its determined by increased excitability of patient nerve’s apparatus that controls the
heart activity
It’s a sign of affection of heart muscles (myocarditis, myocardiac infarction, congenital
heart disease)
Arise as a reflex in diseases of some other organs, in fever, anaemia, neurosis,
hyperthyroidism, after administration of medicinal preparations (atropine sulphate)
Occurs in healthy person under heavy physical load, during running, emotional stress,
smoking or coffee abuse
Palpitation – increased stroke volume or cardiac arrhythmias:
Ventricular extrasystole – “skipped” beat, feeling of sinking, stoppage of heart. Occurs
during exercise or at rest
Supraventricular extrasystole – rapid or irregular palpitation or “fluttering”
Syncope
Syncope – SA node arrest, exit block, AV conduction block (Morgagni-Adams-Stokes
syndrome), ventricular tachycardia or fibrillation; aortic valve disease & hypertrophic
obstructive cardiomyopathy
Fatigue
Cough- congestion in lesser circulations
Usually dry, sometimes small amount of sputum
Haemoptysis : in grave heart disease
Due to congestion in lesser circulations
Mostly occur in patients with mitral heart disease
May occur in embolism of the pulmonary artery
Oedema – venous congestion in greater circulations
Develops only in evening and resolves during night sleep
Occus in malleolus region and on the dorsal side of the foot
Then shins are affected
Heaviness in the abdomen and its enlargement – formation of ascites
Poor apetite – due to disorder of blood circulation in the abdominal organs
Nausea
Vomiting
Page 2 of 120
, Swelling of the abdomen
Deranged sleep
High fever in some diseases such as myocarditis and endocarditis
b) Difference between bronchial and cardiac asthma
Bronchial asthma is another name for the common form of asthma. The term ‘bronchial’
is occasionally used to differentiate it from what doctors sometimes call ‘cardiac’ asthma,
which is not true asthma but breathing difficulties caused by heart failure. Although the
two conditions have similar symptoms, including shortness of breath and wheezing (a
whistling sound in the chest), they have quite different causes.
Cardiac asthma
In cardiac asthma, the reduced pumping efficiency of the left side of the heart leads to a
build up of fluid in the lungs (pulmonary oedema). This fluid build-up can cause
breathlessness and wheezing. Cardiac asthma has very similar symptoms to bronchial
asthma. The main symptoms and signs of cardiac asthma are:
shortness of breath with or without wheezing;
cough;
rapid and shallow breathing;
an increase in blood pressure and heart rate; and
a feeling of apprehension.
The pattern of shortness of breath helps doctors determine which type of asthma you have
— people with bronchial asthma tend to experience shortness of breath early in the
morning, whereas people with heart failure and cardiac asthma often find they wake up
breathless a few hours after going to bed, and have to sit upright to catch their breath.
This is because in people with heart failure, lying down for prolonged periods will cause
fluid to accumulate in the lungs leading to shortness of breath.
Both bronchial and cardiac asthma can make people short of breath when they exert
themselves. In bronchial asthma, symptoms are usually brought on by vigorous exercise
and tend to be worse after the exercise than during it. On the other hand, cardiac asthma
tends to happen during less vigorous exertion — someone with heart failure can find
themselves short of breath while climbing stairs, or in severe cases, while getting dressed.
People with heart failure also often have problems with swollen ankles that worsen
during the course of the day. They may also feel very tired, put on weight and have to
urinate frequently.
Cardiac asthma can be a life-threatening condition
Bronchial asthma
Page 3 of 120
, For most people with bronchial asthma, the pattern is periodic attacks of wheezing
alternating with periods of quite normal breathing. However, some people with bronchial
asthma alternate between chronic (long-term) shortness of breath and episodes in which
they feel even more breathless than usual.
Risks for developing bronchial asthma include being a person who is genetically
susceptible to asthma and being exposed early in life to indoor allergens, such as dust
mites and cockroaches, and having a family history of asthma or allergy. Exposure to the
effects of tobacco smoke before birth or during early childhood also increases the risk of
developing bronchial asthma.
Bronchial asthma attacks can be triggered (precipitated or aggravated) by various factors,
including:
respiratory tract infections;
cold weather;
exercise;
allergens (substances that trigger an allergic reaction) such as pollen and house dust mites;
cigarette smoke and other air pollutants; and
stress.
Some people can develop asthma due to an intolerance that their body develops to aspirin
or other non-steroidal anti-inflammatory drugs (NSAIDs) (in which case exposure to
aspirin or NSAIDs can trigger an asthma attack). Other medicines, such as beta-blockers,
can worsen or unmask bronchial asthma. Other people develop asthma due to an allergy
that they develop to certain chemicals in the workplace (this is called ‘occupational
asthma’, in which case exposure to the chemical triggers an asthma attack).
The symptoms of bronchial asthma include:
a feeling of tightness in the chest;
difficulty in breathing or shortness of breath;
wheezing; and
coughing (particularly at night).
Although there is currently no cure for bronchial asthma, it can be controlled.
c) Difference between neurotic and true angina pectoris
1) neurotic angina pectoris
Seat of pain : left breast nipple (above and below)
Pain character : squeezing, boring, stabbing, intensifying, during breathing
Speed of attack progress : monotonous, slowly increasing and gradually decreasing, in
some cases instantaneous
Pain radiation : Most commonly none, may radiate into left scapula and armpit
Preceding events : Attack develops at rest or in emotional stress
Pain duration : Persist for hour, in some cases instantaneous
Page 4 of 120
