iii.

Symptomatology

Signs/Symptoms Present Justification

Shortness of ✔ Difficulty in breathing (also known as shortness of breath,
Breath breathlessness, or dyspnea) is caused by various
mechanisms related to different problems in the body. The
shortness of breath in heart failure is caused by the
decreased ability of the heart to fill and empty, producing
elevated pressures in the blood vessels around the lung.
Pleural effusion is common in the patient with congestive
heart failure and shortness of breath are also one of the
symptoms of this condition, as the effusion grows larger
with more fluid, the harder it is for the lung to expand and
the more difficult it is for the patient to breathe. Common
symptoms of heart failure are difficulty in breathing upon
exertion seen in people with moderate heart failure
causing shortness of breath with minimal exertion.
Reference:
Beckerman J. (2016). Heart Problems that Affect Your
Breathing. Web.MD.
https://www.webmd.com/lung/heart-conditions-cause-
breathing-problems
Wheezing ✔ In addition to breathlessness, some people with heart
failure develop a cough or wheezing. The wheezing
experienced by CHF patients may be due to a narrowing
or obstruction of the bronchioles rather than simply to
pulmonary congestion. As fluid begins to move into the
lungs, the bronchioles will constrict in an effort to keep
fluid out. This constriction will create wheezing. This has
been referred to as cardiac asthma.

References:
 Mark.H. (2016). Cardiac Asthma: Not Your Typical
Asthma. https://www.uspharmacist.com/article/cardiac-
asthma-not-your-typical-asthma
Edgerly, D. (2017). The Stages of CHF | JEMS. JEMS.
https://www.jems.com/patient-care/stages-chf/
Crepitant moist ✔ In the clinical setting of heart failure, crepitant moist rales
rales and wheezing are auscultatory findings of fluid retention,
elevated left-sided heart filling pressures, and pulmonary
edema, which if uncorrected can progress to fluid
collection in the pleural space. These chest findings will
generally occur with other manifestations of fluid overload
and congestion—dyspnea, gallop sounds, loud P2, and
elevated jugular venous pressure.
References:
Leier, C. V., & Chatterjee, K. (2017). The Physical
Examination in Heart Failure Part II. Congestive Heart
Failure, 13(2), 99-0103. https://doi.org/10.1111/j.1527-
5299.2007.06491.x
Presence of S3 and ✔ The presence of a Third Heart Sound S3 may results from
S4 heart sound increased atrial pressure leading to increased flow rates,
as seen in congestive heart failure, which is the most
common cause of a S3. Associated dilated
cardiomyopathy with dilated ventricles also contribute to
the sound. On the other hand, a presence of a S4 heart
sound can be an important sign of diastolic heart failure or
active ischemia and is rarely a normal finding. Diastolic
heart failure frequently results from moderate to severe left
ventricular hypertrophy, or LVH, resulting in impaired
relaxation (compliance) of the LV. In this setting, a S4 is
often heard.

Reference:
 Silverman, M. E. (2021). The Third Heart Sound. Nih.gov;
Butterworths.
https://www.ncbi.nlm.nih.gov/books/NBK342/
Williams, E. S. (2021). The Fourth Heart Sound. Nih.gov;
Butterworths.
https://www.ncbi.nlm.nih.gov/books/NBK344/
High Blood ✔ With heart failure, the heart doesn't pump as well as it
Pressure should. So your body doesn't get enough blood and
oxygen. When this occurs, the body believes that there
isn't enough fluid inside its vessels. The body's hormone
and nervous systems try to make up for this by increasing
blood pressure, holding on to salt (sodium) and water in
the body, and increasing heart rate. These responses are
the body's attempt to compensate for the poor blood
circulation and backup of blood.
Reference:
Pai R. & Gabica M. (2020). Heart Failure: Compensation
by the Heart and Body | Michigan
Medicine.Uofmhealth.org.
https://www.uofmhealth.org/health-library/aa86963
Tachycardia ✔ If the body doesn’t receive enough oxygen the body's
hormone and nervous systems try to make up for this by
increasing the heart rate and the blood pressure. In some
circumstances this may cause Multiple different
arrhythmias can occur in patients with HF, resulting in
volume overload from reduced cardiac output.
References:
Patel, J. (2007). Tachycardia-Induced Heart Failure. The
Permanente Journal, 11(3). https://doi.org/10.7812/tpp/07-
008
Heart arrhythmia - Symptoms and causes. (2020). Mayo
Clinic;https://www.mayoclinic.org/diseases-
 conditions/heart-arrhythmia/symptoms-
Jugular Vein ✔ JVD is a sign of increased central venous pressure (CVP).
distention Increased blood volume, which can occur with heart
failure, or anything that interferes with filling of the right
atrium or movement of the blood into the right ventricle,
can increase the central venous pressure and the amount
of jugular vein distention.
Reference:
Roland, J. (2017). Jugular Vein Distention (JVD): Causes,
Assessment, and More. Healthline; Healthline Media.
https://www.healthline.com/health/jvd
Cardiomegaly ✔ An enlarged heart (cardiomegaly) means that the heart is
bigger than normal. The heart can become enlarged if the
muscle works so hard that it thickens, or if the chambers
widen. An enlarged heart isn’t a disease. It’s a symptom of
a heart defect or condition that makes the heart work
harder, such as cardiomyopathy, heart valve problems, or
high blood pressure.
Reference:
Watson, S. (2018). What Causes an Enlarged Heart
(Cardiomegaly) and How’s It Treated Healthline;
HealthlineMedia.
https://www.healthline.com/health/enlarged-heart#causes
Pallor or Cyanotic ✔ Peripheral cyanosis is the bluish discoloration of the distal
extremities (Hands, fingertips, toes), and can sometimes
involve circumoral and periorbital areas. Caused by
several problems and one of them is cardiovascular
problem such as heart failure, due to inadequate pumping
of blood in the heart and lack of pressure prevents the
delivery of adequate supply of oxygenated blood to the
cells and to the extremities causing cyanosis.
Reference:
 Parul P. & Amandeep G. (2021). Central and Peripheral
Cyanosis. Nih.gov; StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK559167/
Cold clammy skin ✔ People with heart failure may find that they often feel cold
in their arms, hands, feet, and legs (the extremities). This
happens because the body is circulating most of the
available blood to the brain and other vital organs to
compensate for the failing heart's inability to pump enough
blood to the entire body. As a result, the extremities get
less blood, and without blood to warm them, these parts of
your body feel cold.
Reference:
Pai R. et.al. (2019). Heart Failure: Less Common
Symptoms. (2019). HealthLink BC.
https://www.healthlinkbc.ca/health-topics/
Bilateral foot ✔ One of the symptoms arises if a person has congestive
Swelling heart failure, one or both of the heart's lower chambers
lose their ability to pump blood effectively. activating of a
series of humoral and neurohumoral mechanisms
(sympathetic (adrenergic) nervous system (SNS) and
renin–angiotensin–aldosterone system (RAAS) that
promote sodium and water reabsorption by the kidneys
and expansion of the extracellular fluid. As a result, blood
can back up in your legs, ankles and feet, causing edema.
Sometimes, this condition can cause fluid to accumulate in
your lungs (pulmonary edema), which can lead to
shortness of breath.

Reference:
Hartupee, J., & Mann, D. L. (2016). Neurohormonal
activation in heart failure with reduced ejection fraction.
Nature Reviews Cardiology, 14(1), 30–38.
 https://doi.org/10.1038/nrcardio.2016.163
Edema - Symptoms and causes. (2020). Mayo Clinic;
https://www.mayoclinic.org/diseases-
conditions/edema/symptoms-causes/syc-20366493
Pre-sacral edema ✔ Edema formation is relatively common in heart failure and
often represents volume overload, although it is frequently
a multifactorial process. Edema is gravity dependent and
thus it typically starts and resides in the feet and ankles.
For the bedridden patient, gravity will preferentially move
edema to the presacral area and to the dependent regions
of the legs, thighs, and back.
References:
Leier, C. V., & Chatterjee, K. (2017). The Physical
Examination in Heart Failure Part II. Congestive Heart
Failure, 13(2), 99-0103. https://doi.org/10.1111/j.1527-
5299.2007.06491.x
Left sided ✔ People who have hemiparesis are still able to move the
Weakness affected side of the body, but with limited strength. It is
also known as a complete or incomplete muscular
weakness or paralysis affecting either side of the body
after a stroke. And as well due to continuous fatigue made
by the Congestive Heart Failure, weakness on the left side
remained.
Reference:
Madormo, C. (2017, June 5). Everything You Should
Know About Hemiparesis. Healthline; Healthline Media.
https://www.healthline.com/health/hemiparesis
Change in mental Poor circulation to the brain and an imbalance in body
status chemistry can be signs of advancing heart failure. If the
brain does not get enough oxygen or sodium levels in the
blood are altered, a person may experience
lightheadedness, confusion and fainting.
Reference:
Malik, A., Brito, D., & Lovely Chhabra. (2021). Congestive
Heart Failure. Nih.gov; StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK430873/
Heart Failure: Types, Symptoms, Causes & Treatments.
(2015). Cleveland Clinic.
https://my.clevelandclinic.org/health/diseases/17069-
heart-failure-understanding-heart-failure

Fatigue ✔ Exercise intolerance and fatigue are often the most

common symptoms of heart failure. This tiredness or
fatigue occurs because less blood reaches the muscles
and tissues, due to the reducing pumping ability of the
heart.
Reference:
Fini, A., & Cruz, D. de A. L. M. da. (2019). Characteristics
of fatigue in heart failure patients: a literature review.
Revista Latino-Americana de Enfermagem, 17(4), 557–
565. https://doi.org/10.1590/s0104-11692009000400019
Chest pain Angina is chest pain or discomfort caused when the heart
muscle doesn't get enough oxygen-rich blood. Angina can
be described as a discomfort, heaviness, pressure,
aching, burning, fullness, squeezing, or painful feeling in
your chest. It can be mistaken for indigestion or heartburn.
Angina may also be felt in the shoulders, arms, neck,
throat, jaw, or back.
 Reference:
Beckerman J. (2021). Symptoms of Heart Disease.
WebMD; WebMD. https://www.webmd.com/heart-
disease/guide/heart-disease-symptoms
Angina (Chest Pain). (2015). Www.heart.org.
https://www.heart.org/en/health-topics/heart-attack/angina-
chest-pain
Weight gain Weight gain is the first sign that your heart failure may be
getting worse. One of the reasons of weight gain is the
fluid retention happening in the body causing edema to
various places. As fluid builds up, weight is also affected.
An increase in weight will usually happen quickly when it is
caused by fluid, with a gain of more than 2kg (4lbs 6oz)
over a couple of days. Whereas an increase that is caused
by body fat will usually happen more gradually over time.
Reference:
Klein G. et. al. (2021). Pathophysiology and management
of heart failure - The Pharmaceutical Journal. (2021,
February 12). The Pharmaceutical Journal.
https://pharmaceutical-
journal.com/article/ld/pathophysiology-and-management-
of-heart-failure
‌Heart Failure: Types, Symptoms, Causes & Treatments.
(2015). Cleveland Clinic.
https://my.clevelandclinic.org/health/diseases/17069-
heart-failure-understanding-heart-failure
Syncope Cardiovascular syncope is a brief loss of consciousness
(from a few seconds to a few minutes), that is
characterized by rapid onset and spontaneous recovery. It
is caused by decreased blood flow to the brain.
Reference:
 Mizrachi, E. M., & Sitammagari, K. K. (2021) Cardiac
Syncope. Nih.gov; StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK526027/
Cardiovascular syncope. (2021). Montreal Heart Institute.
https://www.icm-mhi.org/en/health-care-and-
services/cardiovascular-diseases/cardiovascular-syncope