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Guidelines for Third-year Students of the Medical Department




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2. /11_Cardio_inquiry_2012.doc
3. /12_Pulse_BP_palp_heart_2012.doc
4. /13_Auscultation_heart_N_2012.doc
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Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines For third-year students of the medical department
Guidelines For third-year students of the medical department
Guidelines for Third-year Students of the Medical Department
Guidelines For third-year students of the medical department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department


UKRAINIAN MINISTRY OF PUBLIC HEALTH

Vinnytsya National Medical University n.a. M.I. Pyrogov


«APPROVED»

At the methodological meeting of the internal medicine propedeutics department

Chief of the department

____________ prof. Mostovoy Y.M.

«______»_______________ 20 ___ y.


Guidelines

for Third-year Students of the Medical Department



ubgect

Propedeutics of the internal medicine

Modul №

1

Enclosure module №

3

Topic

Taking history and general visual inspection patients with cardiovascular diseases. Management of the patients and writing part of the case history

Course

3

Faculty

Medical № 1



Methodical recommendations are made in accordance with educationally-qualifying descriptions and educationally-professional programs of preparation of the specialists ratified by Order MES of Ukraine from 16.05 2003 years № 239 and experimentally - curriculum, that is developed on principles of the European credit-transfer system (ECTS) and Ukraine ratified by the order of MPH of Ukraine from 31.01.2005 year № 52.


Vinnytsya- 2012

    1. Importance of the topic

Cardiovascular diseases are the most spread in the world. They are the leading cause of death. Distinguishing heart pathology is very important and every doctor must know main cardiac symptoms and can recognize patient’s appearance and complexity.


2. Concrete aims:

  1. Study principles of taking history at the patient with cardiovascular diseases

  2. Learn general examination features of patient with cardiovascular diseases

  3. Assessment of obtaining data

3. Basic training level


Previous subject

Obtained skill

Normal anatomy

Anatomy of the heart and vessels

Normal physiology

Mechanics of heart working and blood circulation

Histology

Ontogenesis of the cardiovascular system, histological structure of the heart and vessels

Boimedical physics

Principles of liquid flow in a tube

4. Task for self-depending preparation to practical training

4.1. List of the main terms that should know student preparing practical training


Term

Term

palpitation

Syncope

Angina pectoris

Cardiac edema

dizziness

acrocyanosis


4.2. Theoretical questions:

    1. Principal complaints and there refinement at patients with cardiovascular diseases.

    2. Features of disease history (anamnesis morbi) and life history (anamnesis vitae) of patients suffering from cardiovascular diseases.

    3. Peculiarities of general inspection of patients with cardiovascular diseases.

4.3. Practical task that should be performed during practical training

  1. Revealing and assessment of symptoms of cardiovascular disease

  2. Performing general visual inspection of the patients with cardiovascular diseases

  3. Assessment of obtaining finding

Topic content

The symptoms are caused by heart disease result most commonly from myocardial ischemia, from disturbance of the contraction and/or relaxation of the myocardium, from obstruction to blood flow, or from an abnormal cardiac rhythm or rate.


Complaints in the cardiovascular diseases

Specific

Nonspecific

Pain in the heart region; Intermissions; Palpitation; Dyspnea; Asphyxia; Cough; Hemoptysis; Syncope, heaviness at the right subcostal region, oedema

Fever; Sweatiness; Weight loss; Fatigue; Headache; Dizziness; Sleeplessness; Deranged vision and hearing; Voice changes; Dysphagia; Dyspepsia; Thirst; Pain in the abdomen; Pain in the joints

Specific complaints

Pain in the heart region. Pain in the region is one of the most frequent complaints of the patients in the internal diseases clinic.

Diagnostic approach to the patients with pain in the heart region

1. Location: retrosternal, in the apex region, to the left of the sternum...

2. Intensity: severe, rather intense, moderate, mild...

3. Character:

a) superficial or profound ("deep");

b) type of the pain: squeezing, pressing, stabbing, piersing, burning, boring, gnawing, feeling of tightness, shooting;

4. Frequency: seldom, every day, every week, several times a day (to indicate how many times);

5. Duration: transitory, constant, intermittent, attacks of pain (to indicate in seconds, minutes, hours);

6. Radiation: to the left shoulder, left arm, left shoulder-blade, left supraclavicular and subclavicular region, to the back, interscapular region, to the left of the neck, lower jaw, to the epigastric region, to the right half of the chest;

7. Associated features: morbid fear of death, palpitation, intermissions, dyspnoea, weakness, trembling in the body, cramps, feeling of air deficit, dizziness, excessive urination;

8. Provocation: during insignificant physical exertion - during walk: quick, ordinary, slow; ascending the stairs or hill; frosty day; in going out of doors in 10-20 minutes; emotional factors; excessive meal; after alcohol use, smoking; in considerable physical loading; without visible cause.

9. Relieving conditions: is abated by nitroglycerin (how many tablets a day, pain relieve at once, in few seconds, in few minutes); at rest; changing position; physical or emotional exertion; talking; is abated by analgetics.

A number of key characteristic help to distinguish cardiac pain from other causes

Tab.2.2. Differential diagnosis of pain in the heart region from history

Pain features

Disease

Retrosternal, constricting, feeling of heaviness, from few seconds to 15 min, radiate to the left arm, scapula, jaws, the neck, associated with morbid fear of death, comes on with exertion, is relieved by rest, is relieved by nitrates.

Favours angina pectoris (ischemic pain)

Pain as above but prolonged, continuous pain > 20-30 min, more severe, tight or burning, resist at rest, and does not respond to nitrates.

Favours myocardial infarction

Retrosternal, extremely severe, sharp and tearing, piercing, radiate to the spinal column, moves gradually along coarse of the aorta, associated with collapse, syncope, cyanosis, with very sudden onset.

Consider aortic dissection

Middle of the sternum or heart apex or entire heart region, stabbing, shooting, feeling of heaviness, persist several days or may arise in attack during inspiration, coughing, radiate to the left scapular, the neck, epigastric region, left arm, varies in intensity with movements, the phase of respiration, and under the pressure of stetoscope.

Consider pericarditis

Behind manubrium sterni, permanent, does not respond to exertion

Consider aortitis

Very variable in site and intensity, may vary with posture or movement, very commonly accompanied by local tenderness over the rib or costal cartilage.

Consider musculosceletal

cause

Intermission is solitary beats at various intervals, sometimes one, two, three, and more beats, accompanied by feeling of sinking heart, arrest, lack of air are characteristic for preliminary heart contractions, i.e. extrasystolic arrhythmia, which is often is not a consequence of anorganic heart disease but occurs in regulation disorders. It is said that the more unpleasant is the feeling of extrasystole, the more probable is their functional origin.

Extrasystoles are frequently found in healthy subjects (emotional exertion, in heavy smokers, in coffee, strong tee, and alcohol abuse), and their prevalence increases with age. Extrasystoles can occur in hyperthyroidism, menopause, digitalis and adrenaline toxicity as well as by reflex in the diseases of the abdominal organs. Premature beats are common in patients with coronary heart disease (especially in acute myocardial infarction), hypertension, rheumatic heart valvular disease, myocarditis, and heart failure. Patients with premature cardiac contraction feel their heart missing a beat (escape beat) with subsequent strong stroke.

Palpitation is subjective feeling of accelerated and intensified heart contractions onto the chest wall. This is a symptom experienced by most people at some time in their lives. Heart palpitation is clinical sign of tachycardia. Accurate assessment of palpitation requires an exact description of the sensation and it is often helpful to ask patients to explain their symptoms by taping out the heart beat on their chest or a table top.

Palpitation is a symptom, mainly, of organic affection of the cardiovascular system. In this case, it has lingering character, more expressive without any external causes, and moreover, accompanied by the pain in the heart region, disorders of the heart rate, feeling of compression in the chest, feeling of fear, stoppage of breathing, headache, noise in the ears, and "net" before eyes.

The evaluation of palpitation: important questions

(Davidson's principles and practice of medicine, 1999).

  • Is the palpitation continuous or intermittent?

  • Is the heart beat regular or irregular?

  • What is the approximate heart rate?

  • Do the symptoms occur in discrete attacks?

  • Is the onset abrupt?

  • How do attacks terminate?

  • Are there any associated symptoms? e.g. chest pain

  • Lightheadedness

  • Polyuria (a feature of supraventricular tachycardia)

  • Are there any precipitating factors? e.g. exercise, alcohol

  • Is there clinical evidence of structural heart disease? e.g. Coronary heart disease, Valvular heart disease

Palpitation periodic, of not long duration, appeared regular after moderate physical activity, is a symptom of the heart failure. In increased pressure in the lesser circulation, elevated pressure in the orifice of the vena cava by reflex through the sympathetic nerve accelerates cardiac rate (Bainbrigde reflex) to unload lesser circulation.

Palpitation often develops as a reflex in diseases of some internal organs: in disease of the central nervous system, neurosis, endocrine pathology (thyrotoxicosis), in fever, anemia, hypotension, and in many infectious diseases.

Palpitation causes

Physiological

Pathological

Cardiac diseases

Noncardiac causes

Physical exertion


Emotional exertion

Strong tea, coffee, alcohol


Drugs (adrenaline,

caffeine, atropine sulfate)

Coronary heart disease

Rheumocarditis

Pericarditis

Heart valvular disease

Cardiac tumor

Myocardiopathy

Mitral valve prolapse

Ventricular preexcitation syndromes (Wolf-Parkinson-White Syndrome, Clerk-Levi-Critesko Synrome)

Diseases of the central nervous system, neurosis

Endocrine pathology

Digestive diseases


Fever


Dyspnoea (breathlessness). The term "dyspnoea" is derived from the Greek roots dys (difficult, painful) and pnoia (breathing). Breathlessness or dyspnoea is disorder of the respiratory ventilation of the lungs, manifested by unreasonably accelerated and intensified breathing. Patients describe dyspnoea as 'the sensation of difficult, laboured, uncomfortable breathing', as 'distressing feeling of air deficit', and as 'the consciousness of the necessity for increased respiratory effort'. Often dyspnea accompanied by the feeling of the fear and alarm, and by others unpleasant feelings.

Dyspnoea is a cardinal symptom of left heart failure and occurs in many others cardiovascular conditions.

Some common causes of dyspnoea

Types of dyspnoea

Cardiovascular causes

Other causes

Exertional dyspnoea

Left heart failure left ventricular failure acute and chronic, mitral valve disease, Atrial myxoma

Congenital heart disease

Pulmonary vascular disease pulmonary embolism, acute and chronic other causes of pulmonary hypertension

Angina equivalent

Lung disease

Upper airways obstruction

Fluid overload

Anaemia

Obesity

Psychogenic

Orthopnoea

Left heart failure

Lung disease

Diaphragmatic weakness

Paroxysmal nocturnal dyspnoea

Left heart failure

Nocturnal asthma

Gastro-oesophageal reflux with aspiration

Acute dyspnoea at rest

Acute myocardial infarction Supraventricular or ventricular tachycardia Acute dissection of the aortic root

Mitral chordal or papillary muscle rupture Large pulmonary embolism Mitral obstruction by left atrial ball thrombus or left atrial myxoma Obstruction or dehiscence of an artificial valve Infundibular spasm of Fallot's tetralogy

Asthma

Pneumothorax

Aspiration/inn aled foreign body

Metabolic acidosis

Massive haemorrhage


Different types of dyspnoea can be distinguished in clinical practice, although they often coexist.

1. Exertional dyspnoea: this may be graded according to the revised New York Heart Association scale. The severity of cardiac disease may be underestimated if the patient's physical activities are restricted for any other reason - sedentary habit, intermittent claudication, or arthritis.

2. Orthopnoea: dyspnoea worse when lying flat than when sitting up or standing is common.

3. Paroxysmal nocturnal dyspnoea: acute dyspnoea waking the patient from sleep. Characteristically the patient sits or stands up, and may throw open the windows for air. Paroxysmal nocturnal dyspnoea can be crudely graded by the number of pillows that patient uses to prop himself up to allow uninterrupted sleep.

4. Acute dyspnoea: this is uncommon. It may complicate myocardial infarction, severe arrhythmias, or number of other catastrophic events.

Other respiratory symptoms may occur with dyspnoea in cardiovascular disease:

1. Acute pulmonary oedema: acute severe dyspnoea accompanied by cough producing copious white or pale pink frothy sputum. There is usually cyanosis, sweating, tachycardia, and raised systemic blood pressure. Dyspnoea with copious pale pink frothy sputum also occurs in the rare condition of alveolar cell carcinoma of the lung.

2. Dry cough: a persistent dry cough may occur in chronic left heart failure, particularly after exercise and whenlying flat in bed at night. A dry cough may persist for about half an hour after an episode of paroxysmal nocturnal dyspnoea. Treatment with angiotensin-converting enzyme inhibitors sometimes causes troublesome cough.

3. Haemoptysis: coughing large amounts of blood is a dramatic symptom and has many causes. Small haemoptysis occur in severe mitral stenosis and occasionally in severe left ventricular failure. Massive or exsanguinating haemoptysis may occur with rupture of a thoracic aortic aneurysm, pulmonary artery aneurysm, or arteriovenous malformation.

4. Irregular respiration: Cheyne-Stokes periodic respiration is well known to occur in advanced cardiac failure, but is uncommon. Cyclical variation in ventilation without frank apnoeic phases is relatively common during sleep in moderate and severe heart failure.

Cardiac dyspnoea is caused by upset gas exchange and accumulation of underoxidized metabolites in the blood, which stimulate the respiratory center to accelerate and deepen respiration. Especially pronounced disorders in gas exchange arise in blood congestion in the lesser circulation, when the respiratory surface and respiratory excursion of the lungs decrease.

Asphyxia is attack of grave dyspnoea that occur due to acute congestion in the lungs and upset of gas exchange in acute left ventricular failure, and observes in the patients with myocardial infarction, aortic stenosis and regurgitation, and in essential hypertension. Attacks of asphyxia, which are known as cardiac asthma, arise suddenly at rest or soon after physical or emotional stress, and usually during night sleep. This can be explained by an increased vagus tonus during sleep, which causes narrowing of the coronary arteries and thus impairs nutrition of the myocardium.

During an attack of cardiac asthma in patients appears feeling of intense pressure in the chest, acute lack of air; the patient suffocates, catches the air by the mouth, marked weakness develops, and appears cold sweat. The skin becomes pallid and cyanotic. The face of the patient, not infrequently, expresses the fear and suffering. Respiration becomes superficial and accelerated, inspiratory dyspnoea develops. The patient become coughing and expectorated tenacious sputum. During an attack of cardiac asthma the patient has to assume forced position - orthopnoea, or stands up. If congestion in the lesser circulation progresses, edema of the lungs develops. The feeling of suffocation and cough intensify still more, respiration becomes stertorous, ample foaming sputum with traces of blood (pink or red) is expectorated. Edema of the lungs requires prompt and energetic measure to be taken to prevent possible death of the patient.

Cough in the patients with cardiovascular diseases is due to congestion in the lesser circulation. Cough, as a rule, at first dry, arises during exertion, and particularly in the lying posture of the patient. In prolonged congestion cough is with sputum.

Symptomatic features in the differential diagnosis of cardiac cough

Cough features

Causes of cough

Disease

Periodic, dry, persistent, sonorous, comes on with exertion, at rest, in the lying position, at night

Congestion in the lesser circulation, increases of bronchial secretion

Chronic heart failure

Periodic with insignificant bloody sputum, comes on with exertion, in lying position

Significant hypertension in the lesser circulation

Mitral stenosis

In attacks, dry, mainly at night, comes on directly before the beginning of the night sleep or in 1-2 hours of staying in the bed. In the morning the cough resumes, but slightly of lesser intensity, after expectorating of the mucus sputum the condition of the patient relieves

Aggravation of the septic process and spreading of infection to the upper respiratory tract

Long-standing septic endocarditis

Dry, transitory, sharp rending, accompanied by sensation of pain in the heart

Irritation of the pleural coughing zone

Pericarditis

Strong, sonorous, dry, barking, and dull.

Pressure of enlarged great vessels on bronchi and trachea

Aortic or pulmonary aneurysm

Haemoptysis. Coughing up blood is an alarming symptom and nearly always brings the patient to the doctor. Haemoptysis in cardiac pathology is mostly due to congestion in the lesser circulation and rupture of fine bronchial vessels during coughing.

Tab. 2.10. Symptomatic features in the differential diagnosis of haemoptysis in cardiovascular pathology

Haemoptysis features

Causes of haemoptysis

Disease

In a form of streaks of the blood in the sputum

Congestion in the lesser circulation, rupture of fine bronchial vessels during coughing

Mitral stenosis

In a form of ample foaming sputum with traces of blood (pink or red)

Sudden significant pressure elevation in the lesser circulation, erythrocytes diapedesis through the vessels walls into respiratory tract

Acute left ventricular failure (pulmonary edema)

Traces of blood in a form of streaks or clots

Pulmonary hypertension, erythrocytes diapedesis through the vessels walls into respiratory tract

Pulmonary thromboembolism Pulmonary infarction

Traces of blood or bleeding

Break of the aortic aneurysm to the bronchi, trachea, lungs

Aortic aneurysm dissection

In a form of streaks of blood in insignificant rnucus sputum

Disorders of vessels penetrability, erythrocytes diapedesis

In elderly patients with

atherosclerosis of pulmonary and bronchial arteries


Syncope - is sudden loss of consciousness. Cardiac syncope is caused by a sudden drop in cardiac output and recoverable loss of adequate blood supply to the brain (cerebral ischemia) due to an arrhythmic or a mechanical problem (Tab.2.11)

A faint is often preceded by a brief feeling of "lightheadness"; vision then darkens and there may be ringing in the ears.

Vasovagal syncope may be provoked by some emotionally charged event (e.g. venepuncture) and almost always occurs from the standing position.

Cardiac syncope may be provoked by exertion (e.g. with severe aortic stenosis) or occur completely "out of the blue" (as in heart block). The loss of consciousness is brief, and the patient recovers quickly as long as he or she has assumed the horizontal position.

Common causes of cardiac syncope

Arrhythmia

Bradycardia (especially sick sinus syndrome, complete atrio-ventricular block)

Tachycardia (especially ventricular tachycardia)

Ventricular preexitation syndromes (WPW, CLC)

Atrial fibrillation and flutter)

Mechanical

Ischemic left ventricular dysfunction

Aortic stenosis

Mitral valve prolapse Hypertrophic obstructive cardiomyopathy

In vasovagal syncope the loss of consciousness is gradual and rarely associated with injury. There is no amnesia for events that occur after regaining awareness. During a syncopal attack incontinence of urine can occur and there may be some stiffening of the limbs and even some brief twitching of the limbs, but tongue-biting never occurs.

Whenever possible, an accurate description of syncope should be obtained from the patient and a witness. A careful history will often reveal the cause of syncope without recourse to complex and expensive investigations.

Typical features of cardiac and neurogenic syncope

Features

Cardiac syncope

Neurogenic syncope

Premonitory symptoms

Lightheadness Palpitation Chest pain Breathlessness

Headache

Confusion

Hyperexcitability

Olfactory hallucinations

"Aura"

Unconscious period

Extreme "death-like" pallor

Prolonged (> 1 min) unconsciousness

Motor seizure activity*

Tongue-biting Urinary incontinence

Recovery

Rapid recovery (<1min)

Flushing

Prolonged confusion (> 5 min) Headache

Focal neurological signs

*NB. Cardiac syncope can also cause convulsions by inducing cerebral anoxia.


General condition depends on severity of the disease. Condition is satisfactory in the patients with cardiovascular pathology in compensation stage. Condition becomes worse in progression of pathological process and associated with complications.

Posture of the cardiac patients may be active, passive or forced. Active posture is in patients with heart valvular diseases, arterial hypertension, and coronary heart disease without sighs of the heart failure. Passive posture - horizontal with low head of the bed is observed in the patients with acute vascular failure. In some cardiac diseases patients assume forced posture.

Forced posture of the patients in cardiovascular diseases

Posture

Pathological condition

Pathophysiological mechanisms

Upright

Attack of angina pectoris

Tissue oxygen demand reduce at rest, decreased myocardial ischemia

On the right side with high head of the bed

Chronic heart failure of II degree

Re-distribution of blood into the iow extremities, reducing of circulating blood volume, decreasing

Orthopnoea

Acute left ventricular failure, chronic heart failure of II-III degree

blood volume, decreasing of venous pressure in the lesser circulation, improvement of gas exchange in the "alveoli-pulmonary capillaries" system, displacement of ascitis fluid

Sitting posture bending forward

Dry pericarditis

Pericardial layers presses to one another, reduce their movement that decrease irritation of pain receptors in pericardium

Knee-elbow posture

Effusive pericarditis

Improvement of diastolic cardiac function


Consciousness of the patients with various cardiovascular diseases is clear. Significant hypoxia, as a result of acute and chronic heart failure, is accompanied by consciousness disorders in a form of stupor or sopor.

Skin and visible mucosa colour changes is of important diagnostic significance.

Changes of skin and visible mucosa colour in cardiovascular pathology.


Color

Pathological conditions

Mechanisms of color changes

Cyanosis

Mitral valvular diseases

Acute and chronic left ventricularfailure

Thromboembolism of the pulmonary artery

Congenital heart diseases

Aerz's syndrom

Secondary pulmonary hypertension

Restricted pulmonary circulation

Artery-venous blood shunting

Primary pulmonary hypertension

Constant pallor

Aortic stenosis

Aortic regurgitation

Low stoke volume

Low diastolic pressure

Transitory pallor

Acute vascular failure

Low storke volume, peripheral vascular spasms, re­distribution of blood

Growing pallor

Aortic aneurysm dissection

Bleeding, shock

Pallor with yellowish tint (coffee with milk)

Infectious endocarditis

Anaemia increase hemolysis of erythrocytes

Jaundice

Chronic right ventricular failure Infectious endocarditis

Cardiac liver cirrhosis, infectious-toxic hepatitis

Jaundice with acrocyanosis

Total heart failure

Cardiac liver cirrhosis, slow peripheral circulation

Inspection of the face and the neck.

'Fades mitrale' is characterized by cyanotic blush on the cheeks, cyanotic lips, tip of the nose, ears, young-looking, observes in the patients with mitral stenosis.

Face of the patient with aortic regurgitation is pale, rhythmic movements of the head, synchronous with carotid arteries pulsation - Musset's symptom is observed.

'Corvisart 'sface' observes in patients with severe heart failure. The face is edematous, pale yellowish with cyanotic tint, the eyes are dull and eyelids are sticky, always open mouth, cyanotic lips.

Excitement, fear of death, suffering expression of the face are typical to the patients with acute left ventricular failure.

In myocardial infarction complicated by cardiogenic shock the face of the patient is pale with cyanotic hue, covered by cold sweat.

'Stokes' collar' — marked dilation of neck veins, oedema of the neck, head, shoulders. These signs arise as a result of compression of superior vena cava by aortic aneurysm, tumor of mediastinum, and enlarged mediastinal lymph nodes.

Cardiac oedema. Right heart failure produces a high jugular venous pressure, with hepatic congestion and dependent peripheral oedema. Oedema is caused by penetration of fluid through the capillary walls and its accumulation in tissues. Cardiac oedema can first be latent. Retention of fluid in the body does not immediately cause visible oedema but provokes a rapid gain in the patient's weight and his decreased urination. Oedema becomes visible in the first instance in the malleolus region, on the dorsal side of the foot, shins (if the patient sits or stands), and in sacral region (if the patient keeps bed). Oedema first develops only in the evening annd resolves during the night sleep. If the heart failure progresses, oedema increases, and transudate may accumulate in the body's cavities: in the abdominal cavity (ascitis), pleural cavity (hydrothorax), and in the pericardium (hydropericardium). General distribution of oedema throughout the entire body is called anasarca.

There are following methods of oedema revelation: inspection, palpation, patient weighing, and diuresis control.

Methods of oedema revelation

Method

Features

Inspection

Swollen glossy skin. The specific relief features of the oedema-affected parts of the body disappear due to the leveling of all irregularities on the body surface. Stretched and tense skin appears transparent, and is especially transparent on loose subcutaneous tissues (the eyelids, the scrotum, etc.)

Palpation

When the pressed by the finger, the oedematous skin overlying bones (external surface of the leg, malleolus, loin, etc) remains depressed for 1-2 minutes after the pressure is released

Weighing of the patient

Gain of the body mass

Diuresis control

The amount of intake fluid exceeds the amount of urine


For revelation of cavities oedema percussion, auscultation, X-ray and ultrasound examination methods are also used.

It should be remembered that general oedema can be caused not only by cardiac pathology, but also by renal diseases (Tab. 2.17), hypofunction of the thyroid gland, and by long-standing starvation. Considerable oedema of low limbs, accompanied by cyanosis of the low part of the body, dilated venous network in the navel region, ascitis that are caused by obstruction to blood flow in vena cava inferior trunk are classified as vena cava inferior syndrome.

Symptomatic features in the differential diagnosis of cardiac and renal oedema


Features

Cardiac oedema

Renal oedema

Location, character

Ascending character, starts from low extremities and spread upward

Descending character, starts from the face and spread downward

Time of arising

More pronounced in the evening

More pronounced in the morning

Colour of the skin

Cyanotic

Pallor

Temperature of the skin

Cold

Warm

Skeletal and muscular system. Marfan's syndrome is characterized by affection of the aorta in a form of aneurysm, coarctation, regurgitation and others congenital heart valvular diseases. Phenotype of the patients - tall, long narrow limbs, arachnodactyly, kyphoscoliosis, deformation of the sternum, and hypermobility of the joints.

Drum-stick (Hippocratic) fingers - clubbing of the terminal phalanges of the fingers and toes, nails in a form of 'hour glass' -are characteristic of congenital heart valvular diseases, subacute septic endocarditis, and chronic cor pulmonale.

In aortic coarctation disproportion of the muscular system of upper and low limbs are observed: muscles of upper limbs are hypertrophied, and on the other hand, muscles of low limbs are relatively hypotrophied.

7. Reference source


  1. Zh. D. Semidotskaya, O.S. Bilchenko, I.A. Cherniacova, K.P. Zharko Introduction to the course of internal disease. Book 1. Diagnosis // Kharkiv, 2005. – P. 112-123.

  2. Barbara Bates, Lynn S. Bickley, Robert A. Hoekelman Physical Examination and History Taking // J.P. Lippincott Company, Philadelphia. – P. 241-250.


Lecturer Demchuk H.V.

Test for self-control

1. What are the cardiovascular symptoms?

A. Chest pain, cough, dyspnea, wheezes, haemoptysis.

B. Pain in the heart region, palpitation, intermissions, oedema

C. Headache, dizziness, dysphagia, nausea, vomiting.

D. Pain in the right subcostal region, bitter taste, brown urine, skin itching, jaundice.

E. Back pain, dysuria, ishuria, eyes oedema, weakness.

2. What are the cardiovascular symptoms?

A. Abdominal pain, nausea, vomiting

B. Dyspnea, faint (syncope), palpitation, dry cough

C. Cough with rusty sputum, chest pain, dyspnea

D. Swelling abdomen, constipation, melena

E. Oedema, dysuria, haematuria

3. What feature does the pain at angina pectoris have?

A. Be caused by physical extension

B. Duration under 15 minutes

C. Constricting, feeling of heaviness

D. Radiate to the left hand and scapula

E..All mentioned above

4. What feature does not the pain at myocardial infarction have?

A. Prolonged, continuous > 20-30 min.

B. Severe, tight or burning.

C Relief at rest.

D. Does not respond to nitrates.

E. Radiate to both hands, jaws, neck.

5. If patient has heart failure his cough is characterized with

A. appearing at lying position

B. a lot of rusty sputum

C. it is permanent

D. it is loud

E. all mentioned above.

6. If patient has feeling of solitary beats at various intervals it is named

A. exrtasistole

B. palpitation

C. syncope

D. dizziness

E. heart dyspnea

7. If patient has feeling of accelerated and intensified heart contractions onto the chest wall it is named

A. exrtasistole

B. palpitation

C. syncope

D. heart dyspnea

E. heart pain

8. If patient has a lot of foamy pink liquid sputum it means he has

A. Pulmonary edema

B. Pulmonary embolism

C. Aortic aneurysm dissection

D. all from above

E. Northing from above

9. Which type of dyspnea is observed at the patients with cardiovascular diseases?

A. Expiratory

B. Inspiratory

C. Mixed

D. Changing

E. All mentioned above.

10. What is feature of dyspnea at patient with cardiac asthma attack?

A. Appear at night

B. Accompanying with dry cough

C. Inspiratory

D. Ortopnea position in the bed

E. all mentioned above

11. Which of the following disorders is not likely to be associated with hemoptysis?

A. Mitral stenosis

B. Pulmonary embolism

C. Pulmonary edema

D. Pericarditis

E. None of the above

12. What characteristics of edema at patient with heart failure?

A. Asymmetrical on the part of body which patient lies on.

B. Firstly on the face than gradually spreads to body down.

C Firstly on the legs than gradually spreads to body up

D. Hear the heart region

E. Only on abdomen and hands

13. What position does a patient with cardiovascular insufficiency occupy?

  1. . A forced sitting position with the legs let down.

  2. The patient prefers to lie on the affected side.

  3. The patient sits upright or resting the hands on the edge of the table of chair.

  4. A lying position on the side (lateral recumbent position) with the head thrown back and the bent legs pulled up to the abdomen.

  5. A forced knee-elbow position.

14. What mechanisms are caused by the orthopnoea posture?

  1. Tissue oxygen demand reduce at rest, decreased myocardial ischemia

  2. Re-distribution of blood into the iow extremities, reducing of circulating blood volume,

  3. Decreasing blood volume, decreasing of venous pressure in the lesser circulation, improvement of gas exchange in the "alveoli-pulmonary capillaries" system, displacement of ascitis fluid

  4. Pericardial layers presses to one another, reduce their movement that decrease irritation of pain receptors in pericardium

  5. Improvement of diastolic cardiac function

15. What kind of posture is observed at angina pectopis?

  1. Upright

  2. On the right side with high head of the bed

  3. Orthopnoea

  4. Sitting posture bending forward

  5. Knee-elbow posture

16. What kind of posture is observed at acute left ventricular failure?

  1. Upright

  2. On the right side with high head of the bed

  3. Orthopnoea

  4. Sitting posture bending forward

  5. Knee-elbow posture

17. What cardiovascular disease is characterized with constant pale skin color?

A. Angina pectoris

B. Mitral stenosis

C. aortic valve diseases

D Essential hypertension

E. All mentioned above

18. Which of the following conditions is least to produce jugular venous distention?

A. right heart failure

B. Chronic left heart failure

C. Chronic hypoxemia

D. Liver failure

E. circulation insufficiency

19. What kind of cyanosis is usually observed at patient with cardiovascular diseases?

A. Central, warm

B. peripheral, cold

C. peripheral warm

D. Local (near heart region), cold

E. Diffuse warm

20. Which method can we use for establishing edema

A. Visual inspection

B. Palpation

C. weighing patient

D. measuring leg circumstance

E. All mentioned above.


Control questions:

  1. What are features of chest pain at angina pectoris?

  2. What are features of chest pain at myocardial infarction?

  3. What is a palpitation and which diseases it accompanies?

  4. What are intermissions and which diseases they accompany?

  5. What is syncope and which diseases it accompanies?

  6. What are features of dyspnoea at cardiovascular patients?

  7. What are features of cough at cardiovascular patients?

  8. What are features of hemoptysis at cardiovascular patients?

  9. What postures in the bed can patient with cardiovascular disease occupy?

  10. What are features of cyanosis at cardiovascular patients?

  11. What are features of oedema at cardiovascular patients?

4.3. Practical task that should be performed during practical training

  1. Asking patient about cardiovascular symptoms

  2. Taking history of cardiovascular patient

  3. Doing general visual inspection of cardiovascular patient

  4. Assessing obtaining data



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