Ageing, deconditioning, and/or obesity may cause a reduction in effort tolerance due to dyspnoea and/or fatigue, but without the additional major and minor criteria for diagnosing heart failure.
Elucidation of the precise reason for exercise intolerance can be difficult because several disorders may co-exist in the same patient. Echocardiography in heart failure shows characteristic signs of heart failure. However, a clear distinction can sometimes be made only by measurements of gas exchange or blood oxygen saturation or by invasive haemodynamic measurements during graded levels of exercise (i.e., cardiopulmonary exercise test with VO₂ max).
Dyspnoea may be episodic, with or without environmental triggers, and is usually accompanied by cough, wheezing, sputum, and a history of smoking or industrial exposure.
Pulmonary function tests will give definite diagnosis of an obstructive or restrictive pulmonary disease. Plasma B-type natriuretic peptide levels may be intermediate (100 to 400 nanograms/L or 100 to 400 picograms/mL) in COPD.
Patients may present with fever, cough, and productive sputum, with focal signs of consolidation (increased vocal fremitus and bronchial breathing).
CXR may show signs of consolidation. FBC may show elevated WBC, and blood cultures may be positive for the aetiological organism.
Sudden onset of chest pain, dyspnoea, and haemoptysis, especially after childbirth, are suggestive of PE. Dyspnoea with or without chest pain may be present in other conditions associated with venous thrombosis and PE (e.g., cancer, prolonged immobilisation, postoperative state).
ECG is abnormal in the majority of patients with PE and may show a deep S wave in lead I and a deep Q wave and T-wave inversion in lead III (S1-Q3-T3). Other common changes include sinus tachycardia, complete or incomplete right bundle-branch block, and T-wave inversion in the inferior (II, III, aVF) or the anterior leads (V1 to V4).
Normal levels of D-dimers can help to exclude PE, but elevated levels occur in other conditions (e.g., aortic dissection and many types of cardiomyopathies) as well as in PE.
Patients most commonly present with dyspnoea, but other frequent complaints include cough, orthopnoea, paroxysmal nocturnal dyspnoea, haemoptysis, and chest discomfort, which are also common symptoms of pulmonary embolism. PPCM is defined on the basis of 4 criteria: 1) development of cardiac failure in the last month of pregnancy or within 5 months of delivery; 2) absence of an identifiable cause for the cardiac failure; 3) absence of recognisable heart disease before the last month of pregnancy; 4) left ventricular systolic dysfunction shown on echocardiograph. A number of potential risk factors may point to the diagnosis of PPCM, including age >30 years, multiparity, women of African descent, pregnancy with multiple fetuses, a history of pre-eclampsia/eclampsia/post-partum hypertension, and maternal cocaine misuse.
In the presence of raised D-dimers (commonplace in pregnancy) and positive risk factors for thromboembolic events, echocardiography will identify the underlying left ventricular systolic dysfunction and point to the diagnosis of PPCM. It usually shows left ventricular enlargement and significant global reduction in ejection fraction. Other findings may include left atrial enlargement, mitral and tricuspid regurgitation, and a small pericardial effusion.
Typically causes jaundice, fatigue, nausea, peripheral oedema, ascites, bruising and prolonged bleeding, gynaecomastia, and haematemesis.
LFTs are abnormal. Ultrasound or CT scan may detect ascites and liver abnormalities. Liver biopsy shows characteristic cirrhotic changes and may reveal the underlying cause.
Typically causes peripheral oedema, fatigue, dyspnoea, and loss of appetite.
Urinalysis shows proteinuria, and serum albumin is reduced. Twenty-four-hour urine collection shows >3.5 g protein. Serum urea and creatinine clearance may be abnormal in later stages. Serum cholesterol and triglyceride levels may be raised. Kidney ultrasound and biopsy may reveal the underlying cause.
May present with chest pain, typically worse on lying down, swallowing or coughing; tachycardia; dyspnoea; cough; oedema; fatigue; and low-grade fever. Pericardial friction rub may be heard at the left sternal border or apex.
ECG may show electrical alternans or ST elevation and T wave flattening or inversion. Echocardiography may detect pericardial effusion, tamponade, and pericardial fibrosis. CT scan or MRI may show thickened pericardium. Pericardial biopsy may reveal the underlying cause.
Oedema affects lower limbs only, and varicose veins may be present. Skin over the lower legs may be darkened, with ulceration.
Doppler examination may detect incompetent valves in varicose veins.
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