This document provides guidance on assessing symptoms related to cardiac issues in geriatric patients. It discusses how to evaluate dyspnea, cough, palpitations, chest pain, leg swelling, and other symptoms by asking about duration, onset, precipitating/relieving factors, and associated symptoms. Specific questions are provided to assess orthopnea, paroxysmal nocturnal dyspnea, hemoptysis, edema, and different types of chest pain. Causes and characteristics of different conditions like pulmonary venous congestion, acute pulmonary edema, and low cardiac output are also summarized.

1. Clinical Assessment
part 2
Dr Doha Rasheedy
Lecturer of Geriatric Medicine
Department of Geriatric and Gerontology
Ain Shams University

2. REVIEW OF SYSTEMS

3. • 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

4. CARDIAC

6. PVC

7. 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.

8. DYSPNEA
• an uncomfortable subjective awareness of
one’s own breathing.
• Are they sure that they stop due to
breathlessness or is it some other reason
(arthritic knees for example)?

9. 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?

10. 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

11. Grading: NYHA Functional Classification

12. 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.

13. 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.

14. • 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

15. 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

16. Acute pulmonary edema
• Severe dyspnea +cough (frothy blood
tinged) expecturation +crepitation +
tachcardia + tachypnea.

17. 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]

18. 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???

19. Cough expectoration
• Cough is a pulmonary rather than cardiac
cause but can be due to PVC
• Frothy, blood tinged
• Dry cough: ACEIs

20. SVC

21. Systemic congestion
• In right ventricular failure.
• Manifestations:
1. Oedema L.L. usually before ascites
2. Hepatic congestion: Pain in right hypochondrium + Jaundice.
3. 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

22. • 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?

23. Causes of unilateral LL edema
• DVT
• Cellulitis
• Trauma
• Immobility hemiplegia
• lymphedema

24. Causes of bilateral LL edema
• Most common: chronic venous
insufficiency
• Heart failure
• Nephrotic, cirrhosis, nutritional
hypoalbuminemia
• IVC obstruction
• Lymphedema pelvic tumor
• immobility

30. PALPITATION

31. 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.

32. 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,

33. 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

34. CHEST PAIN

35. Chest
Pain
cardiac
Non
cardiac

36. 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 ?

38. 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

39. Radiation of anngina

40. 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

41. 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 anti-
inflammatory drugs
• Accompanied by Pericardial rub
• Causes: pericarditis (MI, viral infection, autoimmune,
radiotherapy, after surgery, catheter ablation, angiography)

42. 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

43. 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

44. LOW COP

45. Causes of low COP
Stenotic valve lesions (MS, AS, TS,
PS)
Pulmonary embolism, pulmonary
hypertension
↓cariac filling dt ↓VR e.g hypovolemia
↓cariac filling dt diastolic relaxation
constrictive pericarditis, restrictive
cardiomyopathy
arrhythmia
Heart failure

46. Manifest as
• Easy fatigue
• Claudication
• Oliguria
• Dizziness
• Syncope
• Anginal pain
• Lack of concentration
• Headache
• Blurring of vision

47. 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?

48. 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?

52. CYANOSIS

53. 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

56. • 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 Eisenmenger’s reaction. When patent
ductus arteriosus (PDA) goes in for Eisenmenger’s
reaction,

57. • 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?

58. • Differential central cyanosis: in the
lower half of the body only
• PDA with reversed shunt.
• PDA with coarctation of aorta.

59. JAUNDICE

60. 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).

61. FEVER

62. 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

63. EMBOLIC MANIFESTATIONS

64. source
• Left atrium : MS, AF
• Left ventricle: MI
• Prosthetic valve: IEC
• Aorta: athermatous plaque

65. effects
• Hemiplegia
• Blindness
• Painless heamaturia
• IO acute abdomen
• Limb ischemia

66. HYPERTENSION

67. hypertension
• No symptoms suggest the diagnosis of
hypertension, only history of regular use of
anti hypertensive drug.
• Asymptomatic
• Headache.
• Blurring of vision.
• Tinnitus.
• Epistaxis.

68. PRESSURE MANIFESTATIONS

69. 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