Symptoms of Cardiac & Respiratory Diseases

Mohammed Zeitoun
Metabolism Department Alexandria University

Dyspnea

Dyspnea
Definition:

Subjective feeling of difficulty in breathing

concerning the rate, rhythm or depth of respiration.

How do the patient describe dyspnea

Cannot get enough air.

Air does not go all the way down.

Tightness in the chest.

Grades of Dyspnea
Grade I: Difficulty of breathing on doing MORE
than the usual daily effort (Physiological).

Grade II: Difficulty of breathing on doing the

usual daily effort.

Grade III: Difficulty of breathing on doing LESS

than the usual daily effort.

Grade IV: Difficulty of breathing at rest.

Dyspnea
Is the dyspnea related only to exertion? How far can the patient walk at a normal
pace?

Is there is variability in the symptom?

Any times of the day or night that are

usually worse that others?

Types of Dyspnea
Exertional Dyspnea: Dyspnea on Effort Orthopnea. Paroxysmal Nocturnal Dyspnea (PND).

Causes of Dyspnea
Physiological:
With Exercise.

Pathological:
Cardiac Causes: e.g. Left Heart Failure, Pericardial
Effusion.

Pulmonary Causes: ANY Chest Disease e.g.

Pneumonia, Bronchial Asthma, Lung Collapse, Pulmonary Fibrosis, Pulmonary Embolism, . .

Psychogenic: (Hysterical)
History of emotional stress, commonly in females. Diagnosed by Exclusion of Organic Causes.

Causes of Dyspnea
Pulmonary
Pulmonary embolism Obstructive lung disease Interstitial lung disease Pleural effusion

Pneumonia
Acute Bronchitis

Causes of Dyspnea
Cardiac:
Congestive heart failure. Pericardial effusion and tamponade

Psychogenic:

Anxiety.
Hysteria.

Toxic dyspnea
The overdose of morphine and pentobarbital can depress respiratory center causing slow respiration.

Haematologicl dyspnea
The decrease of oxygen-carrying capacity and oxygen content develop abnormal respiration and increase heart rate, such as severe anemia, carbon monoxide.

Differential Diagnosis
Composed of four general categories
Cardiac Pulmonary Mixed cardiac or pulmonary non-cardiac or non-pulmonary

Noncardiac or Nonpulmonary Etiology

Metabolic conditions (e.g. acidosis) Pain Trauma Neuromuscular disorders Functional (anxiety,panic disorders,
hyperventilation)

Chemical exposure

Accompanying symptoms Paroxysmal dyspnea with wheezing

It is present in: Bronchial asthma.

Cardiac asthma.

Accompanying symptoms
Dyspnea with chest pain
It is frequently observed in:
Lobar pneumonia. Pulmonary infarction. Spontaneous pneumothorax. Acute myocardial infarction.

Accompanying symptoms
Dyspnea with fever
It is frequently observed in:
Pneumonia Lung abscess. Pleurisy Acute pericarditis

Accompanying symptoms
Dyspnea with cough & purulent sputum
It is frequently observed in:
Chronic bronchitis. Emphysema. Purulent pneumonia Lung abscess.

Accompanying symptoms
Dyspnea with large amount of

foamy sputum
is often seen in: Acute left ventricular heart failure Organo-phosphorus poisoning.

Accompanying symptoms
Dyspnea with coma
is often seen in: Cerebral hemorrhage.

Uremia.
Diabetic ketoacidosis.

Orthopnea
Definition: Difficulty in breathing in the supine
position; relived by sitting up.

Mechanism:

Reduce the degree of pulmonary congestion by pooling blood in the lower extremities Improve the diaphragmatic movement

Orthopnea

Paroxysmal nocturnal dyspnea

Definition: respiratory distress that awakens
patients from sleep in hunger to air (usually occurs 2 to 4 hours after onset of sleep) compels the patient to sit upright or stand.

Diagnostic Tests
Chest radiographs Electrocardiograph Screening spirometry

 In cases where test results inconclusive

Complete PFTs
ABGs

EKG
Exercise treadmill testing.

 There is no single specific treatment for dyspnea.

Treatment varies according to patients condition

Chief complaint. History. Exam. Laboratory & radiological study results.

Chest Pain

Chest Pain
Comment on Chest pain: Site. Radiation. Character. Duration. Precipitating Factors. Relieving Factors. Associated Symptoms.

Chest Pain
e.g. Anginal Pain: Site: Retrosternal. Radiation: Left Shoulder, Left Arm, neck or jaw. Character: Tightness, heaviness or Squeezing. Duration: Minutes Precipitating Factors: Exercise or Emotional Stress Relieving Factors: Rest or SL Nitroglycerine Associated Symptoms: Sweating & Palpitation

Chest Pain
e.g. Anginal Pain: A careful history is the single most important
means of diagnosing angina.

The typical patient is a middle-aged or elderly

man or woman with one or more of the cardiovascular risk factors (smoking, hypertension or dyslipidemia)

Causes of Chest Pain

Cardiac Causes:

CHD: Angina Pectoris & Myocardial Infarction. Pericarditis. Dissecting Aortic Aneurysm.

Causes of Chest Pain

Non-Cardiac Causes:
Chest Wall: e.g. Fracture Ribs, Myositis, Neuralgia.

Pleuro-Pulmonary: e.g. Pleurisy, Pneumothorax,

Pulmonary Embolism.

Mediastinum: e.g. Mediastinitis, Oesophageal

malignancy, Oesophageal Spasm.

Diaphragm: e.g. hiatus Hernia Abdomen: e.g. Cholecystitis, Subphrenic Abscess.

Causes of Acute Chest Pain

CHD: Angina Pectoris & Myocardial Infarction. Acute Pericarditis

Dissecting Aortic Aneurysm. Pulmonary Embolism. Pneumothorax. Acute Pleurisy. Oesophageal Spasm.

Palpitation

Palpitation
Definition: Awareness of the heartbeat. A description of the rate and rhythm of the
palpitation is essential e.g. rapid irregular
palpitation is typical of atrial fibirllation.

syncope

Cardiac syncope
Syncope is a sudden transient loss of consciousness and postural tone with spontaneous recovery. Restoration of appropriate behavior and orientation after a syncopal episode is usually immediate. Retrograde amnesia is uncommon.

Cardiac syncope
Syncope is an important clinical problem because it is a common, costly, often disabling, may cause injury, and may be the only warning sign before sudden cardiac death ( SCD). Neuro-cardiogenic syncope may have an early warning (nausea , yawning). The patient appears pale and diaphoretic, and revive more slowly, without signs of seizure or a prolonged post-ictal state.

Cough

Cough
Definition:

Cough is an explosive expiratory maneuver that is

reflexively intended to clear the airways.

Coughing is a normal response to the presence of

mucus or other foreign material in the airway or upper airway, but persistent coughing is annoying and generally indicates irritation of the pulmonary airways.

Cough is a deep expiratory effort against a closed

glottis, which opens suddenly, with a jet of air.

Causes of Cough
Central Causes: Irritation of the Brain Stem e.g. Encephalitis, Vascular accedents, Brain tumours. Reflex Causes:

Due to Irritation of the Vagus nerve or its branches ALL Chest Diseases as Pharyngitis, Bronchitis,
Pneumonia, Lung abscess, . Hysterical Causes:

Psychogenic cough, associated with history of

emotional stress, commonly in females.

Types of Cough
Productive Cough:

It brings out sputum. It should not be suppressed.

Dry Cough:

It brings no sputum. It should be suppressed as it is useless.

Cough
How long had the cough been present? Is the cough worse at any time of day or night? Dry cough at night bronchial asthma? Is the cough aggravated by anything, for example dust pollen or cold air?

Evaluation of Cough
URI and sinus symptoms suggest postnasal drip
syndrome, but postnasal drip can causes cough without other symptoms.

Heartburn, hoarseness, and chronic nocturnal or early

morning cough, especially if no other symptoms are present, suggests GERD.

Cough after exposure to dusts or allergens suggests

Bronchial Asthma.

Chronic cough with production of purulent sputum in

smokers suggests Chronic Bbronchitis. A change in cough in these patients may, however, be an early manifestation of Lung Cancer.

Expectoration

Expectoration
Definition:

It is the passage of sputum out of the

respiratory tract.

Expectoration
Is sputum produced? What does it look like? How much is produced?

Comment on Expectoration
Amount: Per 24 hours e.g. 5CC, 15CC, 30CC, 100CC,
200CC.

Colour: White: Allergic (BA), Viral infection. Yellowish: Bacterial infection e.g. Streptococci Greenish: Pseudomonas. Black: Pneumoconiosis or Smokers.

Odour: Fetid sputum

bacteria.

indicates infection with anaerobic

Comment on Expectoration
Aspect (Consistency):
Mucoid: Bronchial Asthma. Mucopurulent: Bronchitis, Pneumonia. Purulent: Suppurative lung diseases e.g. Lung
abscess, Bronchiectasis.

Frothy Blood-tinged: Pulmonary Oedema.

Time of Occurrence: Mostly in the morning e.g. Bronchiectasis.

Comment on Expectoration
Relation to Posture:
Lung Abscess: When the patient lies on the
healthy side.

Bronchiectasis: when the patient leans forwards

especially with the head low.

Haemoptysis

Haemoptysis
Definition:
It is Coughing of Blood originating from Below
the Vocal Cords.

Bleeding originating from Above the Vocal

Cords is considered False Haemoptysis.

Haemoptysis may range from Blood-streaked

Sputum to Frank Haemoptysis.

Causes of Haemoptysis
Respiratory Causes:
Traumatic: e.g. Foreign Body. Inflammatory: - Specific: e.g. TB - Non-Specific: e.g. Bronchitis, Pneumonia,
Bronchiectasis, Lung Abscess

Neoplastic: - Benign: e.g. Bronchial Adenoma. - Malignant: e.g. Bronchogenic Carcinoma.

Vascular: - Pulmonary Embolism. - Pulmonary Oedema.

Causes of Haemoptysis
Cardio-Vascular Causes: Mitral Stenosis. Left Heart Failure. Aortic Aneurysm weeping into a bronchus.

General Causes: Haemorrhagic Diseases Haemophilia. Leukemia.

D.D. between Haemoptysis & Haematemesis

Haemoptysis
Definition Color Nature Reaction After the attack Coughing of Blood Bright Red (Oxyhaemoglobin) Frothy Alkaline Blood-tinged Sputum

Haematemesis
Vomiting of Blood Dark Brown (Acid Haematin) Mixed with Food Particles Acidic Melena

Haemoptysis
Is there is any blood in the sputum? Is it fresh or altered? How often has it been seen? For how long?

Wheezing

Wheezing
Do you hear any noises coming from the chest? Sometimes wheezing is noticed by others (especially by a partner at night when asthma is worse).

Questions ?