2.

I – Symptoms of lung congestion: 3 1- Dyspnea: - Due to difficult in inflation and deflation of congested lung. - At first it occurs on sever exertion then in moderate & later on mild. 2- Orthopnea: - It is dyspnea on lying down. - Mechanism: during lying down: - Increase venous return.- High position of the diaphragm. - In ability or weakness or insufficient action of accessory muscles of respiration.

Paroxysmal nocturnal dyspnea and pulmonary edema. - The patient is awakened up after few hours of sleep by sever dyspnea, extreme anxiety. - The associated symptoms are palpitation - Tachycardia – Tremors – pallor – excessive sweating and chest pain. - In cases of pulmonary edema the patient cough and expectorates whitish sputum sometimes it may be blood tinged. - The intensity of the symptoms is often described like suffocation and patients may get out of bed, occasionally throwing open the window to relief their distress.

Haemoptysis: Coughing of blood. 5- Recurrent winter bronchitis: The patients get severe cough with expectoration of mucopurnlent sputum, usually during winter months, later on it may be all the year round.

6 Congested pulsated neck veins. Congested pulsated enlarged tender liver. Ascitis. Jaundice. Dyspepsia: sense of pain or discomfort after meal. II- Symptoms of systemic congestion:

7 - Edema of the lower limb: A. Unilateral oedema: - Deep venous thrombosis. - Soft tissue infection. - Trauma. - Immobility: hemiplegia. B. Bilateral: - Heart failure. - Chronic venous in sufficiency. - Hypoproteinemia. - lymphatic obstruction.

III- Cardiac pain: 8 1- Angina: Cause. Characteristics: Burning- Refered 2- Myocardial infarction: - Cause: coronary occlusion. -characteristics: - Similar sites to angina. - More sever, persists at rest.

Pericardial pain: - Cause: Pericarditis. - Characteristics: - Sharp,Varies with movement. - More localized. 4- Aortic pain: - Causes: dissection of aorta - Characteristics: Sever sudden onset-- Tearing pain may cause syncope.

10 B- Provoking factors: “Factors which precipitate pain“. C- Relieving factors: a) In case of angina, pain is relieved by rest or short acting coronary vasodilators. b) In myocardial infarction: The pain may not be relieved except by morphine. D- Duration of pain:

11 IV- Low cardiac output symptoms: This is caused by diminished blood supply to vital organs as: 1- Brain.2- Myocardium. 3 – Retina. 4- Kidneys. 1- Giddness and dizziness particularly on exertion. 2- Blurring of vision. 3- Anginal pain. 4- Oliguria " Diminished volume of urine"

12 Syncope: 1- Postural hypotension: 2- Arrhythmias. 3- Left ventricular outflow obstruction: - Sever aortic stenosis and hyper trophic cardiomyopathy are associated with obstruction of the left ventricular outflow tract. - It may cause syncope especially on exertion when cardiac out put fails to meet the increased metabolic demand.

V- Palpitation: - It is the sensation of the heart beat in the chest. - It may be in: 1- Too rapid heart beats. 2- Too slow heart beats. 3- Too irregular heart beat 4-Anxiety neurosis sensation: 13

14 VI- Mediastinal compression symptoms: - Are due to compression of the mediastinal structures due to the following causes: 1- Aortic aneurysm. 2- Enlargement of cardiac chambers. 3- Pericardial effusion.

The symptoms: Pressure over trachea → dyspnea. Pressure over the oesophygus → difficult in swallowing. Pressure over intercostal nerves → sever inter costal pain. Pressure over phrenic nerve → pain → increase severity of dyspnea. Pressure over vagus nerve → hoarseness of voice. Pressure over subclavian artery → ischemic pain in the limbs and inequality of the pulse. Pressure over large veins → symptoms of systemic congestion. 15

16

17

18.

19

20

21.

22

23

24

25

26

27

28.

29

30.

31

32

33

34

35

36