Page 19 - Clinical Pearls in Cardiology

History and General Examination 7

of chest wall during breathing. This may cause
dyspnea through the activation of chest wall position
sensors. Reduced pulmonary compliance in
pulmonary edema imposes an elastic overload and
increases the work of breathing. Increase in airway
resistance due to reflex bronchoconstriction imparts
a resistive overload. Finally, pulmonary vascular
distension and interstitial edema may directly
stimulate the nerve endings and receptors like
J receptors. All the above factors act together to
produce the sensation of dyspnea.
• Cheyne–Stokes respiration: The intermittent waxing
and waning of breathing is usually the result of low
cardiac output in heart failure. It is really a physical
sign. It is often noticed by the patient’s caregiver
during the night when breathing slows down and
stops for some seconds before starting again.
• Hemoptysis: Hemoptysis and pulmonary hemorrhage
may be seen in patients with mitral valve disease. The
bleeding may arise either from the pulmonary
microcirculation or from the engorged submucosal
bronchial veins.
12. How will you differentiate cardiac syncope from
vasovagal syncope and seizure?
Syncope is defined as a transient loss of consciousness
with spontaneous recovery. It is commonly described as
“fainting” or “blackout.” In those with cardiac syncope
(due to arrhythmia or structural heart disease), the onset
of syncopal attack is usually sudden and often there
are no premonitory symptoms. There is extreme pallor
during the period of unconsciousness and recovery
is usually very rapid (less than 1 minute) with facial
flushing.