Analysis of Systemic Symptoms
1. Non specific symptoms
• Fatigue. It is described as lethargy, weakness, listlessness, malaise, lack of stamina, arises after activity or exercise, is intermittent and variable in intensity and suggests chronic liver disease.
• Nausea occurs with more severe liver disease, is again a nonspecific symptoms and usually accompanies fatigue or vomiting. Vomiting is rarely persistent in liver disease.
Box 2.5: SYMPTOMSPERTAININGTOHEPATOBILIARYSYSTEM
1. Constitutional or nonspecific symptoms·
•Fatigue
•Weakness
•Nausea, vomiting
•Anorexia or poor appetite
•Malaise
2. Specific symptoms (i.e. they are liver-specific, suggest the cause such a hepatitis or cirrhosis and/or complications such as end-stage liver disease or encephalopathy)
•Jaundice
•Dark coloured urine, light coloured stools
•Abdominal distension- (ascites)
•Swelling or oedema feet
•Fetor hepaticus
•Flapping tremors
•Encephalopathic features (disturbed conscious-ness, disturbed speech and sleep pattern, bizarre hand-writing)
•Abdominal pain
•Bloating
•Haematemesis and malena
•Pruritus
Table 2.8: Causes of constipation Gastrointestinal 2. Others (i) Dietary e.g. lack of fibres (i) Drugs
and/or fluid intake • Opiates
(ii) Motility disorders • Anticholinergics
• Irritable bowel • Calcium antagonists
syndrome • Iron supplements
• Acute intestinal • Aluminium-containing
obstruction antacids
• Chronic intestinal (ii) Neurological pseudoobstruction • Multiple sclerosis
• Spinal cord compression (iii) Structural/organic • CVA
• Colonic carcinoma • Parkinsonism
• Diverticular disease (iii) Endocrinal/metabolic
• Stricture • Diabetes mellitus
• Hirschsprung’s • Hypothyroidism
disease • Hypercalcaemia
(iv) Painful anorectal • Pregnancy
conditions (iv) General
• Piles (haemorrhoids) • Old age
• Anal fissure • Depression
• Faecal impaction • Immobility or bed-riddened
masses in the abdomen and specific to right hypochondrium are discussed under the examination of abdomen Chapter 13.
Jaundice
Jaundice is yellowness of sclera, mucous membranes and skin, occurs due to raised serum bilirubin. Normal serum bilirubin is 0.3 to 1.5 mg%. Jaundice appears when serum bilirubin is > 2.5 mg%. Serum bilirubin less than 2.5 mg but more than normal indicate subclinical jaundice. The clinical jaundice may be progressive or may appear intermittently. Work-up of a patient with jaundice is given in the Table 2.9. Ask about certain features which will give you presumptive diagnosis.
Table 2.9: Clinical work-up of a case with jaundice Features (ask about them in history) Tentative diagnosis
1. Jaundice with fever, abdominal • Viral or drug induced pain, anorexia, distaste to food hepatitis or liver abscess and smoking
2. Jaundice in haemophilics, IV • Acute transfusion hepatitis drug abuser and male hom- B or C, chronic active
osexual hepatitis if duration of
jaundice is >6 months 3. Jaundice with dark -coloured • Haemolytic jaundice due
urine and stool to any cause
4. Pruritus (itching) with jaundice, • Cholestatic (obstructive) acholic white-coloured stool, jaundice (intra or xanthomatous extrahepatic cholestasis) or
biliary cirrhosis
5. Abdominal pain with fluctuating • Bile duct stone or stricture,
jaundice pancreatitis
6. Painless progressive jaundice • Carcinoma of pancreas with palpable gallbladder
7. Jaundice, ascites with prominent • Portal hypertension abdominal veins and history of (cirrhotic, noncirrhotic,
haematemesis Budd-Chiari syndrome)
8. Jaundice with pregnancy • Hepatic or cholestatic jaundice of pregnancy 9. Recurrent jaundice • Congenital
hyperbilirubin-aemia or recurrent benign cholestasis
Jaundice is the hallmark of liver disease and perhaps the most reliable marker of severity. Patient usually report darkening of the urine before they note the scleral icterus. In obstructive jaundice, the stools are clay -coloured while urine is dark--coloured. Jaundice without dark urine usually indicates unconjugated (indirect) hyperbilirubinaemia and is typical of haemolytic jaundice and genetic disorder of bilirubin conjugation (Gilbert’s syndrome and Criggler-Najjar syndrome). In these genetic disorders, the jaundice is more noticeable during fasting and with stress.
• Poor appetite with weight loss occurs commonly in acute liver disease but is rare in chronic disease. Diarrhoea (steatorrhoea) is uncommon in liver disease except with severe jaundice. On the other hand constipation may commonly occur and may exacerbate the symptoms of end-stage hepatic disease such as encephalopathy.
• Right upper quadrant pain occurs in many liver diseases and is usually marked by tenderness in this area. The pain arises due to stretching or irritation of Glisson’s capsule which surrounds the liver and is a pain sensitive structure due to rich in nerve endings. Severe pain due to liver involvement is seen in liver abscess, severe venoocclusive disease, Budd-Chiari syndrome and acute hepatitis. Occasional colicky pain in right hypochondrium indicates biliary colic (stricture, stone, tumour). Pain radiating to shoulder is due to involvement of diaphragmatic pleura (pneumonia) or liver (liver abscess or malignancy liver) or due to subphrenic abscess.
• Pruritus (itching). It occurs in acute liver disease appearing early in obstructive jaundice somewhat later in hepatocellular jaundice (acute hepatitis). Itching also occurs as a presenting symptom in certain chronic liver diseases i.e.
primary biliary cirrhosis or cholestatic jaundice of pregnancy and sclerosing cholangitis.
• Haematemesis and malena in liver disease occur from rupture of oesophageal varices by passage of hard bolus of food in patients with portal hypertension or due to coagulation disorders.
• Symptoms of hepatic insufficiency or end -stage liver disease include progressive jaundice, haematological alterations (anaemia, thrombo-cytopenia, panthrombo-cytopenia, bleeding tendencies) symptoms of portal hypertension (ascites, fetor hepaticus, caput medusae, haematemesis), endocrinal changes (gynaecomastia, testicular atrophy, breast atrophy in female) and pigmentation.
Mass abdomen
Mass abdomen refers to intra-abdominal masses in relation to various viscera in the abdomen. Mass abdomen may produce fullness of abdomen or visible swelling, dragging sensation in abdomen, pain abdomen or may just be asymptomatic i.e. patient is not aware of it. Malignant masses or tumours produce decreased/
loss of appetite or weight loss. The possible sites of
Cardiovascular system (CVS) symptoms
The symptoms pertaining to cardiovascular system are many and their interpretation varies from patient to patient. The common symptoms are given in the Box 2.6.
Box 2.6: SYMPTOMATOLOGYOF CVS
• Dyspnoea • Palpitation • Fatigue
• Pain • Syncope • Cyanosis
• Oedema • Cough
• Chest pain • Haemoptysis Symptoms analysis
Dyspnoea
It is defined as consciousness of breathing which normally does not occur except during severe exertion, emotional stress or during anxious events. It can be cardiac or respiratory origin. Here dyspnoea as a cardiovascular symptom will be analysed and discussed though respiratory disease may coexist if there is some common aetiological factor such as smoking. The grading/class of dyspnoea is described in the Table 2.10.
Table 2.10: New York Heart Association Functional Classification
Grade Description
I. Patients with cardiac disease but without limitation of physical activity. There is no dyspnoea on ordinary physical activity
II. Patients with cardiac disease resulting in slight limitation of physical activity. They are comfortable at rest but become dyspnoeic on ordinary physical activity.
III. Patients with cardiac disease resulting in marked limitation of physical activity. They are comfortable at rest. Less than ordinary physical activity causes dyspnoea.
IV. Patients with cardiac disease resulting in inability to carry on any physical activity without discomfort. Dyspnoea is present at rest and increases with mildest exertion.
Dyspnoea on exertion: It is a physiological phenomenon but becomes a symptom of disease if it occurs at exercise at levels below than normal or expected for the patient’s age and degree of previous fitness. Exertional dyspnoea is a presenting symptom of left heart failure irrespective of its cause. It indicates increased work-load on the heart. The conditions in which dyspnoea is a presenting symptom are;
1. Systemic hypertension (accelerated or malignant) 2. Valvular heart disease (mitral, aortic valve stenosis or
regurgitation or both)
3. Cardiomyopathies (dilated, hypertrophic and restrictive)
4. Myocardial diseases-acute MI (papillary muscle dysfunction) or myocarditis
5. Arrhythmia such as atrial fibrillation.
Orthopnoea: Dyspnoea in recumbent (lying flat) position is termed as orthopnoea. The patients with orthopnoea usually try to lie propped up position by using extra-pillows at night. Sometimes, the symptom is so distressing that the patient prefers to sleep upright in a comfortable chair. These patients usually have disturbed sleep at night due to frequent awakenings as their head may slip off the pillows. Orthopnoea indicates advanced heart disease and may or may not be associated with effort (exertional) dyspnoea. The orthopnoeic patients often experience paroxysmal nocturnal dyspnoea (PND).
Paroxysmal nocturnal dyspnoea (PND): The term refers to attacks of breathlessness which generally occur at night and awaken the patients from sleep. The patient with PND or orthopnoea usually sits upright gasping in the bed or sitting on the edge of the bed with legs hanging from the bed. Occasionally, patient may even come out of the bed to open the windows in an attempt to relieve the discomfort/distress. All these positions relieve PND and orthopnoea, but patients with PND characteristically have cough and wheezing and bring out frothy sputum streaked with blood. The mechanisms of PND are:
1. Increased venous return during supine position (recumbency).
2. Shift of oedema fluid from extravascular to intravascular compartment.
3. Reduced adrenergic drive during sleep.
4. Heart rate increases during REM sleep.
5. Vital capacity is reduced in supine position.
Dyspnoea at rest: It indicates an advanced stage of cardiac dyspnoea and occurs in the presence of severe heart failure. Its presence is preceded by worsening effort dyspnoea, orthopnoea and PND, and ankle oedema. These patients have all signs and symptoms of left heart failure—which is a cause of cardiac dyspnoea.
The causes of dyspnoea at rest are given in the Box 2.7.
Box 2.7: CAUSESOFDYSPNOEAATREST
1. Cardiovascular
• Acute left heart failure (acute pulmonary oedema)
• Massive pulmonary embolism (acute cor pulmonale) 2. Respiratory
• Acute severe asthma
• Tension pneumothorax
• Acute bronchopneumonia
• ARDS (Adult respiratory distress syndrome)
• Acute laryngeal oedema 3. Others
• Diabetic ketoacidosis
• Lactic acidosis
• Salicylate poisoning
• Uraemia with fluid overload.
Dyspnoea at rest (acute dyspnoea) is an emergency.
Palpitation
Palpitation is the awareness of heart beat in the chest.
Patients describe it by using different terms such as thumping, pounding, fluttering, jumping, racing and bumping of the heart beat. It may be due to heightened awareness of the heart beating during sinus rhythm (e.g.
after exertion, excessive use of tea and coffee, anxiety, hyperthyroidism and due to catecholamine excess) or due to irregular heart beating or an arrhythmia (e.g.
ventricular ectopics, atrial fibrillation, ventricular tachycardia, atrial tachycardia). Irregularity of heart beat is described by the patient as missing of a beat or jumping or fluttering of heart, is seen in VPCs and atrial fibrillation.
• Palpitation associated with polyuria indicate supraventricular tachycardia. Patient describes it as racing or fluttering of the heart.
• Palpitation with breathlessness indicates either atrial fibrillation or ventricular tachycardia.
Ventricular tachycardia may present with syncope rather than palpitations.
Cough, sputum and haemoptysis
• These are discussed under respiratory symptoms.
Peripheral oedema (Read also the examination of extremities Chapter 10)
It is collection of fluid in the interstitial tissues. Pitting pedal oedema is demonstrated clinically by applying pressure with thumb on the ankles or feet which produces a pit at the site of pressure. The pit stays for sometime (about 10-15 sec) and then slowly disappears.
Peripheral oedema is seen on the ankles or over feet in ambulatory patients; while it appears on the sacrum and thighs in recumbent position or while in bed (bed-riddened patients). Oedema appearing on the face early in the morning is its example and is seen commonly in nephrotic syndrome. The different sites of oedema in different positions represent the effect of gravity.
Oedema may be unilateral or bilateral.
Peripheral oedema is associated with ascites and/
or pleural effusion in severe congestive heart failure. The causes of oedema are summarised in the Box 2.8. Non-pitting peripheral oedema is seen in hypothyroidism (myxoedema).
Box 2.8: CAUSESOFPERIPHERALPITTINGOEDEMA
Unilateral Bilateral
• Lymphatic obstruction e.g. • Congestive heart failure filariasis, pressure due to • Constrictive pericarditis growth. • Nephritic or nephrotic
• Venous obstruction (throm- syndrome
bosis) or insufficiency • Cirrhosis of liver, portal (varicose vein) hypertension
• Infection e.g. cellulitis, • Hypoproteinaemia
carbuncle • Beriberi
• Traumatic e.g. fracture/ • Inferior vena cava
sprains obstruction
• Hereditary e.g. Milroy’s • Angioneurotic oedema
disease • Epidemic dropsy
• Drug induced e.g.
pioglitazone, amlodipin Chest pain
Pain in chest of cardiac origin (originating from myocardium, pericardium, blood vessels etc) is called cardiac chest pain. Noncardiac chest pain also occurs due to a variety of extracardiac disorders and may simulate cardiac chest pain from which it has to be differentiated.
Here we will discuss cardiac chest pain. The causes of cardiac chest pain with their characteristics are given in the Table 2.14.
Syncope
It is loss of consciousness due to fall in BP (hypotension) leading to decreased cerebral perfusion. The feeling of impending loss of consciousness is called presyncope. Both syncope and presyncope may be of cardiac origin, occur due to either decreased cardiac output or decreased peripheral resistance or both. It may be a symptom of neurological disorder (Read syncope as a symptom of nervous system).
Other symptoms of cardiac disease Fatigue
Fatigue or tiredness is a common complaint of patients with heart failure, coronary artery disease, persistent cardiac arrhythmia, hypertension and cyanotic heart disease. It is due to poor cerebral perfusion and oxygenation. It can occur in patients with bacterial endocarditis.
Nocturia
Nocturia means excessive urination of night, can occur due to congestive heart failure. Oliguria can also occur in heart failure.
Cardiovascular disease presenting with noncardiac symptoms i.e.,
• Stroke may be a presenting feature of cerebral embolism from an intracardiac thrombus or atrial fibrillation, endocarditis and hypertension.
• Anorexia, nausea, abdominal pain and jaundice can occur due to liver congestion in patients with heart failure or mesenteric embolism.
Symptoms pertaining to the respiratory system
The symptoms which point to the disease of respiratory system are given in the Box 2.9. Special attention has to be given while taking history of a patient with respiratory disease. Always ask about the following:
1. Family history of tuberculosis, allergies, asthma.
2. Occupational history. Do the symptoms relate to his occupation? Stone cutters, asbestose workers, woollen industries workers have their symptoms increased when at work.
Box 2.9: SYMPTOMSOFRESPIRATORYSYSTEM
• Cough • Wheeze
• Sputum •Haemoptysis
• Dyspnoea • Chest pain
In case symptoms indicate involvement of respiratory system, then proceed to ask questions regarding family history of allergy, asthma and tuberculosis. History of smoking in the present and past is also an important point to be asked. If the disease is episodic like asthma or allergy, then ask whether attacks of breathlessness are spontaneous or induced. What brings about these attacks? Is there any relation of an attack with the dust or exercise or occupation?
Symptoms analysis Cough
Cough is defined as violent expiratory effort to clear the tracheobronchial secretion and is produced by rise in intra-bronchial or intratracheal pressure against closed glottis. With opening of the glottis, the pressure is
released with throwing of secretions out of trachea with production of sound of cough. The cough is the most frequent symptom of respiratory disease for which patient usually seeks medical advice. It is produced by stimulation of the sensory nerves of the mucosa of the pharynx, larynx, trachea and bronchi (smaller bronchi) by inflammatory, mechanical, chemical and thermal stimuli. Rarely, it may arise due to irritation or stimulation of the pleura during the aspiration of a pleural effusion.
The characteristics of cough depend on the site and the nature of the lesion as follows:
1. Post-nasal discharge into pharynx resulting from rhinitis or sinusitis, acute lower respiratory infection produces dry persistent cough
2. Laryngeal involvement (e.g. laryngitis, tumour, whooping) produces harsh, barking, painful persistent cough with stridor (loud sound)
3. Tracheitis produces painful coughing
4. The characteristics of cough originating at various levels of respiratory tract is given in the Box 2.10.
Box 2.10: CHARACTERISTICSOFCOUGHINDISEASESOFTHE BRONCHIANDSMALLAIRWAYS
Disease Nature of cough
Bronchitis Dry or productive, worse in the mornings Asthma Dry or productive, worse at night Bronchial Persistent, usually with haemoptysis carcinoma
Pneumonia Initially dry, later productive with or without blood tinge
Bronchiectasis Productive, copious in amount, postural relationship (change in posture induces sputum production)
Pulmonary Productive with pink frothy sputum, often oedema at night, associated dyspnoea,
orthop-noea, PND and crackles
Interstitial lung Dry, irritant and distressing cough disease
5. Cough with wheezing occurs in COPD and asthma.
The wheezing is nocturnal and reversible in asthma;
while it is irreversible, persistent in COPD.
Prolonged bouts of coughing may give rise to syncope.
6. Single vocal cord paralysis usually the left gives rise to prolonged low-pitched inefficient and bovine cough which is accompanied by hoarseness.
7. Cough may be intermittent/episodic (asthma) or persistent (COPD).
Box 2.11: DIFFERENTIATIONBETWEENHAEMOPTYSIS ANDHAEMATEMESIS
Haemoptysis Haematemesis
• Blood in the sputum Blood in the vomitus
• The prodromal symptom The prodrome is either is either irritation of throat nausea or abdominal
or cough discomfort
• Blood is bright red or Blood is magenta-coloured
frothy or brownish-black due to
formation of acid haematin
• Blood in sputum is Reaction of blood is acidic alkaline in reaction
• It is mixed with sputum It is mixed with food particles