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Diseases » Arrhythmias » Causes
 

Causes of Arrhythmias

Contents
  1. Arrhythmias: Introduction
  2. List of Causes
  3. Drugs/substances (68 causes)
  4. Drug interaction (572 causes)
  5. Hidden causes
  6. Excerpts from book chapters
  7. Complication causes
  8. Causes of symptoms
  9. News
  10. Related cause information

List of causes of Arrhythmias

Following is a list of causes or underlying conditions (see also Misdiagnosis of underlying causes of Arrhythmias) that could possibly cause Arrhythmias includes:

More causes: see full list of causes for Arrhythmias

Causes of Arrhythmias (Diseases Database):

The follow list shows some of the possible medical causes of Arrhythmias that are listed by the Diseases Database:

Source: Diseases Database

Arrhythmias Causes: Book Excerpts

Arrhythmias as a complication of other conditions:

Other conditions that might have Arrhythmias as a complication may, potentially, be an underlying cause of Arrhythmias. Our database lists the following as having Arrhythmias as a complication of that condition:

Arrhythmias as a symptom:

Conditions listing Arrhythmias as a symptom may also be potential underlying causes of Arrhythmias. Our database lists the following as having Arrhythmias as a symptom of that condition:

Medications or substances causing Arrhythmias:

The following drugs, medications, substances or toxins are some of the possible causes of Arrhythmias as a symptom. This list is incomplete and various other drugs or substances may cause your symptoms. Always advise your doctor of any medications or treatments you are using, including prescription, over-the-counter, supplements, herbal or alternative treatments.

See full list of 68 medications causing Arrhythmias


Drug interactions causing Arrhythmias:

When combined, certain drugs, medications, substances or toxins may react causing Arrhythmias as a symptom.

The list below is incomplete and various other drugs or substances may cause your symptoms. Always advise your doctor of any medications or treatments you are using, including prescription, over-the-counter, supplements, herbal or alternative treatments.

  • Entacapone and isoproterenol interaction
  • Comtan isoproterenol interaction
  • Entacapone and epinephrine interaction
  • Comtan epinephrine interaction
  • Entacapone and ephedrine interaction
  • more interactions...»

See full list of 572 drug interactions causing Arrhythmias

What causes Arrhythmias?

Article excerpts about the causes of Arrhythmias:

NHLBI, Arrhythmia: NHLBI (Excerpt)

Many times, there is no recognizable cause of an arrhythmia. Heart disease may cause arrhythmias. Other causes include: stress, caffeine, tobacco, alcohol, diet pills, and cough and cold medicines. (Source: excerpt from NHLBI, Arrhythmia: NHLBI)

NHLBI, Arrhythmia: NHLBI (Excerpt)

An arrhythmia may occur for one of several reasons:

  • Instead of beginning in the sinus node, the heartbeat begins in another part of the heart.
  • The sinus node develops an abnormal rate or rhythm.
  • A patient has a heart block.
(Source: excerpt from NHLBI, Arrhythmia: NHLBI)

Medical news summaries relating to Arrhythmias:

The following medical news items are relevant to causes of Arrhythmias:

Related information on causes of Arrhythmias:

As with all medical conditions, there may be many causal factors. Further relevant information on causes of Arrhythmias may be found in:

Causes of Arrhythmias: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about the causes of Arrhythmias.

Bradycardia: Differential Diagnosis
(In a Page: Signs and Symptoms)

  • Sinus bradycardia
    –Heart rate <60 bpm with normal-appearing P waves before each QRS wave (narrow complex)
    –Most often due to increased vagal tone or medications (e.g., β-blockers)
    –Normally seen in healthy young adults and well-trained athletes
    –May occur with hypothermia, advanced liver disease, hypothyroidism, sinoatrial node disease, anorexia nervosa, sleep disorders, and increased intracranial pressure
  • Medications (e.g., β-blockers)
  • Sinus node dysfunction
    –May occur as result of sinus node fibrosis (e.g., aging) or infiltrative diseases (e.g., amyloidosis)
    –SSS: Symptomatic bradycardia with sinus node dysfunction
    –Tachycardia-bradycardia syndrome: SSS manifested by tachyarrhthymias alternating with bradyarrhthymias
  • Heart block
    –First-degree AV block: Fixed prolongation of PR interval (PR ≥200 msec); results from slowed conduction through AV node
    –Second-degree AV block, Mobitz I (Wenckebach): Results from delayed conduction through AV node; progressive prolongation of PR interval occurs until a QRS is dropped (typically benign)
    –Second-degree AV block, Mobitz II: Results from disease in the bundle of His; PR is constant, but sporadic P waves are not conducted (may be life threatening because of risk of complete heart block or ventricular asystole)
    –Complete heart block: Atrial impulses are not conducted to the ventricles; thus, atrial activity occurs independent of ventricular activity (AV dissociation, with atrial rate faster than ventricular rate)
  • Congenital heart block
  • Aortic stenosis
  • Myocardial infarction
    –More common with inferior wall MI
  • Atrial fibrillation/flutter with high-degree block
  • Infections (e.g., Lyme disease)
>

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Palpitations: Differential Diagnosis
(In a Page: Signs and Symptoms)

  • Premature atrial contractions
  • Premature ventricular contractions
  • Sinus tachycardia
    –Regular heart rhythm at 100–140 bpm
  • Atrial fibrillation
    –Irregularly irregular heart rate
  • Atrial flutter
    –Regular heart rhythm at about 150 bpm
  • Drugs leading to tachyarrhythmias (e.g., aminophylline, amphetamines, alcohol, atropine, cocaine, coffee, epinephrine, ephedrine, MAO inhibitors, tea, thyroid extract, tobacco)
  • Psychiatric disorders (anxiety, panic reactions)
  • Anemia (with exertion)
  • Heart failure (with exertion)
  • Menopausal syndrome (with hot flashes)
  • Paroxysmal atrial tachycardia
  • Re-entry tachycardias, including Wolff-Parkinson-White syndrome
  • Ventricular tachycardia
  • Atrioventricular heart blocks
  • Junctional tachycardia
  • Mitral valve prolapse
  • Myocardial ischemia
  • Hyperthyroidism-associated arrhythmias
  • Severe deconditioning (with exertion)
  • Hypoglycemia
  • Postural hypotension
  • Atrial septal defect
  • Adrenal tumor
  • Pheochromocytoma

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Tachycardia: Differential Diagnosis
(In a Page: Signs and Symptoms)

  • Sinus tachycardia
    –Regular rhythm, narrow QRS complex
    –Originates at sinus node (normal P waves)
    –Occurs in response to physiologic stimuli (e.g., volume depletion, fever, pain, thyrotoxicosis)
  • Ectopic atrial tachycardia
    –Regular rhythm, narrow QRS complex
    –Atrial focus other than sinus node
    –P waves are often inverted in inferior leads
    • Atrial flutter
      –Narrow QRS complex
      –Usually regular, but may be irregular
      –Caused by a re-entrant circuit in atrium
      –Characteristic “sawtooth” pattern on ECG
      –Atrial rate typically 250–350 bpm
      –Ventricular rate usually 1/2 atrial rate (2:1 block), but may be 3:1, 4:1, etc.
  • Junctional tachycardia
    –Regular rhythm, narrow QRS complex
    –Originates in AV node
    –P waves may be absent or retrograde
  • AVNRT
    –Regular rhythm, narrow QRS complex
    –Due to reentrant circuit in or near AV node
    –Rate typically 170–220 bpm
    –P waves may be absent or retrograde
  • Orthodromic AV reentrant tachycardia
    –Regular rhythm, narrow QRS complex
    –Caused by reentrant circuit at AV node
    –Abrupt onset/offset
    –WPW syndrome is most common example
    –ECG reveals delta waves
  • Ventricular tachycardia
    –Regular rhythm, wide QRS complex
    –AV dissociation on ECG
    –May cause sudden cardiac death
    –Typically occurs in setting of acute coronary ischemia; other causes include cardiomyopathy, electrolyte disturbances (e.g., hypokalemia, hypomagnesemia), drug toxicity, or congenital abnormalities
    –Torsade de pointes is a specific form of VT associated with electrolyte abnormalities and drug toxicity
  • Antidromic AVRT
    –Wide QRS complex
    –Conduction occurs down bypass tract and up AV node
    –Less common than orthodromic AVRT

    • » READ BOOK EXCERPT ONLINE »

    Source: In a Page: Signs and Symptoms, 2004

    Irregular Heart Rhythms: Differential Diagnosis
    (In a Page: Signs and Symptoms)

    • Atrial fibrillation
      –One of the most common causes of irregular rhythm
      –Narrow QRS complex without organized atrial contraction (no P waves)
      –Etiologies include infection, thyrotoxicosis, alcohol, cocaine, amphetamines, myocarditis, pericarditis, hypertensive crisis, ischemia, MI, CHF, hypoxia, PE, hypertension, valvular heart disease
    • Atrial flutter with variable block
      –Narrow QRS complex
      –ECG: “Sawtooth” flutter waves
      –Atrial rate is typically 250–350 bpm
      –Ventricular rate is usually 1/2 or 1/3 of atrial rate (2:1 or 3:1 block)
      –Irregular when variable block is present
      –Result of a macro-reentrant circuit in atrium
    • Premature atrial contractions
    • Paroxysmal atrial tachycardia
    • Multifocal atrial tachycardia
      –Multiple areas of atrial impulses (more than three P wave morphologies) followed by a narrow QRS complex
      –HR ≥ 100 bpm
      –Most often seen in patients with lung disease
    • Wandering atrial pacemaker
      –Multiple areas of atrial impulses (more than three P wave morphologies) followed by a narrow QRS complex
      –HR ≤ 100 bpm
      –Often occurs in athletes and the very young (increased vagal tone)
    • Premature ventricular contractions
    • Sinus arrhythmia

    » READ BOOK EXCERPT ONLINE »

    Source: In a Page: Signs and Symptoms, 2004

    Murmurs - Diastolic: Differential Diagnosis
    (In a Page: Signs and Symptoms)

    • Aortic insufficiency
      –Decrescendo murmur heard best at the right second intercostal space
    • Austin Flint murmur
      –Late diastolic rumble of severe aortic regurgitation
      –A result of aortic regurgitation so severe that it causes diastolic mitral regurgitation
    • Mitral stenosis
      –Opening snap with mid-diastolic rumble, especially in the left lateral decubitus position
    • Pulmonary insufficiency
      –Accentuated P2 and decrescendo murmur at the left second/third intercostal spaces
    • Tricuspid stenosis
      –Mid-diastolic rumble at the left sternal border
      –Increases with inspiration
    • Cervical venous hum (disappears upon pressure to the jugular vein)
    • Hepatic venous hum (disappears with epigastric pressure)
    • Mammary souffle (in pregnancy; disappears on compressing breast)
    • PDA (continuous machinery sound)
    • Coronary or pulmonary arteriovenous fistula
    • Coarctation of the aorta
    • ASD with left-to-right shunt
    • Atrial myxoma (“tumor plop”)
    • Pericardial knock (constrictive pericarditis)
    • Bronchial collaterals (congenital heart disease)
    • Anomalous pulmonary venous drainage with left-to-right shunt
    • Pulmonary artery branch stenosis
    • Carey-Coombs murmur (mid-diastolic murmur that occurs in acute rheumatic fever)

    » READ BOOK EXCERPT ONLINE »

    Source: In a Page: Signs and Symptoms, 2004

    Murmurs - Systolic: Differential Diagnosis
    (In a Page: Signs and Symptoms)

    • Innocent systolic murmur
      –Heard at left sternal border
      –Increased when supine
      –May be caused by increased flow states (e.g., anemia, hypovolemia, fever)
    • Still's murmur
    • Mitral valve prolapse
      –Midsystolic click with late systolic murmur that shifts with maneuvers
    • Aortic stenosis
      –Right side at second intercostal space
      –Radiates to carotid arteries
    • Aortic sclerosis
      –Right side at second intercostal space
      –Midsystole
    • Hyperthyroidism
    • Cervical venous hum
      –Disappears with jugular vein pressure
    • Hepatic venous hum
      –Disappears with epigastric pressure
    • Mammary souffle
      –Occurs in pregnancy
      –Disappears upon compression of breast
    • Bicuspid aortic valve
      –Right side at second intercostal space
      –Little radiation
      –Possible early diastolic aortic murmur
      –Opening sound of aortic valve heard in early systole (systolic ejection click)
    • Mitral insufficiency
      –Holosystolic murmur heard best in the left lateral decubitus position
      –S1 is usually diminished in intensity
    • Tricuspid insufficiency
      –Holosystolic murmur at second/third intercostal spaces
    • Endocarditis
      –Abrupt onset of new murmur
    • Peripheral pulmonary artery stenosis
    • Atrial or ventricular septal defect
    • Ventricular septal defect
    • Patent ductus arteriosus (continuous machinery sound, second left intercostal space)
    • Coarctation of the aorta
    • Left ventricular outflow tract obstruction
    • Pulmonary artery stenosis
    • Prosthetic valve noises
    • Pericardial friction rubs
    • Papillary muscle dysfunction
    • Pulmonic outflow obstruction
    • Coronary/pulmonary arteriovenous fistula

    » READ BOOK EXCERPT ONLINE »

    Source: In a Page: Signs and Symptoms, 2004

    Bradycardia: Differential Diagnosis
    (In A Page: Pediatric Signs and Symptoms)

      • Vasovagal response
        –Defecation, yawning, rectal stimulation, placement of nasogastric tube, sight of blood, etc.
      • Drug reaction
        –β-blockers, calcium channel blockers (diltiazem, verapamil), carbamates, clonidine, digoxin, opiates, organophosphates, gamma-hydroxybutyrate (“date rape” drug), and plants (lily of the valley, foxglove, oleander)
    • Healthy athlete
      –Sinus bradycardia
    • Hypothermia
    • GER (in infants, especially premature)
    • Low birth weight infants: Sinus bradycardia (great variations in sinus rate, can have junctional escape beats)
    • Congenital complete heart block: Associated with maternal SLE
    • Congenital heart disease
    • Sepsis
    • Obstructive sleep apnea
      –Seen in children with obesity, tonsillar or adenoid hypertrophy, craniofacial anomalies, neuromuscular diseases
      –Hypoxia and hypercapnia lead to pulmonary hypertension and arrhythmia
    • Electrolyte abnormalities can lead to dysrhythmias
      • Anorexia nervosa
        –Prolonged QT syndrome and junctional arrhythmia
        –Associated hypokalemia may also cause ECG changes and life-threatening dysrhythmias
    • AV node blocks (second- and third-degree)
    • Idioventricular rhythm
    • Hypothyroidism (myxedema)
    • Allergic reaction/anaphylaxis
    • Increased intracranial pressure (IVH, extradural hemorrhage, trauma, etc.)
    • Sick sinus syndrome (tachy-brady syndrome)
    • Psittacosis, typhoid fever, Lassa fever
    • Myocardial infarction

    » READ BOOK EXCERPT ONLINE »

    Source: In A Page: Pediatric Signs and Symptoms, 2007

    Tachycardia/Palpitations: Differential Diagnosis
    (In A Page: Pediatric Signs and Symptoms)

    • Sinus tachycardia
      –Most common cause of a fast heart rate
      –Normal response to stress (fever, pain, anxiety, dehydration, exercise, anemia, caffeine, tobacco, albuterol)
      –<180 beats/min and variable; ECG shows an upright P wave in lead I and AVF
    • Supraventricular tachycardia (SVT)
      –Most common pathologic cause of tachycardia/palpitations in children
      –Narrow QRS complex (<0.08 seconds)
      –Almost all hemodynamically stable
      –Often paroxysmal
      –Usually AV re-entry or AV node re-entry; both have HR >180 and intermittent sudden onset and resolution
    • AV re-entry
      –Involves an accessory electrical bypass tract connecting the atrium and ventricle (thereby “bypassing” the AV node)
      –Often associated with Wolff-Parkinson-White (WPW) syndrome (short PR interval, widened QRS interval, “delta” wave)
      –Most common in <10 years of age
    • AV node re-entry
      –Involves re-entry within the AV node
      –Most common in >10 yrs of age
    • Atrial fibrillation/flutter
      –Occurs almost exclusively in patients with underlying congenital heart disease
      –Macro (flutter) or micro (fibrillation) re-entry circuits within the atrium, usually around an old surgical scar
      –Common in patients status post-Fontan or Mustard-Senning procedures
    • Ectopic/multifocal atrial tachycardia
      –Involves one or more automatic electrical foci in the atrium causing irregular tachycardia with a heart rate <180
      –The tachycardia has a slow onset and resolution
    • Wide-complex tachycardia
      –Assume ventricular tachycardia until proven otherwise
      –SVT with bundle branch block (either permanent or rate-related)
      –Antidromic WPW: Re-entry loop in which the ventricle is depolarized via the bypass tract, creating a wide-complex tachycardia

      • >>>>

    » READ BOOK EXCERPT ONLINE »

    Source: In A Page: Pediatric Signs and Symptoms, 2007

    Bradycardia: Medical causes
    (Handbook of Signs & Symptoms (Third Edition))

    ❑ Cardiac arrhythmia. Depending on the type of arrhythmia and the patient's tolerance of it, bradycardia may be transient or sustained, benign or life-threatening. Related findings include hypotension, palpitations, dizziness, weakness, syncope, and fatigue.

    ❑ Cardiomyopathy. Cardiomyopathy is a potentially life-threatening disorder that may cause transient or sustained bradycardia. Other findings include dizziness, syncope, edema, fatigue, jugular vein distention, orthopnea, dyspnea, and peripheral cyanosis.

    ❑ Hypothermia. Bradycardia usually appears when the core temperature drops below 89.6° F (32° C). It's accompanied by shivering, peripheral cyanosis, muscle rigidity, bradypnea, and confusion leading to stupor.

    ❑ Hypothyroidism. Hypothyroidism causes severe bradycardia in addition to fatigue, constipation, unexplained weight gain, and sensitivity to cold. Related signs include cool, dry, thick skin; sparse, dry hair; facial swelling; periorbital edema; thick, brittle nails; and confusion leading to stupor.

    ❑ Myocardial infarction (MI). Sinus bradycardia is the most common arrhythmia associated with an acute MI. Accompanying signs and symptoms of an MI include an aching, burning, or viselike pressure in the chest that may radiate to the jaw, shoulder, arm, back, or epigastric area; nausea and vomiting; cool, clammy, and pale or cyanotic skin; anxiety; and dyspnea. Blood pressure may be elevated or depressed. Auscultation may reveal abnormal heart sounds.

    Other causes

    ❑ Diagnostic tests. Cardiac catheterization and electrophysiologic studies can induce temporary bradycardia.

    ❑ Drugs. Beta-adrenergic blockers and some calcium channel blockers, cardiac glycosides, topical miotics (such as pilocarpine), protamine, quinidine and other antiarrhythmics, and sympatholytics may cause transient bradycardia. Failure to take thyroid replacements may cause bradycardia.

    ❑ Invasive treatments. Suctioning can induce hypoxia and vagal stimulation, causing bradycardia. Cardiac surgery can cause edema or damage to conduction tissues, causing bradycardia.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Murmurs: Medical causes
    (Handbook of Signs & Symptoms (Third Edition))

    Aortic insufficiency

    Acute aortic insufficiency typically produces a soft, short diastolic murmur over the left sternal border that’s best heard when the patient sits and leans forward and at the end of a forced held expiration. S2 may be soft or absent. Sometimes, a soft, short midsystolic murmur may also be heard over the second right intercostal space. Associated findings include tachycardia, dyspnea, jugular vein distention, crackles, increased fatigue, and pale, cool extremities.

    Chronic aortic insufficiency causes a high-pitched, blowing, decrescendo diastolic murmur that’s best heard over the second or third right intercostal space or the left sternal border with the patient sitting, leaning forward, and holding his breath after deep expiration. An Austin Flint murmur — a rumbling, mid-to-late diastolic murmur best heard at the apex — may also occur. Complications may not develop until the patient is between ages 40 to 50; then, typical findings include palpitations, tachycardia, angina, increased fatigue, dyspnea, orthopnea, and crackles.

    Aortic stenosis

    With aortic stenosis, the murmur is systolic, beginning after S1 and ending at or before aortic valve closure. It’s harsh and grating, medium-pitched, and crescendo-decrescendo. Loudest over the second right intercostal space when the patient is sitting and leaning forward, this murmur may also be heard at the apex, at the suprasternal notch (Erb’s point), and over the carotid arteries.

    If the patient has advanced disease, S2 may be heard as a single sound, with inaudible aortic closure. An early systolic ejection click at the apex is typical, but is absent when the valve is severely calcified. Associated signs and symptoms usually don’t appear until age 30 in congenital aortic stenosis, ages 30 to 65 in stenosis due to rheumatic disease, and after age 65 in calcific aortic stenosis. They may include dizziness, syncope, dyspnea on exertion, paroxysmal nocturnal dyspnea, fatigue, and angina.

    Cardiomyopathy (hypertrophic)

    Hypertrophic cardiomyopathy generates a harsh late systolic murmur, ending at S2. Best heard over the left sternal border and at the apex, the murmur is commonly accompanied by an audible S3or S4. The murmur decreases with squatting and increases with sitting down. Major associated symptoms are dyspnea and chest pain; palpitations, dizziness, and syncope may also occur.

    Mitral insufficiency

    Acute mitral insufficiency is characterized by a medium-pitched blowing, early systolic or holosystolic decrescendo murmur at the apex, along with a widely split S2 and commonly an S4. This murmur doesn’t get louder on inspiration as with tricuspid insufficiency. Associated findings typically include tachycardia and signs of acute pulmonary edema.

    Chronic mitral insufficiency produces a high-pitched, blowing, holosystolic plateau murmur that’s loudest at the apex and usually radiates to the axilla or back. Fatigue, dyspnea, and palpitations may also occur.

    Mitral prolapse

    Mitral prolapse generates a midsystolic to late-systolic click with a high-pitched late-systolic crescendo murmur, best heard at the apex. Occasionally, multiple clicks may be heard, with or without a systolic murmur. Associated findings include cardiac awareness, migraine headaches, dizziness, weakness, syncope, palpitations, chest pain, dyspnea, severe episodic fatigue, mood swings, and anxiety.

    Mitral stenosis

    With mitral stenosis, the murmur is soft, low-pitched, rumbling, crescendo-decrescendo, and diastolic, accompanied by a loud S1 or an opening snap — a cardinal sign. It’s best heard at the apex with the patient in the left lateral position. Mild exercise helps make this murmur audible.

    With severe stenosis, the murmur of mitral regurgitation may also be heard. Other findings include hemoptysis, exertional dyspnea and fatigue, and signs of acute pulmonary edema.

    Myxomas

    A left atrial myxoma (most common) usually produces a mid- diastolic murmur and a holosystolic murmur that’s loudest at the apex, with an S4, an early diastolic thudding sound (tumor plop), and a loud, widely split S1.Related features include dyspnea, orthopnea, chest pain, fatigue, weight loss, and syncope.

    A right atrial myxoma causes a late diastolic rumbling murmur, a holosystolic crescendo murmur, and tumor plop, best heard at the lower left sternal border. Other findings include fatigue, peripheral edema, ascites, and hepatomegaly.

    A left ventricular myxoma (rare) produces a systolic murmur, best heard at the lower left sternal border; arrhythmias; dyspnea; and syncope.

    A right ventricular myxoma commonly generates a systolic ejection murmur with delayed S2 and a tumor plop, best heard at the left sternal border. It’s accompanied by peripheral edema, hepatomegaly, ascites, dyspnea, and syncope.

    Papillary muscle rupture

    With papillary muscle rupture — a life-threatening complication of an acute MI — a loud holosystolic murmur can be auscultated at the apex. Related findings include severe dyspnea, chest pain, syncope, hemoptysis, tachycardia, and hypotension.

    Rheumatic fever with pericarditis

    A pericardial friction rub along with murmurs and gallops are heard best with the patient leaning forward on his hands and knees during forced expiration. The most common murmurs heard are the systolic murmur of mitral regurgitation, a midsystolic murmur due to swelling of the mitral valve leaflet, and the diastolic murmur of aortic regurgitation. Other signs and symptoms include a fever, joint and sternal pain, edema, and tachypnea.

    Tricuspid insufficiency

    Tricuspid insufficiency is a valvular abnormality that’s characterized by a soft, high-pitched, holosystolic blowing murmur that increases with inspiration (Carvallo’s sign), decreases with exhalation and Valsalva’s maneuver, and is best heard over the lower left sternal border and the xiphoid area. Following a lengthy asymptomatic period, exertional dyspnea and orthopnea may develop, along with jugular vein distention, ascites, peripheral cyanosis and edema, muscle wasting, fatigue, weakness, and syncope.

    Tricuspid stenosis

    Tricuspid stenosis is a valvular disorder that produces a diastolic murmur similar to that of mitral stenosis, but louder with inspiration and decreased with exhalation and Valsalva’s maneuver. S1 may also be louder. Associated signs and symptoms include fatigue, syncope, peripheral edema, jugular vein distention, ascites, hepatomegaly, and dyspnea.

    Other causes

    Treatments

    Prosthetic valve replacement may cause variable murmurs, depending on the location, valve composition, and method of operation.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Palpitations: Medical causes
    (Handbook of Signs & Symptoms (Third Edition))

    Anxiety attack (acute)

    Anxiety is the most common cause of palpitations in children and adults. With this disorder, palpitations may be accompanied by diaphoresis, facial flushing, trembling, and an impending sense of doom. Almost invariably, patients hyperventilate, which may lead to dizziness, weakness, and syncope. Other typical findings include tachycardia, precordial pain, shortness of breath, restlessness, and insomnia.

    Cardiac arrhythmias

    Paroxysmal or sustained palpitations may be accompanied by dizziness, weakness, and fatigue. The patient may also experience an irregular, rapid, or slow pulse rate; decreased blood pressure; confusion; pallor; oliguria; and diaphoresis.

    Hypertension

    With hypertension, the patient may be asymptomatic or may complain of sustained palpitations alone or with a headache, dizziness, tinnitus, and fatigue. His blood pressure typically exceeds 140/90 mm Hg. He may also experience nausea and vomiting, seizures, and a decreased level of consciousness.

    Hypocalcemia

    Typically, hypocalcemia produces palpitations, weakness, and fatigue. It progresses from paresthesia to muscle tension and carpopedal spasms. The patient may also exhibit muscle twitching, hyperactive deep tendon reflexes, chorea, and positive Chvostek’s and Trousseau’s signs.

    Mitral prolapse

    Mitral prolapse is a valvular disorder that may cause paroxysmal palpitations accompanied by sharp, stabbing, or aching precordial pain. The hallmark of this disorder, however, is a midsystolic click followed by an apical systolic murmur. Associated signs and symptoms may include dyspnea, dizziness, severe fatigue, a migraine headache, anxiety, paroxysmal tachycardia, crackles, and peripheral edema.

    Mitral stenosis

    Early features of mitral stenosis typically include sustained palpitations accompanied by exertional dyspnea and fatigue. Auscultation also reveals a loud S1 or opening snap and a rumbling diastolic murmur at the apex. Patients may also experience related signs and symptoms, such as an atrial gallop and, with advanced mitral stenosis, orthopnea, dyspnea at rest, paroxysmal nocturnal dyspnea, peripheral edema, jugular vein distention, ascites, hepatomegaly, and atrial fibrillation.

    Thyrotoxicosis

    A characteristic symptom of thyrotoxicosis, sustained palpitations may be accompanied by tachycardia, dyspnea, weight loss despite increased appetite, diarrhea, tremors, nervousness, diaphoresis, heat intolerance and, possibly, exophthalmos and an enlarged thyroid. The patient may also experience an atrial or a ventricular gallop.

    Other causes

    Drugs

    Palpitations may result from drugs that precipitate cardiac arrhythmias or increase cardiac output, such as cardiac glycosides; sympathomimetics, such as cocaine; ganglionic blockers; beta-adrenergic blockers; calcium channel blockers; atropine; and minoxidil.

    Herb Alert

    Herbal remedies, such as ginseng, may cause adverse reactions, including palpitations and an irregular heartbeat.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Pulse rhythm abnormality: Medical causes
    (Handbook of Signs & Symptoms (Third Edition))

    Arrhythmias

    An abnormal pulse rhythm may be the only sign of a cardiac arrhythmia. The patient may complain of palpitations, a fluttering heartbeat, or weak and skipped beats. Pulses may be weak and rapid or slow. Depending on the specific arrhythmia, dull chest pain or discomfort and hypotension may occur. Associated findings, if any, reflect decreased cardiac output. Neurologic findings, for example, include confusion, dizziness, light-headedness, a decreased LOC and, sometimes, seizures. Other findings include decreased urine output, dyspnea, tachypnea, pallor, and diaphoresis.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Pulse, absent or weak: Medical causes
    (Handbook of Signs & Symptoms (Third Edition))

    Aortic aneurysm (dissecting)

    When a dissecting aneurysm affects circulation to the innominate, left common carotid, subclavian, or femoral artery, it causes weak or absent arterial pulses distal to the affected area. Absent or diminished pulses occur in 50% of patients with proximal dissection and usually involve the brachiocephalic vessels. Pulse deficits are much less common in patients with distal dissection and tend to involve the left subclavian and femoral arteries. Tearing pain usually develops suddenly in the chest and neck and may radiate to the upper and lower back and abdomen. Other findings include syncope, loss of consciousness, weakness or transient paralysis of the legs or arms, the diastolic murmur of aortic insufficiency, systemic hypotension, and mottled skin below the waist.

    Aortic arch syndrome (Takayasu’s arteritis)

    Aortic arch syndrome produces weak or abruptly absent carotid pulses and unequal or absent radial pulses. These signs are usually preceded by malaise, night sweats, pallor, nausea, anorexia, weight loss, arthralgia, and Raynaud’s phenomenon. Other findings include neck, shoulder, and chest pain; paresthesia; intermittent claudication; bruits; vision disturbances; dizziness; and syncope. If the carotid artery is involved, diplopia and transient blindness may occur.

    Aortic bifurcation occlusion (acute)

    Aortic bifurcation occlusion is a rare disorder that produces abrupt absence of all leg pulses. The patient reports moderate to severe pain in the legs and, less commonly, in the abdomen, lumbosacral area, or perineum. Also, his legs are cold, pale, numb, and flaccid.

    Aortic stenosis

    With aortic stenosis, the carotid pulse is sustained but weak. Dyspnea (especially on exertion or paroxysmal nocturnal), chest pain, and syncope dominate the clinical picture. The patient commonly has an atrial gallop. Other findings include a harsh systolic ejection murmur, crackles, palpitations, fatigue, and narrowed pulse pressure.

    Arrhythmias

    Cardiac arrhythmias may produce generalized weak pulses accompanied by cool, clammy skin. Other findings reflect the arrhythmia’s severity and may include hypotension, chest pain, dyspnea, dizziness, and a decreased level of consciousness (LOC).

    Arterial occlusion

    With acute occlusion, arterial pulses distal to the obstruction are unilaterally weak and then absent. The affected limb is cool, pale, and cyanotic, with an increased capillary refill time, and the patient complains of moderate to severe pain and paresthesia. A line of color and temperature demarcation develops at the level of obstruction. Varying degrees of limb paralysis may also occur, along with intense intermittent claudication. With chronic occlusion, occurring with disorders such as arteriosclerosis and Buerger’s disease, pulses in the affected limb weaken gradually.

    Cardiac tamponade

    Life-threatening cardiac tamponade causes a weak, rapid pulse accompanied by these classic findings: paradoxical pulse, jugular vein distention, hypotension, and muffled heart sounds. Narrowed pulse pressure, pericardial friction rub, and hepatomegaly may also occur. The patient may appear anxious, restless, and cyanotic and may have chest pain, clammy skin, dyspnea, and tachypnea.

    Coarctation of the aorta

    Findings of coarctation of the aorta include bounding pulses in the arms and neck, with decreased pulsations and systolic pulse pressure in the lower extremities.

    Peripheral vascular disease

    Peripheral vascular disease causes a weakening and loss of peripheral pulses. The patient complains of aching pain distal to the occlusion that worsens with exercise and abates with rest. The skin feels cool and shows decreased hair growth. Impotence may occur in male patients with occlusion in the descending aorta or femoral areas.

    Pulmonary embolism

    Pulmonary embolism causes a generalized weak, rapid pulse. It may also cause an abrupt onset of chest pain, tachycardia, dyspnea, apprehension, syncope, diaphoresis, and cyanosis. Acute respiratory findings include tachypnea, dyspnea, decreased breath sounds, crackles, a pleural friction rub, and a cough — possibly with blood-tinged sputum.

    Shock

    With anaphylactic shock, pulses become rapid and weak and then uniformly absent within seconds or minutes after exposure to an allergen. This is preceded by hypotension, anxiety, restlessness, feelings of doom, intense itching, a pounding headache and, possibly, urticaria.

    With cardiogenic shock, peripheral pulses are absent and central pulses are weak, depending on the degree of vascular collapse. Pulse pressure is narrow. A drop in systolic blood pressure to 30 mm Hg below baseline, or a sustained reading below 80 mm Hg, produces poor tissue perfusion. Resulting signs include cold, pale, clammy skin; tachycardia; rapid, shallow respirations; oliguria; restlessness; confusion; and obtundation.

    With hypovolemic shock, all pulses in the extremities become weak and then uniformly absent, depending on the severity of hypovolemia. As shock progresses, remaining pulses become thready and more rapid. Early signs of cardiogenic shock include restlessness, thirst, tachypnea, and cool, pale skin. Late signs include hypotension with narrowing pulse pressure, clammy skin, a drop in urine output to less than
    25 ml/hour, confusion, a decreased LOC and, possibly, hypothermia.

    With septic shock, all pulses in the extremities first become weak. Depending on the degree of vascular collapse, pulses may then become uniformly absent. Shock is heralded by chills, a sudden fever and, possibly, nausea, vomiting, and diarrhea. Typically, the patient experiences tachycardia, tachypnea, and flushed, warm, and dry skin. As shock progresses, he develops thirst, hypotension, anxiety, restlessness, and confusion. Then pulse pressure narrows and the skin becomes cold, clammy, and cyanotic. The patient experiences severe hypotension, oliguria or anuria, respiratory failure, and coma.

    Thoracic outlet syndrome

    A patient with thoracic outlet syndrome may develop gradual or abrupt weakness or loss of the pulses in the arms, depending on how quickly vessels in the neck compress. These pulse changes commonly occur after the patient works with his hands above his shoulders, lifts a weight, or abducts his arm. Paresthesia and pain occur along the ulnar distribution of the arm and disappear as soon as the patient returns his arm to a neutral position. The patient may also have asymmetrical blood pressure and cool, pale skin.

    Other causes

    Treatments

    Localized absent pulse may occur distal to arteriovenous shunts for dialysis.

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    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Pulsus bisferiens: Medical causes
    (Handbook of Signs & Symptoms (Third Edition))

    Aortic insufficiency

    Aortic insufficiency is a heart defect that’s the most common organic cause of a biferious pulse. Most patients with chronic aortic insufficiency are asymptomatic until ages 40 to 50. However, exertional dyspnea, worsening fatigue, orthopnea and, eventually, paroxysmal nocturnal dyspnea may develop.

    Acute aortic insufficiency may produce signs and symptoms of left-sided heart failure and cardiovascular collapse, such as weakness, severe dyspnea, hypotension, a ventricular gallop, and tachycardia. Additional findings include chest pain, palpitations, pallor, and strong, abrupt carotid pulsations. The patient may also exhibit widened pulse pressure and one or more murmurs, especially an apical diastolic rumble (Austin Flint murmur).

    High cardiac output states

    Pulsus bisferiens commonly occurs with high output states, such as anemia, thyrotoxicosis, a fever, and exercise. Associated findings vary with the underlying cause and may include moderate tachycardia, a cervical venous hum, and widened pulse pressure.

    Hypertrophic obstructive cardiomyopathy

    About 40% of patients with hypertrophic obstructive cardiomyopathy have pulsus bisferiens because of a pressure gradient in the left ventricular outflow tract. Recorded more often than it’s palpated, the pulse rises rapidly, and the first wave is the more forceful one. Associated findings include a systolic murmur, dyspnea, angina, fatigue, and syncope.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Tachycardia: Medical causes
    (Handbook of Signs & Symptoms (Third Edition))

    Acute respiratory distress syndrome (ARDS)

    Besides tachycardia, ARDS causes crackles, rhonchi, dyspnea, tachypnea, nasal flaring, and grunting respirations. Other findings include cyanosis, anxiety, decreased LOC, and abnormal chest X-ray findings.

    Adrenocortical insufficiency

    With adrenocortical insufficiency, tachycardia commonly occurs with a weak pulse as well as progressive weakness and fatigue, which may become so severe that the patient requires bed rest. Other signs and symptoms include abdominal pain, nausea and vomiting, altered bowel habits, weight loss, orthostatic hypotension, irritability, bronze skin, decreased libido, and syncope. Some patients report an enhanced sense of taste, smell, and hearing.

    Anaphylactic shock

    With life-threatening anaphylactic shock, tachycardia and hypotension develop within minutes after exposure to an allergen, such as penicillin or an insect sting. Typically, the patient is visibly anxious and has severe pruritus, perhaps with urticaria and a pounding headache. Other findings may include flushed and clammy skin, a cough, dyspnea, nausea, abdominal cramps, seizures, stridor, change or loss of voice associated with laryngeal edema, and urinary urgency and incontinence.

    Anemia

    Tachycardia and bounding pulse are characteristic with anemia. Associated signs and symptoms include fatigue, pallor, dyspnea and, possibly, bleeding tendencies. Auscultation may reveal an atrial gallop, a systolic bruit over the carotid arteries, and crackles.

    Aortic insufficiency

    Accompanying tachycardia with aortic insufficiency are a “water-hammer” bounding pulse and a large, diffuse apical heave. With severe insufficiency, widened pulse pressure occurs. Auscultation reveals a hallmark diastolic murmur that starts with the second heart sound; is decrescendo, high-pitched, and blowing; and is heard best at the left sternal border of the second and third intercostal spaces. An atrial or ventricular gallop, an early systolic murmur, an Austin Flint murmur (apical diastolic rumble), or Duroziez’s sign (a murmur over the femoral artery during systole and diastole) may also be heard. Other findings include angina, dyspnea, palpitations, strong and abrupt carotid pulsations, pallor, and signs of heart failure, such as crackles and jugular vein distention.

    Aortic stenosis

    Typically, aortic stenosis — a valvular disorder — causes tachycardia, a weak, thready pulse, and an atrial gallop. Its chief features, however, are exertional dyspnea, angina, dizziness, and syncope. Aortic stenosis also causes a harsh, crescendo-decrescendo systolic ejection murmur that’s loudest at the right sternal border of the second intercostal space. Other findings include palpitations, crackles, and fatigue.

    Cardiac arrhythmias

    Tachycardia may occur with an irregular heart rhythm. The patient may be hypotensive and report dizziness, palpitations, weakness, and fatigue. Depending on his heart rate, he may also exhibit tachypnea, decreased LOC, and pale, cool, clammy skin.

    Cardiac contusion

    The result of blunt chest trauma, cardiac contusion may cause tachycardia, substernal pain, dyspnea, and palpitations. Assessment may detect sternal ecchymoses and a pericardial friction rub.

    Cardiac tamponade

    With life-threatening cardiac tamponade, tachycardia is commonly accompanied by paradoxical pulse, dyspnea, and tachypnea. The patient is visibly anxious and restless and has cyanotic, clammy skin and distended jugular veins. He may develop muffled heart sounds, pericardial friction rub, chest pain, hypotension, narrowed pulse pressure, and hepatomegaly.

    Cardiogenic shock

    Although many features of cardiogenic shock appear in other types of shock, they’re usually more profound in this type. Accompanying tachycardia are weak, thready pulse; narrowing pulse pressure; hypotension; tachypnea; cold, pale, clammy, and cyanotic skin; oliguria; restlessness; and altered LOC.

    Cholera

    Signs of cholera include abrupt watery diarrhea and vomiting. Severe fluid and electrolyte loss leads to tachycardia, thirst, weakness, muscle cramps, decreased skin turgor, oliguria, and hypotension. Without treatment, death can occur within hours.

    Chronic obstructive pulmonary disease (COPD)

    Although the clinical picture varies widely with COPD, tachycardia is a common sign. Other characteristic findings include cough, tachypnea, dyspnea, pursed-lip breathing, accessory muscle use, cyanosis, diminished breath sounds, rhonchi, crackles, and wheezing. Clubbing and barrel chest are usually late findings.

    Diabetic ketoacidosis

    Life-threatening diabetic ketoacidosis commonly produces tachycardia and a thready pulse. Its cardinal sign, however, is Kussmaul’s respirations — abnormally rapid, deep breathing. Other signs and symptoms of acidosis include fruity breath odor, orthostatic hypotension, generalized weakness, anorexia, nausea, vomiting, and abdominal pain. The patient’s LOC may vary from lethargy to coma.

    Heart failure

    Especially common with left-sided heart failure, tachycardia may be accompanied by a ventricular gallop, fatigue, dyspnea (exertional and paroxysmal nocturnal), orthopnea, and leg edema. Eventually, the patient develops widespread signs and symptoms, such as palpitations, narrowed pulse pressure, hypotension, tachypnea, crackles, dependent edema, weight gain, slowed mental response, diaphoresis, pallor and, possibly, oliguria. Late signs include hemoptysis, cyanosis, and marked hepatomegaly and pitting edema.

    Hyperosmolar hyperglycemic nonketotic syndrome

    A rapidly deteriorating LOC is commonly accompanied by tachycardia, hypotension, tachypnea, seizures, oliguria, and severe dehydration with poor skin turgor and dry mucous membranes.

    Hypertensive crisis

    Life-threatening hypertensive crisis is characterized by tachycardia, tachypnea, diastolic blood pressure that exceeds 120 mm Hg, and systolic blood pressure that may exceed 200 mm Hg. Typically, the patient develops pulmonary edema with jugular vein distention, dyspnea, and pink, frothy sputum. Related findings include chest pain, severe headache, drowsiness, confusion, anxiety, tinnitus, epistaxis, muscle twitching, seizures, nausea, and vomiting. Focal neurologic signs, such as paresthesia, may also occur.

    Hypoglycemia

    A common sign of hypoglycemia, tachycardia accompanies hypothermia, nervousness, trembling, fatigue, malaise, weakness, headache, hunger, nausea, diaphoresis, and moist, clammy skin. Central nervous system effects include blurred or double vision, motor weakness, hemiplegia, seizures, and decreased LOC.

    Hypovolemia

    Tachycardia may occur with hypovolemia. Associated findings include hypotension, decreased skin turgor, sunken eyeballs, thirst, syncope, and dry skin and tongue.

    Hypovolemic shock

    Mild tachycardia, an early sign of life-threatening hypovolemic shock, may be accompanied by tachypnea, restlessness, thirst, and pale, cool skin. As shock progresses, the patient’s skin becomes clammy and his pulse becomes increasingly rapid and thready. He may also develop hypotension, narrowed pulse pressure, oliguria, subnormal body temperature, and decreased LOC.

    Neurogenic shock

    Tachycardia or bradycardia may accompany tachypnea, apprehension, oliguria, variable body temperature, decreased LOC, and warm, dry skin.

    Orthostatic hypotension

    Tachycardia accompanies the characteristic signs and symptoms of orthostatic hypotension, which include dizziness, syncope, pallor, blurred vision, diaphoresis, and nausea.

    Pneumothorax

    Life-threatening pneumothorax causes tachycardia and other signs and symptoms of distress, such as severe dyspnea and chest pain, tachypnea, and cyanosis. Related findings include dry cough, subcutaneous crepitation, absent or decreased breath sounds, cessation of normal chest movement on the affected side, and decreased vocal fremitus.

    Pulmonary embolism

    With pulmonary embolism, tachycardia is usually preceded by sudden dyspnea, angina, or pleuritic chest pain. Common associated signs and symptoms include weak peripheral pulses, cyanosis, tachypnea, low-grade fever, restlessness, diaphoresis, and a dry cough or a cough with blood-tinged sputum.

    Thyrotoxicosis

    Tachycardia is a classic feature of thyrotoxicosis — a thyroid disorder. Others include an enlarged thyroid, nervousness, heat intolerance, weight loss despite increased appetite, diaphoresis, diarrhea, tremors, and palpitations. Although also considered characteristic, exophthalmos is sometimes absent.

    Because thyrotoxicosis affects virtually every body system, its associated features are diverse and numerous. Some examples include full and bounding pulse, widened pulse pressure, dyspnea, anorexia, nausea, vomiting, altered bowel habits, hepatomegaly, and muscle weakness, fatigue, and atrophy. The patient’s skin is smooth, warm, and flushed; his hair is fine and soft and may gray prematurely or fall out. The female patient may have a reduced libido and oligomenorrhea or amenorrhea; the male patient may exhibit a reduced libido and gynecomastia.

    Other causes

    Diagnostic tests

    Cardiac catheterization and electrophysiologic studies may induce transient tachycardia.

    Drugs and alcohol

    Various drugs affect the nervous system, circulatory system, or heart muscle, resulting in tachycardia. Examples of these include sympathomimetics; phenothiazines; anticholinergics, such as atropine; thyroid drugs; vasodilators, such as hydralazine; acetylcholinesterase inhibitors, such as captopril; nitrates, such as nitroglycerin; alpha-adrenergic blockers, such as phentolamine; and beta-adrenergic bronchodilators, such as albuterol. Excessive caffeine intake and alcohol intoxication may also cause tachycardia.

    Surgery and pacemakers

    Cardiac surgery and pacemaker malfunction or wire irritation may cause tachycardia.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Cardiac arrhythmias: Causes
    (Professional Guide to Diseases (Eighth Edition))

    Arrhythmias may be congenital or they may result from one of several factors, including myocardial ischemia, myocardial infarction, or organic heart disease. Drug ingestion (cocaine, amphetamines, caffeine, beta-blockers, psychotropics, sympathomimetics), drug toxicity, or degeneration of the conductive tissue necessary to maintain normal heart rhythm (sick sinus syndrome) can sometimes precipitate arrhythmias. People with imbalances of blood chemistries or those with a history of cardiac conditions (coronary artery disease or heart valve disorders) are at higher risk for developing arrhythmias.

    » READ BOOK EXCERPT ONLINE »

    Source: Professional Guide to Diseases (Eighth Edition), 2005

    Bradycardia: Medical causes
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Cardiac arrhythmias

    Depending on the type of arrhythmia and the patient’s tolerance of it, bradycardia may be transient or sustained and benign or life-threatening. Related findings include hypotension, palpitations, dizziness, weakness, syncope, and fatigue.

    Cardiomyopathy

    Cardiomyopathy is a potentially life-threatening disorder that may cause transient or sustained bradycardia. Other findings include dizziness, syncope, edema, fatigue, jugular vein distention, orthopnea, dyspnea, and peripheral cyanosis.

    Cervical spinal injury

    Bradycardia may be transient or sustained, depending on the severity of the injury. Its onset coincides with sympathetic denervation. Associated signs and symptoms include hypotension, decreased body temperature, slowed peristalsis, leg paralysis, and partial arm and respiratory muscle paralysis.

    Hypothermia

    Bradycardia usually appears when the core temperature drops below 89.6° F (32° C). It’s accompanied by shivering, peripheral cyanosis, muscle rigidity, bradypnea, and confusion leading to stupor.

    Hypothyroidism

    Hypothyroidism causes severe bradycardia in addition to fatigue, constipation, unexplained weight gain, and sensitivity to cold. Related signs include cool, dry, thick skin; sparse, dry hair; facial swelling; periorbital edema; thick, brittle nails; and confusion leading to stupor.

    Increased intracranial pressure (ICP)

    Bradycardia occurs as a late sign of increased ICP along with rapid respiratory rate, elevated systolic pressure, decreased diastolic pressure, and widened pulse pressure. Associated signs and symptoms include persistent headache, projectile vomiting, decreased level of consciousness (LOC), and fixed, unequal, and possibly dilated pupils.

    Myocardial infarction (MI)

    Sinus bradycardia is the most common arrhythmia associated with an acute MI. Accompanying signs and symptoms of an MI include an aching, burning, or viselike pressure in the chest that may radiate to the jaw, shoulder, arm, back, or epigastric area; nausea and vomiting; cool, clammy, and pale or cyanotic skin; anxiety; and dyspnea. Blood pressure may be elevated or depressed. Auscultation may reveal abnormal heart sounds.

    Other causes

    Diagnostic tests

    Cardiac catheterization and electrophysiologic studies can induce temporary bradycardia.

    Drugs

    Beta-adrenergic blockers, some calcium channel blockers, cardiac glycosides, topical miotics (such as pilocarpine), protamine, quinidine and other antiarrhythmics, and sympatholytics may cause transient bradycardia. Failure to take thyroid replacements may cause bradycardia.

    Invasive treatments

    Suctioning can induce hypoxia and vagal stimulation, causing bradycardia. Cardiac surgery can cause edema or damage to conduction tissues, causing bradycardia.

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    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Murmurs: Medical causes
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Aortic insufficiency

    Acute aortic insufficiency typically produces a soft, short diastolic murmur over the left sternal border that’s best heard when the patient sits and leans forward and at the end of a forced held expiration. S2 may be soft or absent. Sometimes, a soft, short midsystolic murmur may also be heard over the second right intercostal space. Associated findings include tachycardia, dyspnea, jugular vein distention, crackles, increased fatigue, and pale, cool extremities.

    Chronic aortic insufficiency causes a high-pitched, blowing, decrescendo diastolic murmur that’s best heard over the second or third right intercostal space or the left sternal border with the patient sitting, leaning forward, and holding his breath after deep expiration. An Austin Flint murmur—a rumbling, mid-to-late diastolic murmur best heard at the apex—may also occur. Complications may not develop until ages 40 to 50; then, typical findings include palpitations, tachycardia, angina, increased fatigue, dyspnea, orthopnea, and crackles.

    Aortic stenosis

    With this valvular disorder, the murmur is systolic, beginning after S1 and ending at or before aortic valve closure. It’s harsh and grating, medium-pitched, and crescendo-decrescendo. Loudest over the second right intercostal space when the patient is sitting and leaning forward, this murmur may also be heard at the apex, at the suprasternal notch (Erb’s point), and over the carotid arteries.

    If the patient has advanced disease, S2 may be heard as a single sound, with inaudible aortic closure. An early systolic ejection click at the apex is typical but is absent when the valve is severely calcified. Associated signs and symptoms usually don’t appear until age 30 in congenital aortic stenosis, ages 30 to 65 in stenosis due to rheumatic disease, and after age 65 in calcific aortic stenosis. They may include dizziness, syncope, dyspnea on exertion, paroxysmal nocturnal dyspnea, fatigue, and angina.

    Cardiomyopathy (hypertrophic)

    This disorder generates a harsh late systolic murmur, ending at S2. Best heard over the left sternal border and at the apex, the murmur is commonly accompanied by an audible S3or S4. The murmur decreases with squatting and increases with sitting down. Major associated symptoms are dyspnea and chest pain; palpitations, dizziness, and syncope may also occur.

    Mitral insufficiency

    Acute mitral insufficiency is characterized by a medium-pitched blowing, early systolic or holosystolic decrescendo murmur at the apex, along with a widely split S2 and commonly an S4. This murmur doesn’t get louder on inspiration as with tricuspid insufficiency. Associated findings typically include tachycardia and signs of acute pulmonary edema.

    Chronic mitral insufficiency produces a high-pitched, blowing, holosystolic plateau murmur that’s loudest at the apex and usually radiates to the axilla or back. Fatigue, dyspnea, and palpitations may also occur.

    Mitral prolapse

    This disorder generates a midsystolic to late-systolic click with a high-pitched late-systolic crescendo murmur, best heard at the apex. Occasionally, multiple clicks may be heard, with or without a systolic murmur. Associated findings include cardiac awareness, migraine headaches, dizziness, weakness, syncope, palpitations, chest pain, dyspnea, severe episodic fatigue, mood swings, and anxiety.

    Mitral stenosis

    With this valvular disorder, the murmur is soft, low-pitched, rumbling, crescendo-decrescendo, and diastolic, accompanied by a loud S1 or an opening snap—a cardinal sign. It’s best heard at the apex with the patient in the left lateral position. Mild exercise will help make this murmur audible.

    With severe stenosis, the murmur of mitral insufficiency may also be heard. Other findings include hemoptysis, exertional dyspnea and fatigue, and signs of acute pulmonary edema.

    Myxomas

    A left atrial myxoma (most common) usually produces a middiastolic murmur and a holosystolic murmur that’s loudest at the apex, with an S4, an early diastolic thudding sound (tumor plop), and a loud, widely split S1.Related features include dyspnea, orthopnea, chest pain, fatigue, weight loss, and syncope.

    A right atrial myxoma causes a late diastolic rumbling murmur, a holosystolic crescendo murmur, and tumor plop, best heard at the lower left sternal border. Other findings include fatigue, peripheral edema, ascites, and hepatomegaly.

    A left ventricular myxoma (rare) produces a systolic murmur, best heard at the lower left sternal border, arrhythmias, dyspnea, and syncope.

    A right ventricular myxoma commonly generates a systolic ejection murmur with delayed S2 and a tumor plop, best heard at the left sternal border. It’s accompanied by peripheral edema, hepatomegaly, ascites, dyspnea, and syncope.

    Papillary muscle rupture

    With this life-threatening complication of an acute MI, a loud holosystolic murmur can be auscultated at the apex. Related findings include severe dyspnea, chest pain, syncope, hemoptysis, tachycardia, and hypotension.

    Rheumatic fever with pericarditis

    A pericardial friction rub along with murmurs and gallops are heard best with the patient leaning forward on his hands and knees during forced expiration. The most common murmurs heard are the systolic murmur of mitral insufficiency, a midsystolic murmur due to swelling of the leaflet of the mitral valve, and the diastolic murmur of aortic insufficiency. Other signs and symptoms include fever, joint and sternal pain, edema, and tachypnea.

    Tricuspid insufficiency

    This valvular abnormality is characterized by a soft, high-pitched, holosystolic blowing murmur that increases with inspiration (Carvallo’s sign), decreases with exhalation and Valsalva’s maneuver, and is best heard over the lower left sternal border and the xiphoid area. Following a lengthy asymptomatic period, exertional dyspnea and orthopnea may develop, along with jugular vein distention, ascites, peripheral cyanosis and edema, muscle wasting, fatigue, weakness, and syncope.

    Tricuspid stenosis

    This valvular disorder produces a diastolic murmur similar to that of mitral stenosis, but louder with inspiration and decreased with exhalation and Valsalva’s maneuver. S1 may also be louder. Associated signs and symptoms include fatigue, syncope, peripheral edema, jugular vein distention, ascites, hepatomegaly, and dyspnea.

    Other causes

    Treatments

    Prosthetic valve replacement may cause variable murmurs, depending on the location, valve composition, and method of operation.

    » READ BOOK EXCERPT ONLINE »

    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Palpitations: Medical causes
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Anemia

    Palpitations may occur with anemia, especially on exertion. Pallor, fatigue, and dyspnea are also common. Associated signs include a systolic ejection murmur, bounding pulse, tachycardia, crackles, an atrial gallop, and a systolic bruit over the carotid arteries.

    Anxiety attack (acute)

    Anxiety is the most common cause of palpitations in children and adults. With this disorder, palpitations may be accompanied by diaphoresis, facial flushing, trembling, and an impending sense of doom. Almost invariably, the patient hyperventilates, which may lead to dizziness, weakness, and syncope. Other typical findings include tachycardia, precordial pain, shortness of breath, restlessness, and insomnia.

    Cardiac arrhythmias

    Paroxysmal or sustained palpitations may be accompanied by dizziness, weakness, and fatigue. The patient may also experience an irregular, rapid, or slow pulse rate; decreased blood pressure; confusion; pallor; oliguria; and diaphoresis.

    Hypertension

    With this disorder, the patient may be asymptomatic or may complain of sustained palpitations alone or with headache, dizziness, tinnitus, and fatigue. His blood pressure typically exceeds 140/90 mm Hg. He may also experience nausea and vomiting, seizures, and decreased level of consciousness (LOC).

    Hypocalcemia

    Typically, this disorder produces palpitations, weakness, and fatigue. It progresses from paresthesia to muscle tension and carpopedal spasms. The patient may also exhibit muscle twitching, hyperactive deep tendon reflexes, chorea, and positive Chvostek’s and Trousseau’s signs.

    Hypoglycemia

    When blood glucose levels drop significantly, the sympathetic nervous system triggers adrenaline production. This may cause sustained palpitations, which may be accompanied by fatigue, irritability, hunger, cold sweats, tremors, tachycardia, anxiety, and headache. Eventually the patient may develop central nervous system reactions. These include blurred or double vision, muscle weakness, hemiplegia, and altered LOC.

    Mitral prolapse

    This valvular disorder may cause paroxysmal palpitations accompanied by sharp, stabbing, or aching precordial pain. The hallmark of this disorder is a midsystolic click followed by an apical systolic murmur. Associated signs and symptoms may include dyspnea, dizziness, severe fatigue, migraine headache, anxiety, paroxysmal tachycardia, crackles, and peripheral edema.

    Mitral stenosis

    Early features of this valvular disorder typically include sustained palpitations accompanied by exertional dyspnea and fatigue. Auscultation also reveals a loud S1 or opening snap, and a rumbling diastolic murmur at the apex. Patients may also experience related signs and symptoms, such as an atrial gallop and, with advanced mitral stenosis, orthopnea, dyspnea at rest, paroxysmal nocturnal dyspnea, peripheral edema, jugular vein distention, ascites, hepatomegaly, and atrial fibrillations.

    Pheochromocytoma

    This rare adrenal medulla tumor causes episodic hypermetabolism, commonly associated with paroxysmal palpitations. The cardinal sign of pheochromocytoma is dramatically elevated blood pressure, which may be sustained or paroxysmal. Associated signs and symptoms include tachycardia, headache, chest or abdominal pain, diaphoresis, warm and pale or flushed skin, paresthesia, tremors, insomnia, nausea and vomiting, and anxiety.

    Sick sinus syndrome

    A patient with this disorder may experience palpitations, as well as bradycardia, tachycardia, chest pain, syncope, and heart failure.

    Thyrotoxicosis

    A characteristic symptom of this disorder, sustained palpitations may be accompanied by tachycardia, dyspnea, weight loss despite increased appetite, diarrhea, tremors, nervousness, diaphoresis, heat intolerance and, possibly, exophthalmos and an enlarged thyroid. The patient may also experience an atrial or ventricular gallop.

    Wolff-Parkinson-White syndrome

    Seen in children and adolescents, this disorder results in recurrent palpitations and frequent episodes of paroxysmal tachycardia.

    Other causes

    Drugs

    Palpitations may result from drugs that precipitate cardiac arrhythmias or increase cardiac output, such as cardiac glycosides; sympathomimetics such as cocaine; ganglionic blockers; beta-adrenergic blockers; calcium channel blockers; atropine; and minoxidil.

    Exercise

    Exercise can normally cause palpitations, as well as in patients with coronary heart disease, hypertension, mitral valve prolapse, and cardiomegaly.

    herb alert  Herbal remedies, such as ginseng and ephedra (ma huang), may cause adverse reactions, including palpitations and an irregular heartbeat. (Note: The FDA has banned the sale of dietary supplements containing ephedra because they pose an unreasonable risk of injury or illness).

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    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Pulse rhythm abnormality: Medical causes
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Arrhythmias

    An abnormal pulse rhythm may be the only sign of a cardiac arrhythmia. The patient may complain of palpitations, a fluttering heartbeat, or weak and skipped beats. Pulses may be weak and rapid or slow. Depending on the specific arrhythmia, dull chest pain or discomfort and hypotension may occur. Associated findings, if any, reflect decreased cardiac output. Neurologic findings, for example, include confusion, dizziness, light-headedness, decreased LOC and, sometimes, seizures. Other findings include decreased urine output, dyspnea, tachypnea, pallor, and diaphoresis.

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    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Pulse, absent or weak: Medical causes
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Aortic aneurysm (dissecting)

    When a dissecting aneurysm affects circulation to the innominate, left common carotid, subclavian, or femoral artery, it causes weak or absent arterial pulses distal to the affected area. Absent or diminished pulses occur in 50% of patients with proximal dissection and usually involve the brachiocephalic vessels. Pulse deficits are much less common in patients with distal dissection and tend to involve the left subclavian and femoral arteries. Tearing pain usually develops suddenly in the chest and neck and may radiate to the upper and lower back and abdomen. Other findings include syncope, loss of consciousness, weakness or transient paralysis of the legs or arms, the diastolic murmur of aortic insufficiency, systemic hypotension, and mottled skin below the waist.

    Aortic arch syndrome (Takayasu’s arteritis)

    This syndrome produces weak or abruptly absent carotid pulses and unequal or absent radial pulses. These signs are usually preceded by malaise, night sweats, pallor, nausea, anorexia, weight loss, arthralgia, and Raynaud’s phenomenon. Other findings include neck, shoulder, and chest pain; paresthesia; intermittent claudication; bruits; vision disturbances; dizziness; and syncope. If the carotid artery is involved, diplopia and transient blindness may occur.

    Aortic bifurcation occlusion (acute)

    This rare disorder produces abrupt absence of all leg pulses. The patient reports moderate to severe pain in the legs and, less commonly, in the abdomen, lumbosacral area, or perineum. Also, his legs are cold, pale, numb, and flaccid.

    Aortic stenosis

    With this disorder, the carotid pulse is sustained but weak. Dyspnea (especially on exertion or paroxysmal nocturnal), chest pain, and syncope dominate the clinical picture. The patient commonly has an atrial gallop. Other findings include a harsh systolic ejection murmur, crackles, palpitations, fatigue, and narrowed pulse pressure.

    Arrhythmias

    Cardiac arrhythmias may produce generalized weak pulses accompanied by cool, clammy skin. Other findings reflect the arrhythmia’s severity and may include hypotension, chest pain, dyspnea, dizziness, and decreased level of consciousness.

    Arterial occlusion

    With acute occlusion, arterial pulses distal to the obstruction are unilaterally weak and then absent. The affected limb is cool, pale, and cyanotic, with increased capillary refill time, and the patient complains of moderate to severe pain and paresthesia. A line of color and temperature demarcation develops at the level of obstruction. Varying degrees of limb paralysis may also occur, along with intense intermittent claudication. With chronic occlusion, occurring with disorders such as arteriosclerosis and Buerger’s disease, pulses in the affected limb weaken gradually.

    Cardiac tamponade

    Life-threatening cardiac tamponade causes a weak, rapid pulse accompanied by these classic findings: paradoxical pulse, jugular vein distention, hypotension, and muffled heart sounds. Narrowed pulse pressure, pericardial friction rub, and hepatomegaly may also occur. The patient may appear anxious, restless, and cyanotic and may have chest pain, clammy skin, dyspnea, and tachypnea.

    Coarctation of the aorta

    Findings of this disorder include bounding pulses in the arms and neck, with decreased pulsations and systolic pulse pressure in the lower extremities.

    Peripheral vascular disease

    This disorder causes a weakening and loss of peripheral pulses. The patient complains of aching pain distal to the occlusion that worsens with exercise and abates with rest. The skin feels cool and shows decreased hair growth. Impotence may occur in male patients with occlusion in the descending aorta or femoral areas.

    Pulmonary embolism

    This disorder causes a generalized weak, rapid pulse. It may also cause abrupt onset of chest pain, tachycardia, dyspnea, apprehension, syncope, diaphoresis, and cyanosis. Acute respiratory findings include tachypnea, dyspnea, decreased breath sounds, crackles, a pleural friction rub, and a cough—possibly with blood-tinged sputum.

    Shock

    With anaphylactic shock, pulses become rapid and weak and then uniformly absent within seconds or minutes after exposure to an allergen. This is preceded by hypotension, anxiety, restlessness, feelings of doom, intense itching, a pounding headache and, possibly, urticaria.

    With cardiogenic shock, peripheral pulses are absent and central pulses are weak, depending on the degree of vascular collapse. Pulse pressure is narrow. A drop in systolic blood pressure to 30 mm Hg below baseline, or a sustained reading below 80 mm Hg, produces poor tissue perfusion. Resulting signs include cold, pale, clammy skin; tachycardia; rapid, shallow respirations; oliguria; restlessness; confusion; and obtundation.

    With hypovolemic shock, all pulses in the extremities become weak and then uniformly absent, depending on the severity of hypovolemia. As shock progresses, remaining pulses become thready and more rapid. Early signs of cardiogenic shock include restlessness, thirst, tachypnea, and cool, pale skin. Late signs include hypotension with narrowing pulse pressure, clammy skin, a drop in urine output to less than 25 ml/hour, confusion, decreased level of consciousness and, possibly, hypothermia.

    With septic shock, all pulses in the extremities first become weak. Depending on the degree of vascular collapse, pulses may then become uniformly absent. Shock is heralded by chills, sudden fever and, possibly, nausea, vomiting, and diarrhea. Typically, the patient experiences tachycardia, tachypnea, and flushed, warm, and dry skin. As shock progresses, he develops thirst, hypotension, anxiety, restlessness, and confusion. Then pulse pressure narrows and the skin becomes cold, clammy, and cyanotic. The patient experiences severe hypotension, oliguria or anuria, respiratory failure, and coma.

    Thoracic outlet syndrome

    A patient with this syndrome may develop gradual or abrupt weakness or loss of the pulses in the arms, depending on how quickly vessels in the neck compress. These pulse changes commonly occur after the patient works with his hands above his shoulders, lifts a weight, or abducts his arm. Paresthesia and pain occur along the ulnar distribution of the arm and disappear as soon as the patient returns his arm to a neutral position. The patient may also have asymmetrical blood pressure and cool, pale skin.

    Other causes

    Treatments

    Localized absent pulse may occur distal to arteriovenous shuntsfor dialysis.

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    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Pulsus bisferiens: Medical causes
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Aortic insufficiency

    This heart defect is the most common organic cause of bisferiens pulse. Most patients with chronic aortic insufficiency are asymptomatic until ages 40 to 50. However, exertional dyspnea, worsening fatigue, orthopnea and, eventually, paroxysmal nocturnal dyspnea may develop.

    Acute aortic insufficiency may produce signs and symptoms of left-sided heart failure and cardiovascular collapse, such as weakness, severe dyspnea, hypotension, ventricular gallop, and tachycardia. Additional findings include chest pain, palpitations, pallor, and strong, abrupt carotid pulsations. The patient may also exhibit widened pulse pressure and one or more murmurs, especially an apical diastolic rumble (Austin Flint murmur).

    Aortic stenosis with aortic insufficiency

    A bisferiens pulse is commonly seen in aortic stenosis that is accompanied by moderately severe aortic insufficiency. In aortic stenosis, the pulse rises slowly and the second wave of the double beat is the more forceful one. This disorder is commonly accompanied by dyspnea and fatigue. Chest pain and syncope aren’t specific in the combined lesion, but they do suggest predominant aortic stenosis.

    High cardiac output states

    Pulsus bisferiens commonly occurs with high output states, such as anemia, thyrotoxicosis, fever, and exercise. Associated findings vary with the underlying cause and may include moderate tachycardia, a cervical venous hum, and widened pulse pressure.

    Hypertrophic obstructive cardiomyopathy

    About 40% of patients with this disorder have pulsus bisferiens because of a pressure gradient in the left ventricular outflow tract. Recorded more often than it’s palpated, the pulse rises rapidly, and the first wave is the more forceful one. Associated findings include a systolic murmur, dyspnea, angina, fatigue, and syncope.

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    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Tachycardia: Medical causes
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Acute respiratory distress syndrome

    Besides tachycardia, this syndrome causes crackles, rhonchi, dyspnea, tachypnea, nasal flaring, and grunting respirations. Other findings include cyanosis, anxiety, decreased LOC, and abnormal chest X-ray findings.

    Adrenocortical insufficiency

    In this disorder, tachycardia is commonly accompanied by a weak pulse as well as progressive weakness and fatigue, which may become so severe that the patient requires bed rest. Other signs and symptoms include abdominal pain, nausea and vomiting, altered bowel habits, weight loss, orthostatic hypotension, irritability, bronze skin, decreased libido, and syncope. Some patients report an enhanced sense of taste, smell, and hearing.

    Alcohol withdrawal syndrome

    Tachycardia can occur with tachypnea, profuse diaphoresis, fever, insomnia, anorexia, and anxiety. The patient is characteristically anxious, irritable, and prone to visual and tactile hallucinations.

    Anaphylactic shock

    In life-threatening anaphylactic shock, tachycardia and hypotension develop within minutes after exposure to an allergen, such as penicillin or an insect sting. Typically, the patient is visibly anxious and has severe pruritus, perhaps with urticaria and a pounding headache. Other findings may include flushed and clammy skin, a cough, dyspnea, nausea, abdominal cramps, seizures, stridor, change or loss of voice associated with laryngeal edema, and urinary urgency and incontinence.

    Anemia

    Tachycardia and bounding pulse are characteristic signs of anemia. Associated signs and symptoms include fatigue, pallor, dyspnea and, possibly, bleeding tendencies. Auscultation may reveal an atrial gallop, a systolic bruit over the carotid arteries, and crackles.

    Anxiety

    A fight-or-flight response produces tachycardia, tachypnea, chest pain, nausea, and light-headedness. The symptoms dissipate as anxiety resolves.

    Aortic insufficiency

    Accompanying tachycardia in this disorder are a “water-hammer” bounding pulse and a large, diffuse apical heave. Severe insufficiency also produces widened pulse pressure. Auscultation reveals a hallmark decrescendo, high-pitched, and blowing diastolic murmur that starts with the second heart sound and is heard best at the left sternal border of the second and third intercostal spaces. An atrial or ventricular gallop, an early systolic murmur, an Austin Flint murmur (apical diastolic rumble), or Duroziez’s sign (a murmur over the femoral artery during systole and diastole) may also be heard. Other findings include angina, dyspnea, palpitations, strong and abrupt carotid pulsations, pallor, and signs of heart failure, such as crackles and neck vein distention.

    Aortic stenosis

    Typically, this valvular disorder causes tachycardia, an atrial gallop, and a weak, thready pulse. Its chief features, however, are exertional dyspnea, angina, dizziness, and syncope. Aortic stenosis also causes a harsh, crescendo-decrescendo systolic ejection murmur that’s loudest at the right sternal border of the second intercostal space. Other findings include palpitations, crackles, and fatigue.

    Cardiac arrhythmias

    Tachycardia may occur with an irregular heart rhythm. The patient may be hypotensive and report dizziness, palpitations, weakness, and fatigue. Depending on his heart rate, he may also exhibit tachypnea, decreased LOC, and pale, cool, clammy skin.

    Cardiac contusion

    The result of blunt chest trauma, a cardiac contusion may cause tachycardia, substernal pain, dyspnea, and palpitations. Assessment may detect sternal ecchymoses and a pericardial friction rub.

    Cardiac tamponade

    In life-threatening cardiac tamponade, tachycardia is commonly accompanied by paradoxical pulse, dyspnea, and tachypnea. The patient is visibly anxious and restless and has cyanotic, clammy skin and distended jugular veins. He may develop muffled heart sounds, a pericardial friction rub, chest pain, hypotension, narrowed pulse pressure, and hepatomegaly.

    Cardiogenic shock

    Although many features of cardiogenic shock appear in other types of shock, they’re usually more profound in this type. Accompanying tachycardia are a weak, thready pulse; narrowed pulse pressure; hypotension; tachypnea; cold, pale, clammy, and cyanotic skin; oliguria; restlessness; and altered LOC.

    Cholera

    This infectious disease is marked by abrupt watery diarrhea and vomiting. Severe fluid and electrolyte loss leads to tachycardia, thirst, weakness, muscle cramps, decreased skin turgor, oliguria, and hypotension. Without treatment, death can occur within hours.

    Chronic obstructive pulmonary disease

    Although clinical findings vary widely in this disorder, tachycardia is a common sign. Other characteristic findings include cough, tachypnea, dyspnea, pursed-lip breathing, accessory muscle use, cyanosis, diminished breath sounds, rhonchi, crackles, and wheezing. Clubbing and barrel chest are usually late findings.

    Diabetic ketoacidosis

    This life-threatening disorder commonly produces tachycardia and a thready pulse. Its cardinal sign, however, is Kussmaul’s respirations—abnormally rapid, deep breathing. Other signs and symptoms of ketoacidosis include fruity breath odor, orthostatic hypotension, generalized weakness, anorexia, nausea, vomiting, and abdominal pain. The patient’s LOC may vary from lethargy to coma.

    Febrile illness

    Fever can cause tachycardia. Related findings reflect the specific disorder.

    Heart failure

    Especially common in left-sided heart failure, tachycardia may be accompanied by a ventricular gallop, fatigue, dyspnea (exertional and paroxysmal nocturnal), orthopnea, and leg edema. Eventually, the patient develops widespread signs and symptoms, such as palpitations, narrowed pulse pressure, hypotension, tachypnea, crackles, dependent edema, weight gain, slowed mental response, diaphoresis, pallor and, possibly, oliguria. Late signs include hemoptysis, cyanosis, marked hepatomegaly, and pitting edema.

    Hyperosmolar hyperglycemic nonketotic syndrome

    A rapidly deteriorating LOC is commonly accompanied by tachycardia, hypotension, tachypnea, seizures, oliguria, and severe dehydration marked by poor skin turgor and dry mucous membranes.

    Hypertensive crisis

    A life-threatening hypertensive crisis is characterized by tachycardia, tachypnea, diastolic blood pressure that exceeds 120 mm Hg, and systolic blood pressure that may exceed 200 mm Hg. Typically, the patient develops pulmonary edema with jugular vein distention, dyspnea, and pink, frothy sputum. Related findings include chest pain, severe headache, drowsiness, confusion, anxiety, tinnitus, epistaxis, muscle twitching, seizures, nausea and vomiting and, possibly, focal neurologic signs such as paresthesia.

    Hypoglycemia

    A common sign of hypoglycemia, tachycardia is accompanied by hypothermia, nervousness, trembling, fatigue, malaise, weakness, headache, hunger, nausea, diaphoresis, and moist, clammy skin. Central nervous system effects include blurred or double vision, motor weakness, hemiplegia, seizures, and decreased LOC.

    Hyponatremia

    Tachycardia is a rare effect of this electrolyte imbalance. Other findings include orthostatic hypotension, headache, muscle twitching and weakness, fatigue, oliguria or anuria, poor skin turgor, thirst, irritability, seizures, nausea and vomiting, and decreased LOC that may progress to coma. Severe hyponatremia may cause cyanosis and signs of vasomotor collapse such as thready pulse.

    Hypovolemia

    Tachycardia may occur with this disorder along with hypotension, decreased skin turgor, sunken eyeballs, thirst, syncope, and dry skin and tongue.

    Hypovolemic shock

    Mild tachycardia, an early sign of life-threatening hypovolemic shock, may be accompanied by tachypnea, restlessness, thirst, and pale, cool skin. As shock progresses, the patient’s skin becomes clammy and his pulse, increasingly rapid and thready. He may also develop hypotension, narrowed pulse pressure, oliguria, subnormal body temperature, and decreased LOC.

    Hypoxemia

    Tachycardia may be accompanied by tachypnea, dyspnea, cyanosis, confusion, syncope, and incoordination.

    Myocardial infarction (MI)

    A life-threatening MI may cause tachycardia or bradycardia. Its classic symptom, however, is crushing substernal chest pain that may radiate to the left arm, jaw, neck, or shoulder. Auscultation may reveal an atrial gallop, a new murmur, and crackles. Other signs and symptoms include dyspnea, diaphoresis, nausea and vomiting, anxiety, restlessness, increased or decreased blood pressure, and pale, clammy skin.

    Neurogenic shock

    Tachycardia or bradycardia may accompany tachypnea, apprehension, oliguria, variable body temperature, decreased LOC, and warm, dry skin.

    Orthostatic hypotension

    Tachycardia accompanies the characteristic signs and symptoms of this condition, which include dizziness, syncope, pallor, blurred vision, diaphoresis, and nausea.

    Pheochromocytoma

    Characterized by sustained or paroxysmal hypertension, this rare tumor may also cause tachycardia and palpitations. Other findings include headache, chest and abdominal pain, diaphoresis, paresthesia, tremors, nausea and vomiting, insomnia, extreme anxiety (possibly even panic), and pale or flushed, warm skin.

    Pneumothorax

    Life-threatening pneumothorax causes tachycardia and other signs and symptoms of distress, such as severe dyspnea and chest pain, tachypnea, and cyanosis. Related findings include dry cough, subcutaneous crepitation, absent or decreased breath sounds, cessation of normal chest movement on the affected side, and decreased vocal fremitus.

    Pulmonary embolism

    In this disorder, tachycardia is usually preceded by sudden dyspnea, angina, or pleuritic chest pain. Common associated signs and symptoms include weak peripheral pulses, cyanosis, tachypnea, low-grade fever, restlessness, diaphoresis, and a dry cough or a cough producing blood-tinged sputum.

    Septic shock

    Initially, septic shock produces chills, sudden fever, tachycardia, tachypnea and, possibly, nausea, vomiting, and diarrhea. The patient’s skin is flushed, warm, and dry; his blood pressure is normal or slightly decreased. Eventually, he may display anxiety; restlessness; thirst; oliguria or anuria; cool, clammy, cyanotic skin; rapid, thready pulse; and severe hypotension. His LOC may decrease progressively, perhaps culminating in a coma.

    Thyrotoxicosis

    Tachycardia is a classic feature of this thyroid disorder. Others include an enlarged thyroid gland, nervousness, heat intolerance, weight loss despite increased appetite, diaphoresis, diarrhea, tremors, palpitations, and sometimes exophthalmos.

    Because thyrotoxicosis affects virtually every body system, its associated features are diverse and numerous. Some examples include full and bounding pulse, widened pulse pressure, dyspnea, anorexia, nausea, vomiting, altered bowel habits, hepatomegaly, and muscle weakness, fatigue, and atrophy. The patient’s skin is smooth, warm, and flushed; his hair is fine and soft and may gray prematurely or fall out. The female patient may have a reduced libido and oligomenorrhea or amenorrhea; the male patient may exhibit a reduced libido and gynecomastia.

    Other causes

    Diagnostic tests

    Cardiac catheterization and electrophysiologic studies may induce transient tachycardia.

    Drugs and alcohol

    Various drugs affect the nervous system, circulatory system, or heart muscle, resulting in tachycardia. Examples of these include sympathomimetics; phenothiazines; anticholinergics such as atropine; thyroid drugs; vasodilators, such as hydralazine and nifedipine; acetylcholinesterase inhibitors such as captopril; nitrates such as nitroglycerin; alpha-adrenergic blockers such as phentolamine; and beta-adrenergic bronchodilators such as albuterol. Excessive caffeine intake and alcohol intoxication may also cause tachycardia.

    Surgery and pacemakers

    Cardiac surgery and pacemaker malfunction or wire irritation may cause tachycardia.

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    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Bradycardia: Differential Overview
    (Field Guide to Bedside Diagnosis)

    Sinus Bradycardia

    ❑ Hypothyroidism

    ❑ Hypervagotonia

    ❑ Hypersensitive carotid sinus

    ❑ Hypothermia

    ❑ Acute increased intracranial pressure

    Complete Heart Block

    ❑ Inferior myocardial infarction

    ❑ Drugs

    ❑ Sick sinus syndrome

    ❑ Viral myocarditis

    ❑ Lyme disease

    ❑ Sarcoidosis

    ❑ Acute rheumatic fever

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    Source: Field Guide to Bedside Diagnosis, 2007

    Palpitations/Tachycardia: Differential Overview
    (Field Guide to Bedside Diagnosis)

    ❑ Sinus tachycardia

    ❑ Paroxysmal supraventricular tachycardia

    ❑ Atrial fibrillation

    ❑ Atrial flutter

    ❑ AV nodal re-entrant tachycardia

    ❑ Ventricular premature beats

    ❑ Anxiety

    ❑ Drugs

    ❑ Anemia

    ❑ Multifocal atrial tachycardia

    ❑ Ventricular tachycardia

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    Source: Field Guide to Bedside Diagnosis, 2007

    Diastolic Murmur: Differential Overview
    (Field Guide to Bedside Diagnosis)

    ❑ Aortic regurgitation

    ❑ Pulmonic regurgitation

    ❑ Mitral stenosis

    ❑ Tricuspid stenosis

    ❑ Atrial septal defect

    ❑ Left anterior descending artery stenosis

    ❑ Atrial myxoma

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    Source: Field Guide to Bedside Diagnosis, 2007

    Systolic Murmur: Differential Overview
    (Field Guide to Bedside Diagnosis)

    ❑ Systolic ejection murmur

    ❑ Mitral regurgitation

    ❑ Mitral valve prolapse

    ❑ Aortic stenosis

    ❑ Aortic valve sclerosis

    ❑ Hypertrophic obstructive cardiomyopathy

    ❑ Atrial septal defect

    ❑ Pulmonic stenosis

    ❑ Tricuspid regurgitation

    ❑ Ventricular septal defect

    ❑ Aortic coarctation

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    Source: Field Guide to Bedside Diagnosis, 2007

    Continuous Murmur: Differential Overview
    (Field Guide to Bedside Diagnosis)

    ❑ Aortic stenosis/aortic insufficiency

    ❑ Pericardial friction rub

    ❑ Pulmonary arteriovenous fistula

    ❑ Venous hum

    ❑ Mammary souffle

    ❑ Aortic coarctation

    ❑ Mediastinal air dissection

    ❑ Patent ductus arteriosis

    ❑ Ruptured sinus of Valsalva

    ❑ Coronary artery fistula

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    Source: Field Guide to Bedside Diagnosis, 2007

    Cardiac arrhythmias: Causes
    (Handbook of Diseases)

    Arrhythmias may be congenital, or they may result from one of several factors, including myocardial ischemia, a myocardial infarction, and organic heart disease. Drug toxicity or degeneration of the conductive tissue necessary to maintain normal heart rhythm (sick sinus syndrome) sometimes can also precipitate arrhythmias.

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    Source: Handbook of Diseases, 2003

    Bradycardia: Medical causes
    (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

    Cardiac arrhythmias

    Depending on the type of arrhythmia and the patient’s tolerance of it, bradycardia may be transient or sustained, benign, or life threatening. Related findings include hypotension, palpitations, dizziness, weakness, syncope, and fatigue.

    Cardiomyopathy

    Cardiomyopathy is a potentially life-threatening disorder that may cause transient or sustained bradycardia. Other findings include dizziness, syncope, edema, fatigue, jugular vein distention, orthopnea, dyspnea, and peripheral cyanosis.

    Cervical spinal injury

    Bradycardia may be transient or sustained, depending on the severity of the injury. Its onset coincides with sympathetic denervation. Associated signs and symptoms include hypotension, decreased body temperature, slowed peristalsis, leg paralysis, and partial arm and respiratory muscle paralysis.

    Hypothermia

    Bradycardia usually appears when the core temperature drops below 89.6° F (32° C). It’s accompanied by shivering, peripheral cyanosis, muscle rigidity, bradypnea, and confusion leading to stupor.

    Hypothyroidism

    Hypothyroidism causes severe bradycardia in addition to fatigue, constipation, unexplained weight gain, and sensitivity to cold. Related signs include cool, dry, thick skin; sparse, dry hair; facial swelling; periorbital edema; thick, brittle nails; and confusion leading to stupor.

    Increased intracranial pressure (ICP)

    Bradycardia occurs as a late sign of increased ICP along with rapid respiratory rate, elevated systolic pressure, decreased diastolic pressure, and widened pulse pressure. Associated signs and symptoms include persistent headache, projectile vomiting, decreased LOC, and fixed, unequal and, possibly, dilated pupils.

    Myocardial infarction (MI)

    Sinus bradycardia is the most common arrhythmia associated with an acute MI. Accompanying signs and symptoms of an MI include an aching, burning, or viselike pressure in the chest that may radiate to the jaw, shoulder, arm, back, or epigastric area; nausea and vomiting; cool, clammy, and pale or cyanotic skin; anxiety; and dyspnea. Blood pressure may be elevated or depressed. Auscultation may reveal abnormal heart sounds.

    Other causes

    Diagnostic tests

    Cardiac catheterization and electrophysiologic studies can induce temporary bradycardia.

    Drugs

    Beta-adrenergic blockers and some calcium channel blockers, cardiac glycosides, topical miotics (such as pilocarpine), protamine, quinidine and other antiarrhythmics, and sympatholytics may cause transient bradycardia. Failure to take thyroid replacements may also cause bradycardia.

    Invasive treatments

    Suctioning can induce hypoxia and vagal stimulation, causing bradycardia. Cardiac surgery can cause edema or damage to conduction tissues, causing bradycardia.

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    Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

    Murmurs: Medical causes
    (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

    Aortic insufficiency

    Acute aortic insufficiency typically produces a soft, short diastolic murmur over the left sternal border that’s best heard when the patient sits and leans forward and at the end of a forced held expiration. S2 may be soft or absent. Sometimes, a soft, short midsystolic murmur may also be heard over the second right intercostal space. Associated findings include tachycardia, dyspnea, jugular vein distention, crackles, increased fatigue, and pale, cool extremities.

    Chronic aortic insufficiency causes a high-pitched, blowing, decrescendo diastolic murmur that’s best heard over the second or third right intercostal space or the left sternal border with the patient sitting, leaning forward, and holding his breath after deep expiration. An Austin Flint murmur — a rumbling, mid-to-late diastolic murmur best heard at the apex — may also occur. Complications may not develop until ages 40 to 50; then, typical findings include palpitations, tachycardia, angina, increased fatigue, dyspnea, orthopnea, and crackles.

    Aortic stenosis

    With aortic stenosis — avalvular disorder — the murmur is systolic, beginning after S1 and ending at or before aortic valve closure. It’s harsh and grating, medium-pitched, and crescendo-decrescendo. Loudest over the second right intercostal space when the patient is sitting and leaning forward, this murmur may also be heard at the apex, at the suprasternal notch (Erb’s point), and over the carotid arteries.

    If the patient has advanced disease, S2 may be heard as a single sound, with inaudible aortic closure. An early systolic ejection click at the apex is typical but is absent when the valve is severely calcified. Associated signs and symptoms usually don’t appear until age 30 in congenital aortic stenosis, ages 30 to 65 in stenosis due to rheumatic disease, and after age 65 in calcific aortic stenosis. They may include dizziness, syncope, dyspnea on exertion, paroxysmal nocturnal dyspnea, fatigue, and angina.

    Cardiomyopathy (hypertrophic)

    Cardiomyopathy generates a harsh late systolic murmur, ending at S2. Best heard over the left sternal border and at the apex, the murmur is commonly accompanied by an audible S3or S4. The murmur decreases with squatting and increases with sitting down. Major associated symptoms are dyspnea and chest pain; palpitations, dizziness, and syncope may also occur.

    Mitral insufficiency

    Acute mitral insufficiency is characterized by a medium-pitched blowing, early systolic or holosystolic decrescendo murmur at the apex, along with a widely split S2 and commonly an S4. This murmur doesn’t get louder on inspiration as with tricuspid insufficiency. Associated findings typically include tachycardia and signs of acute pulmonary edema.

    Chronic mitral insufficiency produces a high-pitched, blowing, holosystolic plateau murmur that’s loudest at the apex and usually radiates to the axilla or back. Fatigue, dyspnea, and palpitations may also occur.

    Mitral prolapse

    Mitral prolapse generates a midsystolic to late-systolic click with a high-pitched late-systolic crescendo murmur, best heard at the apex and left sternal border. Occasionally, multiple clicks may be heard, with or without a systolic murmur. Associated findings include cardiac awareness, migraine headaches, dizziness, weakness, syncope, palpitations, chest pain, dyspnea, severe episodic fatigue, mood swings, and anxiety.

    Mitral stenosis

    With mitral stenosis, the murmur is soft, low-pitched, rumbling, crescendo-decrescendo, and diastolic, accompanied by a loud S1 or an opening snap — a cardinal sign. It’s best heard at the apex with the patient in the left lateral position. Mild exercise will help make this murmur audible.

    With severe stenosis, the murmur of mitral regurgitation may also be heard. Other findings include hemoptysis, exertional dyspnea and fatigue, and signs of acute pulmonary edema.

    Myxomas

    A left atrial myxoma (most common) usually produces a middiastolic murmur and a holosystolic murmur that’s loudest at the apex, with an S4, an early diastolic thudding sound (tumor plop), and a loud, widely split S1.Related features include dyspnea, orthopnea, chest pain, fatigue, weight loss, and syncope.

    A right atrial myxoma causes a late diastolic rumbling murmur, a holosystolic crescendo murmur, and tumor plop, best heard at the lower left sternal border. Other findings include fatigue, peripheral edema, ascites, and hepatomegaly.

    A left ventricular myxoma (rare) produces a systolic murmur, best heard at the lower left sternal border, arrhythmias, dyspnea, and syncope.

    A right ventricular myxoma commonly generates a systolic ejection murmur with delayed S2 and a tumor plop, best heard at the left sternal border. It’s accompanied by peripheral edema, hepatomegaly, ascites, dyspnea, and syncope.

    Papillary muscle rupture

    Papillary muscle rupture is a life-threatening complication of an acute MI, in which a loud holosystolic murmur can be auscultated at the apex. Related findings include severe dyspnea, chest pain, syncope, hemoptysis, tachycardia, and hypotension.

    Rheumatic fever with pericarditis

    A pericardial friction rub along with murmurs and gallops are heard best with the patient leaning forward on his hands and knees during forced expiration. The most common murmurs heard are the systolic murmur of mitral regurgitation, a midsystolic murmur due to swelling of the leaflet of the mitral valve, and the diastolic murmur of aortic regurgitation. Other signs and symptoms include fever, joint and sternal pain, edema, and tachypnea.

    Tricuspid insufficiency

    Tricuspid insufficiency is a valvular abnormality that’s characterized by a soft, high-pitched, holosystolic blowing murmur that increases with inspiration (Carvallo’s sign), decreases with exhalation and Valsalva’s maneuver, and is best heard over the lower left sternal border and the xiphoid area. Following a lengthy asymptomatic period, exertional dyspnea and orthopnea may develop, along with jugular vein distention, ascites, peripheral cyanosis and edema, muscle wasting, fatigue, weakness, and syncope.

    Tricuspid stenosis

    Tricuspid stenosis is a valvular disorder that produces a diastolic murmur similar to that of mitral stenosis, but louder with inspiration and decreased with exhalation and Valsalva’s maneuver. S1 may also be louder. Associated signs and symptoms include fatigue, syncope, peripheral edema, jugular vein distention, ascites, hepatomegaly, and dyspnea.

    Other causes

    Medical treatments

    Prosthetic valve replacement may cause variable murmurs, depending on the location, valve composition, and method of operation.

    » READ BOOK EXCERPT ONLINE »

    Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

    Palpitations: Medical causes
    (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

    Anemia

    Palpitations may occur with anemia, especially on exertion. Pallor, fatigue, and dyspnea are also common. Associated signs include a systolic ejection murmur, bounding pulse, tachycardia, crackles, an atrial gallop, and a systolic bruit over the carotid arteries.

    Anxiety attack (acute)

    Anxiety is the most common cause of palpitations. With this disorder, palpitations may be accompanied by diaphoresis, facial flushing, trembling, and an impending sense of doom. Almost invariably, the patient hyperventilates, which may lead to dizziness, weakness, and syncope. Other typical findings include tachycardia, precordial pain, shortness of breath, restlessness, and insomnia.

    Cardiac arrhythmias

    Paroxysmal or sustained palpitations may be accompanied by dizziness, weakness, and fatigue. The patient may also experience an irregular, rapid, or slow pulse rate as well as decreased blood pressure, confusion, pallor, oliguria, and diaphoresis.

    Hypertension

    With hypertension, the patient may be asymptomatic or may complain of sustained palpitations alone or with headache, dizziness, tinnitus, and fatigue. His blood pressure typically exceeds 140/90 mm Hg.

    Hypocalcemia

    Typically, hypocalcemia produces palpitations, weakness, and fatigue. It progresses from paresthesia to muscle tension and carpopedal spasms. The patient may also exhibit muscle twitching, hyperactive deep tendon reflexes, chorea, and positive Chvostek’s and Trousseau’s signs.

    Hypoglycemia

    When the blood glucose level drops significantly, the sympathetic nervous system triggers adrenaline production. This may cause sustained palpitations, which may be accompanied by fatigue, irritability, hunger, cold sweats, tremors, tachycardia, anxiety, and headache. Eventually, the patient may develop central nervous system reactions. These include blurred or double vision, muscle weakness, hemiplegia, and an altered LOC.

    Mitral prolapse

    A valvular disorder, mitral prolapse may cause paroxysmal palpitations accompanied by sharp, stabbing, or aching precordial pain. The hallmark of this disorder, however, is a midsystolic click followed by an apical systolic murmur. Associated signs and symptoms may include dyspnea, dizziness, severe fatigue, migraine headache, anxiety, paroxysmal tachycardia, crackles, and peripheral edema.

    Mitral stenosis

    Early features of mitral stenosis — a valvular disorder — typically include sustained palpitations accompanied by exertional dyspnea, fatigue, paroxysmal nocturnal dyspnea, and atrial fibrillations. Auscultation also reveals a loud S1 or opening snap and a rumbling diastolic murmur at the apex. Patients may also experience related signs and symptoms, such as an atrial gallop and, with advanced mitral stenosis, orthopnea, dyspnea at rest, peripheral edema, jugular vein distention, ascites, and hepatomegaly.

    Pheochromocytoma

    Pheochromocytoma, a rare adrenal medulla tumor causes episodic hypermetabolism, commonly associated with paroxysmal palpitations. The cardinal sign is dramatically elevated blood pressure, which may be sustained or paroxysmal. Associated signs and symptoms include tachycardia, headache, chest or abdominal pain, diaphoresis, warm and pale or flushed skin, paresthesia, tremors, insomnia, nausea and vomiting, and anxiety.

    Sick sinus syndrome

    A patient with sick sinus syndrome may experience palpitations as well as bradycardia, tachycardia, chest pain, syncope, and heart failure.

    Thyrotoxicosis

    A characteristic symptom of thyrotoxicosis, sustained palpitations may be accompanied by tachycardia, dyspnea, weight loss despite increased appetite, diarrhea, tremors, nervousness, diaphoresis, heat intolerance and, possibly, exophthalmos and an enlarged thyroid. The patient may also experience an atrial or ventricular gallop.

    Wolff-Parkinson-White (WPW) syndrome

    Seen in children and adolescents, WPW syndrome results in recurrent palpitations and frequent episodes of paroxysmal tachycardia.

    Other causes

    Drugs

    Cardiac glycosides and other drugs that precipitate cardiac arrhythmias or increase cardiac output can cause palpitations. Ganglionic blockers, beta-adrenergic blockers, calcium channel blockers, atropine, minoxidil, and sympathomimetics, such as cocaine, can also cause palpitations.

    Exercise

    Palpitations can occur normally with exercise. Patients with coronary heart disease, hypertension, mitral valve prolapse, and cardiomegaly may experience palpitations with exercise.

    Herbal remedies

    Ginseng and other herbal remedies may cause adverse reactions that include palpitations and an irregular heartbeat.

    » READ BOOK EXCERPT ONLINE »

    Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

    Pulse rhythm abnormality: Medical causes
    (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

    Arrhythmias

    An abnormal pulse rhythm may be the only sign of a cardiac arrhythmia. The patient may complain of palpitations, a fluttering heartbeat, or weak and skipped beats. Pulses may be weak and rapid or slow. Depending on the specific arrhythmia, dull chest pain or discomfort and hypotension may occur. Associated findings, if any, reflect decreased cardiac output. Neurologic findings, for example, include confusion, dizziness, light-headedness, a decreased LOC and, sometimes, seizures. Other findings include decreased urine output, dyspnea, tachypnea, pallor, and diaphoresis.

    » READ BOOK EXCERPT ONLINE »

    Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

    Tachycardia: Medical causes
    (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

    See Tachycardia: Causes and associated findings, pages 288 to 291.

    Acute respiratory distress syndrome (ARDS)

    Besides tachycardia, ARDS causes crackles, rhonchi, dyspnea, tachypnea, nasal flaring, and grunting respirations. Other findings include cyanosis, anxiety, a decreased LOC, and abnormal chest X-ray findings.

    Adrenocortical insufficiency

    With adrenocortical insufficiency, tachycardia commonly occurs with a weak pulse as well as progressive weakness and fatigue, which may become so severe that the patient requires bed rest. Other signs and symptoms include abdominal pain, nausea and vomiting, altered bowel habits, weight loss, orthostatic hypotension, irritability, bronze skin, decreased libido, and syncope. The patient may report an enhanced sense of taste, smell, and hearing.

    Alcohol withdrawal syndrome

    Tachycardia can occur with tachypnea, profuse diaphoresis, fever, insomnia, anorexia, and anxiety. The patient is characteristically anxious, irritable, and prone to visual and tactile hallucinations.

    Anaphylactic shock

    With life-threatening anaphylactic shock, tachycardia and hypotension develop within minutes after exposure to an allergen, such as penicillin or an insect sting. Typically, the patient is visibly anxious and has severe pruritus, perhaps with urticaria and a pounding headache. Other findings may include flushed and clammy skin, cough, dyspnea, nausea, abdominal cramps, seizures, stridor, change or loss of voice associated with laryngeal edema, and urinary urgency and incontinence.

    Anemia

    Tachycardia and bounding pulse are characteristic with anemia. Associated signs and symptoms include fatigue, pallor, dyspnea and, possibly, bleeding tendencies. Auscultation may reveal an atrial gallop, a systolic bruit over the carotid arteries, and crackles.

    Anxiety

    A fight-or-flight response produces tachycardia, tachypnea, chest pain, nausea, and light-headedness. The symptoms dissipate as anxiety resolves.

    Aortic insufficiency

    Accompanying tachycardia with aortic insufficiency are a “water-hammer” bounding pulse and a large, diffuse apical heave. With severe insufficiency, widened pulse pressure occurs. Auscultation reveals a hallmark diastolic murmur that starts with S2; is decrescendo, high-pitched, and blowing; and is heard best at the left sternal border of the second and third intercostal spaces. An atrial or ventricular gallop, an early systolic murmur, an Austin Flint murmur (apical diastolic rumble), or Duroziez’s murmur (heard over the femoral artery during systole and diastole) may also be heard. Other findings include angina, dyspnea, palpitations, strong and abrupt carotid pulsations, pallor, and signs of heart failure, such as crackles and jugular vein distention.

    Aortic stenosis

    Typically, aortic stenosis causes tachycardia; a weak, thready pulse; and an atrial gallop. Its chief features, however, are exertional dyspnea, angina, dizziness, and syncope. This valvular disorder also causes a harsh, crescendo-decrescendo systolic ejection murmur that’s loudest at the right sternal border of the second intercostal space. Other findings include palpitations, crackles, and fatigue.

    Cardiac arrhythmias

    Tachycardia may occur with an irregular heart rhythm. The patient may be hypotensive and report dizziness, palpitations, weakness, and fatigue. Depending on his heart rate, he may also exhibit tachypnea, a decreased LOC, and pale, cool, clammy skin.

    Cardiac contusion

    The result of blunt chest trauma, this contusion may cause tachycardia, substernal pain, dyspnea, and palpitations. Assessment may detect sternal ecchymoses and a pericardial friction rub.

    Cardiac tamponade

    With life-threatening cardiac tamponade, tachycardia is commonly accompanied by paradoxical pulse, dyspnea, and tachypnea. The patient is visibly anxious and restless and has cyanotic, clammy skin and distended jugular veins. He may develop muffled heart sounds, a pericardial friction rub, chest pain, hypotension, narrowed pulse pressure, and hepatomegaly.

    Cardiogenic shock

    Although many features of cardiogenic shock appear in other types of shock, they’re usually more profound in this type. Tachycardia is accompanied by narrowing pulse pressure, hypotension, tachypnea, oliguria, restlessness, and an altered LOC. The patient will also exhibit a weak, thready pulse and cold, pale, clammy, and cyanotic skin.

    Cholera

    Signs of cholera, an infectious disorder, include abrupt watery diarrhea and vomiting. Severe fluid and electrolyte loss leads to tachycardia, thirst, weakness, muscle cramps, decreased skin turgor, oliguria, and hypotension. Without treatment, death can occur within hours.

    Chronic obstructive pulmonary disease (COPD)

    Although the clinical picture varies widely with COPD, tachycardia is a common sign. Other characteristic findings include cough, tachypnea, dyspnea, pursed-lip breathing, accessory muscle use, cyanosis, diminished breath sounds, rhonchi, crackles, and wheezing. Clubbing and barrel chest are usually late findings.

    Diabetic ketoacidosis (DKA)

    A life-threatening disorder, DKA commonly produces tachycardia and a thready pulse. Its cardinal sign, however, is Kussmaul’s respirations — abnormally rapid, deep breathing. Other signs and symptoms of DKA include fruity breath odor, orthostatic hypotension, generalized weakness, anorexia, nausea, vomiting, and abdominal pain. The patient’s LOC may vary from lethargy to coma.

    Febrile illness

    Fever can cause tachycardia. Related findings reflect the specific disorder.

    Heart failure

    Especially common with left-sided heart failure, tachycardia may be accompanied by a ventricular gallop, fatigue, dyspnea (exertional and paroxysmal nocturnal), orthopnea, and leg edema. Eventually, the patient develops widespread signs and symptoms, such as palpitations, narrowed pulse pressure, hypotension, tachypnea, crackles, dependent edema, weight gain, slowed mental response, diaphoresis, pallor and, possibly, oliguria. Late signs include hemoptysis, cyanosis, and marked hepatomegaly and pitting edema.

    Hyperosmolar hyperglycemic nonketotic syndrome

    A rapidly deteriorating LOC is commonly accompanied by tachycardia, hypotension, tachypnea, seizures, oliguria, and severe dehydration with poor skin turgor and dry mucous membranes.

    Hypertensive crisis

    Life-threatening hypertensive crisis is characterized by tachycardia, tachypnea, diastolic blood pressure that exceeds 120 mm Hg, and systolic blood pressure that may exceed 200 mm Hg. Typically, the patient develops pulmonary edema with jugular vein distention, dyspnea, and pink, frothy sputum. Related findings include chest pain, severe headache, drowsiness, confusion, anxiety, tinnitus, epistaxis, muscle twitching, seizures, nausea, and vomiting. Focal neurologic signs, such as paresthesia, may also occur.

    Hypoglycemia

    A common sign of hypoglycemia, tachycardia is accompanied by hypothermia, nervousness, trembling, fatigue, malaise, weakness, headache, hunger, nausea, diaphoresis, and moist, clammy skin. Central nervous system effects include blurred or double vision, motor weakness, hemiplegia, seizures, and a decreased LOC.

    Hyponatremia

    Tachycardia, although rare, is a possible effect of hyponatremia, an electrolyte imbalance. Other effects include orthostatic hypotension, headache, muscle twitching and weakness, fatigue, oliguria or anuria, poor skin turgor, thirst, irritability, seizures, nausea and vomiting, and a decreased LOC that may progress to coma. Severe hyponatremia may cause cyanosis and signs of vasomotor collapse such as a thready pulse.

    Hypovolemia

    Tachycardia may occur with hypovolemia. Associated findings include hypotension, decreased skin turgor, sunken eyeballs, thirst, syncope, and dry skin and tongue.

    Hypovolemic shock

    Mild tachycardia, an early sign of life-threatening hypovolemic shock, may be accompanied by tachypnea, restlessness, thirst, and pale, cool skin. As shock progresses, the patient’s skin becomes clammy and his pulse becomes increasingly rapid and thready. He may also develop hypotension, narrowed pulse pressure, oliguria, subnormal body temperature, and a decreased LOC.

    Hypoxemia

    Tachycardia may accompany tachypnea, dyspnea, and cyanosis. Confusion, syncope, and incoordination may also occur.

    Myocardial infarction (MI)

    A life-threatening disorder, an MI may cause tachycardia or bradycardia. Its classic symptom, however, is crushing substernal chest pain that may radiate to the left arm, jaw, neck, or shoulder. Auscultation may reveal an atrial gallop, a new murmur, and crackles. Other signs and symptoms include pallor, clammy skin, dyspnea, diaphoresis, nausea and vomiting, anxiety, restlessness, and increased or decreased blood pressure.

    Neurogenic shock

    Tachycardia or bradycardia may accompany tachypnea, apprehension, oliguria, variable body temperature, a decreased LOC, and warm, dry skin.

    Orthostatic hypotension

    Tachycardia accompanies the characteristic signs and symptoms of orthostatic hypotension, which include dizziness, syncope, pallor, blurred vision, diaphoresis, and nausea.

    Pheochromocytoma

    Characterized by sustained or paroxysmal hypertension, pheochromocytoma is a rare tumor that may also cause tachycardia and palpitations. Other findings include headache; chest and abdominal pain; diaphoresis; pale or flushed, warm skin; paresthesia; tremors; nausea; vomiting; insomnia; and extreme anxiety — possibly even panic.

    Pneumothorax

    Life-threatening pneumothorax causes tachycardia and other signs and symptoms of distress, such as severe dyspnea and chest pain, tachypnea, and cyanosis. Related findings include dry cough, subcutaneous crepitation, absent or decreased breath sounds, cessation of normal chest movement on the affected side, and decreased vocal fremitus.

    Pulmonary embolism

    With pulmonary embolism, tachycardia is usually preceded by sudden dyspnea, angina, or pleuritic chest pain. Common associated signs and symptoms include weak peripheral pulses, cyanosis, tachypnea, low-grade fever, restlessness, diaphoresis, and a dry cough or a cough with blood-tinged sputum.

    Septic shock

    Initially, septic shock produces chills, sudden fever, tachycardia, tachypnea and, possibly, nausea, vomiting, and diarrhea. The patient’s skin is flushed, warm, and dry and his blood pressure is normal or slightly decreased. Eventually, he may display a rapid, thready pulse accompanied by anxiety, restlessness, thirst, oliguria or anuria, severe hypotension, and cool, clammy, cyanotic skin. His LOC may decrease progressively, perhaps culminating in a coma.

    Thyrotoxicosis

    Tachycardia is a classic feature of thyrotoxicosis, a thyroid disorder. Other signs and symptoms include an enlarged thyroid, nervousness, heat intolerance, weight loss despite increased appetite, diaphoresis, diarrhea, tremors, and palpitations. Although also considered characteristic, exophthalmos is sometimes absent.

    Because thyrotoxicosis affects virtually every body system, its associated features are diverse and numerous. Some examples include full and bounding pulse, widened pulse pressure, dyspnea, anorexia, nausea, vomiting, altered bowel habits, hepatomegaly, and muscle weakness, fatigue, and atrophy. The patient’s skin is smooth, warm, and flushed; the hair is fine and soft and may gray prematurely or fall out. The female patient may have a reduced libido and oligomenorrhea or amenorrhea; the male patient may exhibit a reduced libido and gynecomastia.

    Other causes

    Diagnostic tests

    Cardiac catheterization and electrophysiologic studies may induce transient tachycardia.

    Drugs and alcohol

    Various drugs affect the nervous system, circulatory system, or heart muscle, resulting in tachycardia. Examples of these include sympathomimetics; phenothiazines; anticholinergics, such as atropine; thyroid drugs; vasodilators, such as hydralazine and nifedipine; acetylcholinesterase inhibitors, such as captopril; nitrates, such as nitroglycerin; alpha-adrenergic blockers, such as phentolamine; and beta-adrenergic bronchodilators such as albuterol. Excessive caffeine intake and alcohol intoxication may also cause tachycardia.

    Surgery and pacemakers

    Cardiac surgery and pacemaker malfunction or wire irritation may cause tachycardia.

    » READ BOOK EXCERPT ONLINE »

    Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

    Bradycardia: Medical causes
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    Cardiac arrhythmia

    Depending on the type of cardiac arrhythmia and the patient’s tolerance of it, bradycardia may be transient or sustained, benign, or life-threatening. Related findings result from reduced cardiac output and include hypotension, palpitations, dizziness, weakness, dyspnea, chest pain, decreased urine output, altered level of consciousness (LOC), syncope, and fatigue.

    Cardiomyopathy

    Cardiomyopathy, a potentially life-threatening disorder, may cause transient or sustained bradycardia. Other findings include dizziness, syncope, edema, fatigue, jugular vein distention, orthopnea, dyspnea, and peripheral cyanosis.

    Cervical spinal injury

    Bradycardia associated with a cervical spinal injury may be transient or sustained, depending on the severity of the injury. Its onset coincides with sympathetic denervation. Associated signs and symptoms of cervical spinal injury include hypotension, decreased body temperature, slowed peristalsis, leg paralysis, and partial arm and respiratory muscle paralysis.

    Hypothermia

    When core body temperature drops below 89.6° F (32° C), causing hypothermia, bradycardia usually appears. It’s accompanied by shivering, peripheral cyanosis, muscle rigidity, bradypnea, and confusion leading to stupor. If the core temperature drops below 86° F (30° C), the patient may appear dead (in a state of rigor mortis) with no palpable pulse or audible heart sounds.

    Hypothyroidism

    Hypothyroidism causes severe bradycardia in addition to fatigue, constipation, unexplained weight gain, and sensitivity to cold. Related signs include cool, dry, thick skin; sparse, dry hair; facial swelling; periorbital edema; thick, brittle nails; and confusion leading to stupor.

    Myocardial infarction

    Sinus bradycardia is the arrhythmia most commonly associated with acute myocardial infarction (MI). Accompanying signs and symptoms of an MI include an aching, burning, or viselike pressure in the chest that may radiate to the jaw, shoulder, arm, back, or epigastric area; nausea and vomiting; cool, clammy, and pale or cyanotic skin; anxiety; and dyspnea. Blood pressure may be elevated or depressed. Auscultation may reveal abnormal heart sounds.

    Other causes

    Diagnostic tests

    Cardiac catheterization and electrophysiologic studies can induce temporary bradycardia.

    Drugs

    Beta-adrenergic blockers and some calcium channel blockers, cardiac glycosides, topical miotics (such as pilocarpine), protamine, quinidine and other antiarrhythmics, and sympatholytics may cause transient bradycardia. Failure to take thyroid replacements may cause bradycardia.

    Invasive treatments

    Suctioning can induce hypoxia and vagal stimulation, causing bradycardia. Cardiac surgery can cause edema or damage to conduction tissues, causing bradycardia.

    » READ BOOK EXCERPT ONLINE »

    Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

    Murmurs: Medical causes
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    Aortic insufficiency

    Acute aortic insufficiency typically produces a soft, short diastolic murmur over the left sternal border that’s best heard when the patient sits and leans forward and at the end of a forced held expiration. S2 may be soft or absent. Sometimes, a soft, short midsystolic murmur may also be heard over the second right intercostal space. Associated findings include tachycardia, dyspnea, jugular vein distention, crackles, increased fatigue, and pale, cool extremities.

    Chronic aortic insufficiency causes a high-pitched, blowing, decrescendo diastolic murmur that’s best heard over the second or third right intercostal space or the left sternal border with the patient sitting, leaning forward, and holding his breath after deep expiration. An Austin Flint murmur — a rumbling, mid-to-late diastolic murmur best heard at the apex — may also occur. Findings include palpitations, tachycardia, angina, increased fatigue, dyspnea, orthopnea, and crackles.

    Aortic stenosis

    With aortic stenosis, the murmur is systolic, beginning after S1 and ending at or before aortic valve closure. It’s harsh and grating, medium-pitched, and crescendo-decrescendo. Loudest over the second right intercostal space when the patient is sitting and leaning forward, this murmur may also be heard at the apex, at the suprasternal notch (Erb’s point), and over the carotid arteries.

    If the patient has advanced disease, S2 may be heard as a single sound, with inaudible aortic closure. An early systolic ejection click at the apex is typical but is absent when the valve is severely calcified. Associated signs and symptoms may include dizziness, syncope, dyspnea on exertion, paroxysmal nocturnal dyspnea, fatigue, and angina.

    Cardiomyopathy (hypertrophic)

    Hypertrophic cardiomyopathy generates a harsh late systolic murmur, ending at S2. Best heard over the left sternal border and at the apex, the murmur is commonly accompanied by an audible S3or S4. The murmur decreases with squatting and increases with sitting down. Major associated symptoms are dyspnea and chest pain; palpitations, dizziness, and syncope may also occur.

    Mitral insufficiency

    Acute mitral insufficiency is characterized by a medium-pitched blowing, early systolic or holosystolic decrescendo murmur at the apex, along with a widely split S2 and commonly an S4. This murmur doesn’t get louder on inspiration as with tricuspid insufficiency. Associated findings typically include tachycardia and signs of acute pulmonary edema.

    Chronic mitral insufficiency produces a high-pitched, blowing, holosystolic plateau murmur that’s loudest at the apex and usually radiates to the axilla or back. Fatigue, dyspnea, and palpitations may also occur.

    Mitral prolapse

    Mitral prolapse generates a midsystolic to late-systolic click with a high-pitched late-systolic crescendo murmur, best heard at the apex. Occasionally, multiple clicks may be heard, with or without a systolic murmur. Associated findings include cardiac awareness, migraine headaches, dizziness, weakness, syncope, palpitations, chest pain, dyspnea, severe episodic fatigue, mood swings, and anxiety.

    Mitral stenosis

    With mitral stenosis, the murmur is soft, low-pitched, rumbling, crescendo-decrescendo, and diastolic, accompanied by a loud S1 or an opening snap — a cardinal sign. It’s best heard at the apex with the patient in the left lateral position. Mild exercise will help make this murmur audible.

    With severe stenosis, the murmur of mitral insufficiency may also be heard. Other findings include hemoptysis, exertional dyspnea and fatigue, and signs of acute pulmonary edema.

    Papillary muscle rupture

    Papillary muscle rupture, a life-threatening complication of an acute MI, produces a loud holosystolic murmur that can be auscultated at the apex. Related findings include severe dyspnea, chest pain, syncope, hemoptysis, tachycardia, and hypotension.

    Rheumatic fever with pericarditis

    A pericardial friction rub along with murmurs and gallops is heard best with the patient leaning forward on his hands and knees during forced expiration. The most common murmurs heard in patients with rheumatic fever are the systolic murmur of mitral insufficiency, a midsystolic murmur due to swelling of the leaflet of the mitral valve, and the diastolic murmur of aortic insufficiency. Other signs and symptoms include fever, joint and sternal pain, edema, and tachypnea.

    Tricuspid insufficiency

    Tricuspid insufficiency is a valvular abnormality that’s characterized by a soft, high-pitched, holosystolic blowing murmur that increases with inspiration (Carvallo’s sign) and decreases with exhalation and Valsalva’s maneuver. This murmur is best heard over the lower left sternal border and the xiphoid area. Following a lengthy period without symptoms, exertional dyspnea and orthopnea may develop, along with jugular vein distention, ascites, peripheral cyanosis and edema, muscle wasting, fatigue, weakness, and syncope.

    Tricuspid stenosis

    Tricuspid stenosis is a valvular disorder that produces a diastolic murmur similar to that of mitral stenosis, but louder with inspiration and decreased with exhalation and Valsalva’s maneuver. S1 may also be louder. Associated signs and symptoms include fatigue, syncope, peripheral edema, jugular vein distention, ascites, hepatomegaly, and dyspnea.

    Other causes

    Treatments

    Prosthetic valve replacement may cause variable murmurs, depending on the location, valve composition, and method of operation.

    » READ BOOK EXCERPT ONLINE »

    Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

    Palpitations: Medical causes
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    Anemia

    Palpitations may occur with anemia, especially on exertion. Pallor, fatigue, and dyspnea are also common. Associated signs include a systolic ejection murmur, bounding pulse, tachycardia, crackles, an atrial gallop, and a systolic bruit over the carotid arteries.

    Anxiety attack (acute)

    Anxiety is the most common cause of palpitations in children and adults. With this disorder, palpitations may be accompanied by diaphoresis, facial flushing, trembling, and an impending sense of doom. Almost invariably, the patient hyperventilates, which may lead to dizziness, weakness, and syncope. Other typical findings include tachycardia, precordial pain, shortness of breath, restlessness, and insomnia.

    Cardiac arrhythmias

    Paroxysmal or sustained palpitations may be accompanied by dizziness, weakness, and fatigue. The patient may also experience an irregular, rapid, or slow pulse rate; decreased blood pressure; confusion; pallor; chest pain; syncope; oliguria; and diaphoresis.

    Hypertension

    With hypertension, the patient may be asymptomatic or may complain of sustained palpitations alone or with headache, dizziness, tinnitus, and fatigue. His blood pressure typically exceeds 140/90 mm Hg. He may also experience nausea and vomiting, seizures, and decreased level of consciousness (LOC).

    Hypocalcemia

    Typically, hypocalcemia produces palpitations, weakness, and fatigue. It progresses from paresthesia to muscle tension and carpopedal spasms. The patient may also exhibit muscle twitching, hyperactive deep tendon reflexes, chorea, and positive Chvostek’s and Trousseau’s signs.

    Hypoglycemia

    Hypoglycemia occurs when blood glucose levels drop significantly and the sympathetic nervous system triggers adrenaline production. This may cause sustained palpitations, which may be accompanied by fatigue, irritability, hunger, cold sweats, tremors, tachycardia, anxiety, and headache. Eventually, the patient may develop central nervous system reactions, including blurred or double vision, muscle weakness, hemiplegia, and altered LOC.

    Mitral prolapse

    Mitral prolapse may cause paroxysmal palpitations accompanied by sharp, stabbing, or aching precordial pain. The hallmark of this disorder, however, is a midsystolic click followed by an apical systolic murmur. Associated signs and symptoms may include dyspnea, dizziness, severe fatigue, migraine headache, anxiety, paroxysmal tachycardia, crackles, and peripheral edema.

    Mitral stenosis

    Early features of mitral stenosis typically include sustained palpitations accompanied by exertional dyspnea and fatigue. Auscultation also reveals a loud S1 or opening snap, and a rumbling diastolic murmur at the apex. Patients may also experience such related signs and symptoms as an atrial gallop and, with advanced mitral stenosis, orthopnea, dyspnea at rest, paroxysmal nocturnal dyspnea, peripheral edema, jugular vein distention, ascites, hepatomegaly, and atrial fibrillations.

    Pheochromocytoma

    This adrenal medulla tumor causes episodic hypermetabolism, commonly associated with paroxysmal palpitations. The cardinal sign of pheochromocytoma is dramatically elevated blood pressure, which may be sustained or paroxysmal. Associated signs and symptoms include tachycardia, headache, chest or abdominal pain, diaphoresis, warm and pale or flushed skin, paresthesia, tremors, insomnia, nausea and vomiting, and anxiety.

    Thyrotoxicosis

    A characteristic symptom of thyrotoxicosis, sustained palpitations may be accompanied by tachycardia, dyspnea, weight loss despite increased appetite, diarrhea, tremors, nervousness, diaphoresis, heat intolerance and, possibly, exophthalmos and an enlarged thyroid. The patient may also experience an atrial or ventricular gallop.

    Other causes

    Drugs

    Palpitations may result from drugs that precipitate cardiac arrhythmias or increase cardiac output, such as cardiac glycosides; sympathomimetics such as cocaine; ganglionic blockers; beta blockers; calcium channel blockers; atropine; and minoxidil.

    Exercise

    Exercise can normally cause palpitations. In patients with coronary heart disease, exercise can also cause hypertension, mitral valve prolapse, and cardiomegaly.

    » READ BOOK EXCERPT ONLINE »

    Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

    Pulse rhythm abnormality: Medical causes
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    Cardiac arrhythmias

    An abnormal pulse rhythm may be the only sign of a cardiac arrhythmia. The patient may complain of palpitations, a fluttering heartbeat, or weak and skipped beats. Pulses may be weak and rapid or slow. Depending on the specific arrhythmia, dull chest pain or discomfort and hypotension may occur. Associated findings, if any, reflect decreased cardiac output. Neurologic findings, for example, include confusion, dizziness, light-headedness, decreased LOC and, sometimes, seizures. Other findings include decreased urine output, dyspnea, tachypnea, pallor, and diaphoresis.

    » READ BOOK EXCERPT ONLINE »

    Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

    Pulse, absent or weak: Medical causes
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    Aortic aneurysm (dissecting)

    When a dissecting aneurysm affects circulation to the innominate, left common carotid, subclavian, or femoral artery, it causes weak or absent arterial pulses distal to the affected area. Absent or diminished pulses occur in 50% of patients with proximal dissection and usually involve the brachiocephalic vessels. Pulse deficits are much less common in patients with distal dissection and tend to involve the left subclavian and femoral arteries. Tearing pain usually develops suddenly in the chest and neck and may radiate to the upper and lower back and abdomen. Other findings include syncope, loss of consciousness, weakness or transient paralysis of the legs or arms, the diastolic murmur of aortic insufficiency, systemic hypotension, and mottled skin below the waist.

    Aortic stenosis

    With aortic stenosis, the carotid pulse is sustained but weak. Dyspnea (especially paroxysmal dyspnea or dyspnea on exertion), chest pain, and syncope dominate the clinical picture. The patient commonly has an atrial gallop. Other findings include a harsh systolic ejection murmur, crackles, palpitations, fatigue, and narrowed pulse pressure.

    Arterial occlusion

    With acute occlusion, arterial pulses distal to the obstruction are unilaterally weak and then absent. The affected limb is cool, pale, and cyanotic, with increased capillary refill time, and the patient complains of moderate to severe pain and paresthesia. A line of color and temperature demarcation develops at the level of obstruction. Varying degrees of limb paralysis may also occur, along with intense intermittent claudication. With chronic occlusion, occurring with such disorders as arteriosclerosis and Buerger’s disease, pulses in the affected limb weaken gradually.

    Cardiac arrhythmias

    Cardiac arrhythmias may produce generalized weak pulses accompanied by cool, clammy skin. Other findings reflect the arrhythmia’s severity and may include hypotension, chest pain, dyspnea, dizziness, and decreased level of consciousness (LOC).

    Cardiac tamponade

    Life-threatening cardiac tamponade causes a weak, rapid pulse accompanied by these classic findings: paradoxical pulse, jugular vein distention, hypotension, and muffled heart sounds. Narrowed pulse pressure, pericardial friction rub, and hepatomegaly may also occur. The patient may appear anxious, restless, and cyanotic and may have chest pain, clammy skin, dyspnea, and tachypnea.

    Coarctation of the aorta

    Findings of this disorder include bounding pulses in the arms and neck, with decreased pulsations and systolic pulse pressure in the lower extremities. Auscultation may reveal a systolic ejection click at the base and apex of the heart and, occasionally, over the carotid arteries that’s often accompanied by a systolic ejection murmur at the base.

    Peripheral vascular disease

    Peripheral vascular disease causes a weakening and loss of peripheral pulses. The patient complains of aching pain distal to the occlusion that worsens with exercise and abates with rest. The skin feels cool and shows decreased hair growth. Impotence may occur in male patients with occlusion in the descending aorta or femoral areas.

    Pulmonary embolism

    A pulmonary embolism causes a generalized weak, rapid pulse. It may also cause abrupt onset of chest pain, tachycardia, dyspnea, apprehension, syncope, diaphoresis, and cyanosis. Acute respiratory findings include tachypnea, dyspnea, decreased breath sounds, crackles, a pleural friction rub, and a cough — possibly with blood-tinged sputum.

    Shock

    With anaphylactic shock, pulses become rapid and weak and then uniformly absent within seconds or minutes after exposure to an allergen. This is preceded by hypotension, anxiety, restlessness, feelings of doom, intense itching, a pounding headache and, possibly, urticaria.

    With cardiogenic shock, peripheral pulses are absent and central pulses are weak, depending on the degree of vascular collapse. Pulse pressure is narrow. Other signs include cold, pale, clammy skin; hypotension; tachycardia; rapid, shallow respirations; oliguria; restlessness; confusion; and obtundation.

    With hypovolemic shock, all peripheral pulses become weak and then uniformly absent, depending on the severity of hypovolemia. As shock progresses, remaining pulses become thready and more rapid. Early signs of hypovolemic shock include restlessness, thirst, tachypnea, and cool, pale skin. Late signs include hypotension with narrowing pulse pressure, clammy skin, a drop in urine output to less than 25 ml/hour, confusion, decreased LOC and, possibly, hypothermia.

    With septic shock, all pulses in the extremities first become weak. Depending on the degree of vascular collapse, pulses may then become uniformly absent. Shock is heralded by chills, sudden fever and, possibly, nausea, vomiting, and diarrhea. Typically, the patient experiences tachycardia, tachypnea, and flushed, warm, and dry skin. As shock progresses, he develops thirst, hypotension, anxiety, restlessness, and confusion. Then pulse pressure narrows, and the skin becomes cold, clammy, and cyanotic. The patient experiences severe hypotension, oliguria or anuria, respiratory failure, and coma.

    Thoracic outlet syndrome

    In thoracic outlet syndrome, the patient may develop gradual or abrupt weakness or loss of the pulses in the arms, depending on how quickly vessels in the neck compress. These pulse changes commonly occur after the patient works with his hands above his shoulders, lifts a weight, or abducts his arm. Paresthesia and pain occur along the ulnar distribution of the arm and disappear as soon as the patient returns his arm to a neutral position. The patient may also have asymmetrical blood pressure and cool, pale skin.

    Other causes

    Treatments

    Localized absent pulse may occur distal to arteriovenous shuntsfor dialysis.

    » READ BOOK EXCERPT ONLINE »

    Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

    Pulsus bisferiens: Medical causes
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    Aortic insufficiency

    Aortic insufficiency is the most common organic cause of bisferiens pulse. Most patients with chronic aortic insufficiency are asymptomatic until ages 40 to 50. However, exertional dyspnea, worsening fatigue, orthopnea and, eventually, paroxysmal nocturnal dyspnea may develop.

    Acute aortic insufficiency may produce signs and symptoms of left-sided heart failure and cardiovascular collapse, such as weakness, severe dyspnea, hypotension, ventricular gallop, and tachycardia. Additional findings include chest pain, palpitations, pallor, and strong, abrupt carotid pulsations. The patient may also exhibit widened pulse pressure and one or more murmurs, especially an apical diastolic rumble (Austin Flint murmur).

    Aortic stenosis with aortic insufficiency

    A bisferiens pulse is commonly seen in aortic stenosis that’s accompanied by moderately severe aortic insufficiency. In aortic stenosis, the pulse rises slowly and the second wave of the double beat is the more forceful one. This disorder is commonly accompanied by dyspnea and fatigue. Chest pain and syncope aren’t specific in the combined lesion, but they do suggest predominant aortic stenosis.

    High cardiac output states

    Pulsus bisferiens commonly occurs with high cardiac output states, such as anemia, thyrotoxicosis, fever, and exercise. Associated findings vary with the underlying cause and may include moderate tachycardia, a cervical venous hum, and widened pulse pressure.

    Hypertrophic obstructive cardiomyopathy

    About 40% of patients with hypertrophic obstructive cardiomyopathy have pulsus bisferiens because of a pressure gradient in the left ventricular outflow tract. Recorded more often than it’s palpated, the pulse rises rapidly, and the first wave is the more forceful one. Associated findings include a systolic murmur, dyspnea, angina, fatigue, and syncope.

    » READ BOOK EXCERPT ONLINE »

    Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

    Tachycardia: Medical causes
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    Acute respiratory distress syndrome

    Besides tachycardia, acute respiratory distress syndrome (ARDS) causes crackles, rhonchi, dyspnea, tachypnea, nasal flaring, and grunting respirations. Other findings include cyanosis, anxiety, decreased LOC, and abnormal chest X-ray findings.

    Adrenocortical insufficiency

    With adrenocortical insufficiency, tachycardia commonly occurs with a weak pulse as well as progressive weakness and fatigue, which may become so severe that the patient requires bed rest. Other signs and symptoms include abdominal pain, nausea and vomiting, altered bowel habits, weight loss, orthostatic hypotension, irritability, bronze skin, decreased libido, and syncope. Some patients report an enhanced sense of taste, smell, and hearing.

    Alcohol withdrawal syndrome

    Tachycardia along with tachypnea, profuse diaphoresis, fever, insomnia, anorexia, and anxiety can occur in patients experiencing alcohol withdrawal. The patient is characteristically anxious, irritable, and prone to visual and tactile hallucinations.

    Anaphylactic shock

    With life-threatening anaphylactic shock, tachycardia and hypotension develop within minutes after exposure to an allergen, such as penicillin or an insect sting. Typically, the patient is visibly anxious and has severe pruritus, perhaps with urticaria and a pounding headache. Other findings may include flushed and clammy skin, a cough, dyspnea, nausea, abdominal cramps, seizures, stridor, change or loss of voice associated with laryngeal edema, and urinary urgency and incontinence.

    Anemia

    Tachycardia and bounding pulse are characteristic with anemia. Associated signs and symptoms include fatigue, pallor, dyspnea and, possibly, bleeding tendencies. Auscultation may reveal an atrial gallop, a systolic bruit over the carotid arteries, and crackles.

    Anxiety

    A “fight-or-flight” response produces tachycardia, tachypnea; chest pain; cold, clammy skin; dry mouth; nausea; and light-headedness. The symptoms dissipate as anxiety resolves.

    Aortic insufficiency

    With aortic insufficiency, tachycardia is accompanied by a “water-hammer” bounding pulse and a large, diffuse apical heave. With severe insufficiency, widened pulse pressure occurs. Auscultation reveals a hallmark diastolic murmur that starts with the second heart sound; is decrescendo, high-pitched, and blowing; and is heard best at the left sternal border of the second and third intercostal spaces. An atrial or ventricular gallop, an early systolic murmur, an Austin Flint murmur (apical diastolic rumble), or Duroziez’s sign (a murmur over the femoral artery during systole and diastole) may also be heard. Other findings include angina, dyspnea, palpitations, strong and abrupt carotid pulsations, pallor, and signs of heart failure, such as crackles and jugular vein distention.

    Aortic stenosis

    Typically, aortic stenosis causes tachycardia, a weak, thready pulse, and an atrial gallop. Its chief features, however, are exertional dyspnea, angina, dizziness, and syncope. Aortic stenosis also causes a harsh, crescendo-decrescendo systolic ejection murmur that’s loudest at the right sternal border of the second intercostal space. Other findings include palpitations, crackles, and fatigue.

    Cardiac arrhythmias

    Tachycardia may occur with a cardiac arrhythmia. The patient may be hypotensive and report dizziness, palpitations, weakness, and fatigue. Depending on his heart rate, he may also exhibit tachypnea, decreased LOC, and pale, cool, clammy skin.

    Cardiac contusion

    The result of blunt chest trauma, cardiac contusion may cause tachycardia, substernal pain, dyspnea, hypotension, and palpitations. Assessment may detect sternal ecchymoses and a pericardial friction rub.

    Cardiac tamponade

    With life-threatening cardiac tamponade, tachycardia is commonly accompanied by paradoxical pulse, dyspnea, and tachypnea. The patient is visibly anxious and restless and has cyanotic, clammy skin and distended jugular veins. He may develop muffled heart sounds, pericardial friction rub, chest pain, hypotension, narrowed pulse pressure, and hepatomegaly.

    Cardiogenic shock

    Although many features of cardiogenic shock also appear in other types of shock, they’re usually more profound in this type. Accompanying tachycardia are weak, thready pulse; narrowing pulse pressure; hypotension; tachypnea; cold, pale, clammy, and cyanotic skin; oliguria; restlessness; and altered LOC.

    Chronic obstructive pulmonary disease

    Although the clinical picture varies widely with chronic obstructive pulmonary disease (COPD), tachycardia is a common sign. Other characteristic findings include cough, tachypnea, dyspnea, pursed-lip breathing, accessory muscle use, cyanosis, diminished breath sounds, rhonchi, crackles, and wheezing. Clubbing and barrel chest are usually late findings.

    Diabetic ketoacidosis

    Diabetic ketoacidosis is a life-threatening disorder that commonly produces tachycardia and a thready pulse. Its cardinal sign, however, is Kussmaul’s respirations — abnormally rapid, deep breathing. Other signs and symptoms of diabetic ketoacidosis include fruity breath odor, orthostatic hypotension, generalized weakness, anorexia, nausea, vomiting, and abdominal pain. The patient’s LOC may vary from lethargy to coma.

    Febrile illness

    Fever can cause tachycardia, chills, diaphoresis, headache, and weakness. Related findings reflect the specific disorder.

    Heart failure

    Especially common with left-sided heart failure, tachycardia may be accompanied by a ventricular gallop, fatigue, dyspnea (exertional and paroxysmal nocturnal), orthopnea, and leg edema. Eventually, the patient develops widespread signs and symptoms, such as palpitations, narrowed pulse pressure, hypotension, tachypnea, crackles, dependent edema, weight gain, slowed mental response, diaphoresis, pallor and, possibly, oliguria. Late signs include hemoptysis, cyanosis, and marked hepatomegaly and pitting edema.

    Hyperosmolar hyperglycemic nonketotic syndrome

    With hyperosmolar hyperglycemic nonketotic syndrome (HHNS), a rapidly deteriorating LOC is commonly accompanied by tachycardia, hypotension, tachypnea, seizures, oliguria, and severe dehydration with poor skin turgor and dry mucous membranes.

    Hypertensive crisis

    Life-threatening hypertensive crisis is characterized by tachycardia, tachypnea, diastolic blood pressure that exceeds 120 mm Hg, and systolic blood pressure that may exceed 200 mm Hg. Typically, the patient develops pulmonary edema with jugular vein distention, dyspnea, and pink, frothy sputum. Related findings include chest pain, severe headache, drowsiness, confusion, anxiety, tinnitus, epistaxis, muscle twitching, seizures, nausea, and vomiting. Focal neurologic signs, such as paresthesia, may also occur.

    Hypoglycemia

    A common sign of hypoglycemia, tachycardia is accompanied by hypothermia, nervousness, trembling, fatigue, malaise, weakness, headache, hunger, nausea, diaphoresis, and moist, clammy skin. Central nervous system effects include blurred or double vision, motor weakness, hemiplegia, seizures, and decreased LOC.

    Hypovolemia

    Tachycardia may occur with hypovolemia. Associated findings include hypotension, decreased urine output, fatigue, muscle weakness, decreased skin turgor, sunken eyeballs, thirst, syncope, and dry skin and tongue.

    Hypovolemic shock

    Mild tachycardia, an early sign of life-threatening hypovolemic shock, may be accompanied by tachypnea, restlessness, thirst, and pale, cool skin. As shock progresses, the patient’s skin becomes clammy and his pulse, increasingly rapid and thready. He may also develop hypotension, narrowed pulse pressure, oliguria, subnormal body temperature, and decreased LOC.

    Hypoxemia

    With hypoxemia, tachycardia may accompany tachypnea, dyspnea, and cyanosis. Confusion, restlessness, and disorientation may progress to coma and syncope. Incoordination may also occur.

    Myocardial infarction

    Myocardial infarction may cause tachycardia or bradycardia. Its classic symptom, however, is crushing substernal chest pain that may radiate to the left arm, jaw, neck, or shoulder. Auscultation may reveal an atrial gallop, a new murmur, and crackles. Other signs and symptoms include pallor, clammy skin, dyspnea, diaphoresis, nausea and vomiting, anxiety, restlessness, and increased or decreased blood pressure.

    Neurogenic shock

    Tachycardia or bradycardia may accompany tachypnea, apprehension, oliguria, variable body temperature, decreased LOC, and warm, dry skin. Depending on the cause of shock, there also may be motor weakness of the limbs and diaphragm.

    Orthostatic hypotension

    Tachycardia accompanies the characteristic signs and symptoms of orthostatic hypotension, which include dizziness, syncope, pallor, blurred vision, diaphoresis, and nausea. Other signs and symptoms include dim vision, spots before the eyes and, possibly, signs of dehydration.

    Pneumothorax

    Life-threatening pneumothorax causes tachycardia and other signs and symptoms of distress, such as severe dyspnea and chest pain, tachypnea, and cyanosis. Related findings include dry cough, subcutaneous crepitation, absent or decreased breath sounds, cessation of normal chest movement on the affected side, and decreased vocal fremitus.

    Pulmonary embolism

    With pulmonary embolism, tachycardia is usually preceded by sudden dyspnea, angina, or pleuritic chest pain. Common associated signs and symptoms include weak peripheral pulses, cyanosis, tachypnea, low-grade fever, restlessness, diaphoresis, and a dry cough or a cough with blood-tinged sputum.

    Septic shock

    Initially, septic shock produces chills, sudden fever, tachycardia, tachypnea and, possibly, nausea, vomiting, and diarrhea. The patient’s skin is flushed, warm, and dry; his blood pressure is normal or slightly decreased. Eventually, he may display anxiety; restlessness; thirst; oliguria or anuria; cool, clammy, cyanotic skin; rapid, thready pulse; and severe hypotension. His LOC may decrease progressively, perhaps culminating in a coma.

    Thyrotoxicosis

    Tachycardia is a classic feature of thyrotoxicosis. Others include an enlarged thyroid, nervousness, heat intolerance, weight loss despite increased appetite, diaphoresis, diarrhea, tremors, and palpitations. Although also considered characteristic, exophthalmos is sometimes absent.

    Other causes

    Diagnostic tests

    Cardiac catheterization and electrophysiologic studies may induce transient tachycardia.

    Drugs and alcohol

    Various drugs affect the nervous system, circulatory system, or heart muscle, resulting in tachycardia. Examples of these include sympathomimetics; phenothiazines; anticholinergics, such as atropine; thyroid drugs; vasodilators, such as hydralazine and nifedipine; acetylcholinesterase inhibitors, such as captopril; nitrates, such as nitroglycerin; alpha-adrenergic blockers, such as phentolamine; and beta-adrenergic bronchodilators, such as albuterol. Excessive caffeine intake and alcohol intoxication may also cause tachycardia.

    Surgery and pacemakers

    Cardiac surgery and pacemaker malfunction or wire irritation may cause tachycardia.

    » READ BOOK EXCERPT ONLINE »

    Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

    Heart Murmurs (Asymptomatic): Principal Causes of Heart Murmurs (Asymptomatic)
    (The Diagnostic Approach to Symptoms and Signs in Pediatrics)

    1. Normalmurmurs
      1. Systolicejection murmurs
        1. Vibratory systolic murmur
        2. Pulmonary systolic murmur (pulmonarytrunk)
        3. Physiologic peripheral pulmonary systolicmurmur (pulmonary branches)
        4. Supraclavicular or brachiocephalicmurmur
      2. Continuous murmurs
        1. Venoushum
    2. Pathologic murmurs
      1. Systolicmurmurs
        1. Maximalintensity at the upper right sternal border
          1. Valvaraortic stenosis
        2. Maximal intensity at the upper leftsternal border
          1. Valvar pulmonic stenosis
          2. Atrial septal defects
          3. Mild-to-moderate coarctation of theaorta
          4. Small patent ductus arteriosus
        3. Maximal intensity at the lower leftsternal border
          1. Ventricular septal defect
          2. Tricuspid incompetence
        4. Maximal intensity at the apex
          1. Mitralincompetence
          2. Mitral valve prolapse
      2. Diastolic murmurs
        1. Maximalintensity at the upper right sternal border
          1. Aorticvalve incompetence
        2. Maximal intensity at the upper leftsternal border
          1. Pulmonic valve incompetence
        3. Maximal intensity at the lower leftsternal border
          1. Atrial septal defects
          2. Tricuspid stenosis
          3. Moderate-to-severe tricuspid incompetence
        4. Maximal intensity at the apex
          1. Mitralstenosis
          2. Moderate-to-severe mitral incompetence
          3. Moderate left-to-right shunt lesions
      3. Continuous murmurs
        1. Maximalintensity at the upper left sternal border
          1. Moderate patent ductus arteriosus
        2. Maximal intensity at the left mid sternalborder
          1. Aorticpulmonary window
        3. Maximal intensity with variable location
          1. Coronaryarteriovenous fistula
          2. Systemic arteriovenous fistula

    » READ BOOK EXCERPT ONLINE »

    Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

    Bradycardia: Medical causes
    (Nursing: Interpreting Signs and Symptoms)

    Cardiac arrhythmia.Depending on the type of arrhythmia and the patient's tolerance of it, bradycardia may be transient or sustained, benign or life-threatening. Related findings may include hypotension, palpitations, dizziness, weakness, syncope, and fatigue.

    Cardiomyopathy.Cardiomyopathy is a potentially life-threatening disorder that may cause transient or sustained bradycardia. Other findings include dizziness, syncope, edema, fatigue, jugular vein distention, orthopnea, dyspnea, and peripheral cyanosis.

    Hypothermia.Bradycardia usually appears when the core temperature drops below 89.6° F (32° C). It's accompanied by shivering, peripheral cyanosis, muscle rigidity, bradypnea, and confusion leading to stupor.

    Hypothyroidism.Hypothyroidism causes severe bradycardia in addition to fatigue, constipation, unexplained weight gain, and sensitivity to cold. Related signs include cool, dry, thick skin; sparse, dry hair; facial swelling; periorbital edema; thick, brittle nails; and confusion leading to stupor.

    Myocardial infarction (MI).Sinus bradycardia is the most common arrhythmia associated with an acute MI. Accompanying signs and symptoms of an MI include an aching, burning, or viselike pressure in the chest that may radiate to the jaw, shoulder, arm, back, or epigastric area; nausea and vomiting; cool, clammy, and pale or cyanotic skin; anxiety; and dyspnea. Blood pressure may be elevated or decreased. Auscultation may reveal abnormal heart sounds.

    Other causes

    Diagnostic tests.Cardiac catheterization and electrophysiologic studies can induce temporary bradycardia.

    Drugs.Beta-adrenergic blockers and some calcium channel blockers, cardiac glycosides, topical miotics (such as pilocarpine), protamine, quinidine and other antiarrhythmics, and sympatholytics may cause transient bradycardia. Failure to take thyroid replacements may cause bradycardia.

    Invasive treatments.Suctioning can induce hypoxia and vagal stimulation, causing bradycardia. Cardiac surgery can cause edema or damage to conduction tissues, causing bradycardia.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Murmurs: Medical causes
    (Nursing: Interpreting Signs and Symptoms)

    Aortic insufficiency.Acute aortic insufficiency typically produces a soft, short diastolic murmur over the left sternal border that's best heard when the patient sits and leans forward and at the end of a forced held expiration. S2 may be soft or absent. Sometimes, a soft, short midsystolic murmur may also be heard over the second right intercostal space. Associated findings include tachycardia, dyspnea, jugular vein distention, crackles, increased fatigue, and pale, cool extremities.

    Chronic aortic insufficiency causes a high-pitched, blowing, decrescendo diastolic murmur that's best heard over the second or third right intercostal space or the left sternal border with the patient sitting, leaning forward, and holding his breath after deep expiration. An Austin Flint murmur—a rumbling, mid-to-late diastolic murmur best heard at the apex—may also occur. Complications may not develop until the patient is between ages 40 and 50; then, typical findings include palpitations, tachycardia, angina, increased fatigue, dyspnea, orthopnea, and crackles.

    Aortic stenosis.With aortic stenosis, the murmur is systolic, beginning after S1 and ending at or before aortic valve closure. It's harsh and grating, medium-pitched, and crescendo-decrescendo. Loudest over the second right intercostal space when the patient is sitting and leaning forward, this murmur may also be heard at the apex, at the suprasternal notch (Erb's point), and over the carotid arteries.

    If the patient has advanced disease, S2 may be heard as a single sound, with inaudible aortic closure. An early systolic ejection click at the apex is typical, but is absent when the valve is severely calcified. Associated signs and symptoms usually don't appear until age 30 in congenital aortic stenosis, ages 30 to 65 in stenosis due to rheumatic disease, and after age 65 in calcific aortic stenosis. They may include dizziness, syncope, dyspnea on exertion, paroxysmal nocturnal dyspnea, fatigue, and angina.

    Cardiomyopathy (hypertrophic).Hypertrophic cardiomyopathygenerates a harsh late-systolic murmur, ending at S2. Best heard over the left sternal border and at the apex, the murmur is commonly accompanied by an audible S3 or S4. The murmur decreases with squatting and increases with sitting down. Major associated symptoms are dyspnea and chest pain; palpitations, dizziness, and syncope may also occur.

    Mitral insufficiency.Acute mitral insufficiency is characterized by a medium-pitched blowing, early systolic or holosystolic decrescendo murmur at the apex, along with a widely split S2 and commonly an S4. This murmur doesn't get louder on inspiration as with tricuspid insufficiency. Associated findings typically include tachycardia and signs of acute pulmonary edema.

    Chronic mitral insufficiency produces a high-pitched, blowing, holosystolic plateau murmur that's loudest at the apex and usually radiates to the axilla or back. Fatigue, dyspnea, and palpitations may also occur.

    Mitral prolapse.Mitral prolapse generates a midsystolic to late-systolic click with a high-pitched late-systolic crescendo murmur, best heard at the apex. Occasionally, multiple clicks may be heard, with or without a systolic murmur. Associated findings include cardiac awareness, migraine headaches, dizziness, weakness, syncope, palpitations, chest pain, dyspnea, severe episodic fatigue, mood swings, and anxiety.

    Mitral stenosis.With mitral stenosis, the murmur is soft, low-pitched, rumbling, crescendo-decrescendo, and diastolic, accompanied by a loud S1 or an opening snap—a cardinal sign. It's best heard at the apex with the patient in the left lateral position. Mild exercise helps make this murmur audible.

    With severe stenosis, the murmur of mitral insufficiency may also be heard. Other findings include hemoptysis, exertional dyspnea and fatigue, and signs of acute pulmonary edema.

    Myxomas.A left atrial myxoma (most common) usually produces a mid-diastolic murmur and a holosystolic murmur that's loudest at the apex, with an S4, an early diastolic thudding sound (tumor plop), and a loud, widely split S1.Related features include dyspnea, orthopnea, chest pain, fatigue, weight loss, and syncope.

    A right atrial myxoma causes a late-diastolic rumbling murmur, a holosystolic crescendo murmur, and tumor plop, best heard at the lower left sternal border. Other findings include fatigue, peripheral edema, ascites, and hepatomegaly.

    A left ventricular myxoma (rare) produces a systolic murmur, best heard at the lower left sternal border; arrhythmias; dyspnea; and syncope.

    A right ventricular myxoma commonly generates a systolic ejection murmur with delayed S2 and a tumor plop, best heard at the left sternal border. It's accompanied by peripheral edema, hepatomegaly, ascites, dyspnea, and syncope.

    Papillary muscle rupture.With papillary muscle rupture—a life-threatening complication of an acute MI—a loud holosystolic murmur can be auscultated at the apex. Related findings include severe dyspnea, chest pain, syncope, hemoptysis, tachycardia, and hypotension.

    Rheumatic fever with pericarditis.With rheumatic fever, a pericardial friction rub along with murmurs and gallops are heard best with the patient leaning forward on his hands and knees during forced expiration. The most common murmurs heard are the systolic murmur of mitral insufficiency, a midsystolic murmur due to swelling of the mitral valve leaflet, and the diastolic murmur of aortic insufficiency. Other signs and symptoms include fever, joint and sternal pain, edema, and tachypnea.

    Tricuspid insufficiency.Tricuspid insufficiency is characterized by a soft, high-pitched, holosystolic blowing murmur that increases with inspiration (Carvallo's sign), decreases with exhalation and Valsalva's maneuver, and is best heard over the lower left sternal border and the xiphoid area. Following a lengthy period without symptoms, exertional dyspnea and orthopnea may develop, along with jugular vein distention, ascites, peripheral cyanosis and edema, muscle wasting, fatigue, weakness, and syncope.

    Tricuspid stenosis.Tricuspid stenosis produces a diastolic murmur similar to that of mitral stenosis, but louder with inspiration and decreased with exhalation and Valsalva's maneuver. S1 may also be louder. Associated signs and symptoms include fatigue, syncope, peripheral edema, jugular vein distention, ascites, hepatomegaly, and dyspnea.

    Other causes

    Treatments.Prosthetic valve replacement may cause variable murmurs, depending on the location, valve composition, and method of operation.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Palpitations: Medical causes
    (Nursing: Interpreting Signs and Symptoms)

    Anxiety attack (acute).With anxiety, palpitations may be accompanied by diaphoresis, facial flushing, trembling, and an impending sense of doom. Almost invariably, patients hyperventilate, which may lead to dizziness, weakness, and syncope. Other typical findings include tachycardia, precordial pain, shortness of breath, restlessness, and insomnia.

    Cardiac arrhythmias.Paroxysmal or sustained palpitations of a cardiac arrhythmias may be accompanied by dizziness, weakness, and fatigue. The patient may also experience an irregular, rapid, or slow pulse rate; decreased blood pressure; confusion; pallor; oliguria; and diaphoresis.

    Hypertension.With hypertension, the patient may be asymptomatic or may complain of sustained palpitations alone or with headache, dizziness, tinnitus, “blackouts,” and fatigue. His blood pressure typically exceeds 140/90 mm Hg. He may also experience nausea and vomiting, seizures, and decreased level of consciousness.

    Hypocalcemia.Typically, hypocalcemia produces palpitations, weakness, and fatigue. It progresses from paresthesia to muscle tension and carpopedal spasms. The patient may also exhibit muscle twitching, hyperactive deep tendon reflexes, chorea, and positive Chvostek's and Trousseau's signs.

    Mitral prolapse.Mitral prolapse may cause paroxysmal palpitations accompanied by sharp, stabbing, or aching precordial pain. The hallmark of this disorder, however, is a midsystolic click followed by an apical systolic murmur. Associated signs and symptoms may include dyspnea, dizziness, severe fatigue, a migraine headache, anxiety, paroxysmal tachycardia, crackles, and peripheral edema.

    Mitral stenosis.Early features of mitral stenosis typically include sustained palpitations accompanied by exertional dyspnea and fatigue. Auscultation also reveals a loud S1 or opening snap and a rumbling diastolic murmur at the apex. Patients may also experience related signs and symptoms, such as an atrial gallop and, with advanced mitral stenosis, orthopnea, dyspnea at rest, paroxysmal nocturnal dyspnea, peripheral edema, jugular vein distention, ascites, hepatomegaly, and atrial fibrillation.

    Thyrotoxicosis.A characteristic symptom of thyrotoxicosis, sustained palpitations may be accompanied by tachycardia, dyspnea, weight loss despite increased appetite, diarrhea, tremors, nervousness, diaphoresis, heat intolerance and, possibly, exophthalmos and an enlarged thyroid. The patient may also experience an atrial or a ventricular gallop.

    Other causes

    Drugs.Palpitations may result from drugs that precipitate cardiac arrhythmias or increase cardiac output, such as cardiac glycosides; sympathomimetics, such as cocaine; ganglionic blockers; beta-adrenergic blockers; calcium channel blockers; atropine; thyroid supplements; and minoxidil.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Pulse rhythm abnormality: Medical causes
    (Nursing: Interpreting Signs and Symptoms)

    Arrhythmias.An abnormal pulse rhythm may be the only sign of a cardiac arrhythmia. The patient may complain of palpitations, a fluttering heartbeat, or weak and skipped beats. Pulses may be weak and rapid or slow. Depending on the specific arrhythmia, dull chest pain or discomfort and hypotension may occur. Associated findings, if any, reflect decreased cardiac output. Neurologic findings, for example, include confusion, dizziness, light-headedness, decreased LOC and, sometimes, seizures. Other findings include decreased urine output, dyspnea, tachypnea, pallor, and diaphoresis.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Pulse, absent or weak: Medical causes
    (Nursing: Interpreting Signs and Symptoms)

    Aortic aneurysm (dissecting).When a dissecting aneurysm affects circulation to the innominate, left common carotid, subclavian, or femoral artery, it causes weak or absent arterial pulses distal to the affected area. Absent or diminished pulses occur in 50% of patients with proximal dissection and usually involve the brachiocephalic vessels. Pulse deficits are much less common in patients with distal dissection and tend to involve the left subclavian and femoral arteries. Tearing pain usually develops suddenly in the chest and neck and may radiate to the upper and lower back and abdomen. Other findings include syncope, loss of consciousness, weakness or transient paralysis of the legs or arms, the diastolic murmur of aortic insufficiency, systemic hypotension, and mottled skin below the waist.

    Aortic arch syndrome (Takayasu's arteritis).Aortic arch syndrome produces weak or abruptly absent carotid pulses and unequal or absent radial pulses. These signs are usually preceded by malaise, night sweats, pallor, nausea, anorexia, weight loss, arthralgia, and Raynaud's phenomenon. Other findings include neck, shoulder, and chest pain; paresthesia; intermittent claudication; bruits; vision disturbances; dizziness; and syncope. If the carotid artery is involved, diplopia and transient blindness may occur.

    Aortic bifurcation occlusion (acute).Aortic bifurcation occlusionproduces abrupt absence of all leg pulses. The patient reports moderate to severe pain in the legs and, less commonly, in the abdomen, lumbosacral area, or perineum. Also, his legs are cold, pale, numb, and flaccid.

    Aortic stenosis.With aortic stenosis, the carotid pulse is sustained but weak. Dyspnea (especially on exertion or paroxysmal nocturnal), chest pain, and syncope dominate the clinical picture. The patient commonly has an atrial gallop. Other findings include a harsh systolic ejection murmur, crackles, palpitations, fatigue, and narrowed pulse pressure.

    Arrhythmias.Cardiac arrhythmias may produce generalized weak pulses accompanied by cool, clammy skin. Other findings reflect the arrhythmia's severity and may include hypotension, chest pain, dyspnea, dizziness, and decreased level of consciousness (LOC).

    Arterial occlusion.Withacute occlusion, arterial pulses distal to the obstruction are unilaterally weak and then absent. The affected limb is cool, pale, and cyanotic, with an increased capillary refill time, and the patient complains of moderate to severe pain and paresthesia. A line of color and temperature demarcation develops at the level of obstruction. Varying degrees of limb paralysis may also occur, along with intense intermittent claudication. With chronic occlusion, occurring with disorders such as arteriosclerosis and Buerger's disease, pulses in the affected limb weaken gradually.

    Cardiac tamponade.Life-threatening cardiac tamponade causes a weak, rapid pulse accompanied by these classic findings: paradoxical pulse, jugular vein distention, hypotension, and muffled heart sounds. Narrowed pulse pressure, pericardial friction rub, and hepatomegaly may also occur. The patient may appear anxious, restless, and cyanotic and may have chest pain, clammy skin, dyspnea, and tachypnea.

    Coarctation of the aorta.Findings of coarctation of the aorta include bounding pulses in the arms and neck, with decreased pulsations and systolic pulse pressure in the lower extremities.

    Peripheral vascular disease.Peripheral vascular disease causes a weakening and loss of peripheral pulses. The patient complains of aching pain distal to the occlusion that worsens with exercise and abates with rest. The skin feels cool and shows decreased hair growth. Impotence may occur in male patients with occlusion in the descending aorta or femoral areas.

    Pulmonary embolism.Pulmonary embolism causes a generalized weak, rapid pulse. It may also cause an abrupt onset of chest pain, tachycardia, dyspnea, apprehension, syncope, diaphoresis, and cyanosis. Acute respiratory findings include tachypnea, dyspnea, decreased breath sounds, crackles, a pleural friction rub, and a cough—possibly with blood-tinged sputum.

    Shock.With anaphylactic shock, pulses become rapid and weak and then uniformly absent within seconds or minutes after exposure to an allergen. This is preceded by hypotension, anxiety, restlessness, feelings of doom, intense itching, a pounding headache and, possibly, urticaria.

    With cardiogenic shock, peripheral pulses are absent and central pulses are weak, depending on the degree of vascular collapse. Pulse pressure is narrow. A drop in systolic blood pressure to 30 mm Hg below baseline, or a sustained reading below 80 mm Hg, produces poor tissue perfusion. Resulting signs include cold, pale, clammy skin; tachycardia; rapid, shallow respirations; oliguria; restlessness; confusion; and obtundation.

    With hypovolemic shock, all pulses in the extremities become weak and then uniformly absent, depending on the severity of hypovolemia. As shock progresses, remaining pulses become thready and more rapid. Early signs of hypovolemic shock include restlessness, thirst, tachypnea, and cool, pale skin. Late signs include hypotension with narrowing pulse pressure, clammy skin, a drop in urine output to less than 25 ml/hour, confusion, decreased LOC and, possibly, hypothermia.

    With septic shock, all pulses in the extremities first become weak. Depending on the degree of vascular collapse, pulses may then become uniformly absent. Shock is heralded by chills, a sudden fever and, possibly, nausea, vomiting, and diarrhea. Typically, the patient experiences tachycardia, tachypnea, and flushed, warm, and dry skin. As shock progresses, he develops thirst, hypotension, anxiety, restlessness, and confusion. Then pulse pressure narrows and the skin becomes cold, clammy, and cyanotic. The patient experiences severe hypotension, oliguria or anuria, respiratory failure, and coma.

    Thoracic outlet syndrome.A patient with thoracic outletsyndrome may develop gradual or abrupt weakness or loss of the pulses in the arms, depending on how quickly vessels in the neck compress. These pulse changes commonly occur after the patient works with his hands above his shoulders, lifts a weight, or abducts his arm. Paresthesia and pain occur along the ulnar distribution of the arm and disappear as soon as the patient returns his arm to a neutral position. The patient may also have asymmetrical blood pressure and cool, pale skin.

    Other causes

    Treatments.Localized absent pulse may occur distal to arteriovenous shunts for dialysis or following orthopedic injury or repair.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Pulsus bisferiens: Medical causes
    (Nursing: Interpreting Signs and Symptoms)

    Aortic insufficiency.Aortic insufficiency may cause exertional dyspnea, worsening fatigue, orthopnea and, eventually, andparoxysmal nocturnal dyspnea.

    Acute aortic insufficiency may produce signs and symptoms of left-sided heart failure and cardiovascular collapse, such as weakness, severe dyspnea, hypotension, a ventricular gallop, and tachycardia. Additional findings include chest pain, palpitations, pallor, and strong, abrupt carotid pulsations. The patient may also exhibit widened pulse pressure and one or more murmurs, especially an apical diastolic rumble (Austin Flint murmur).

    High cardiac output states.Pulsus bisferiens commonly occurs with high output states, such as anemia, thyrotoxicosis, fever, and exercise. Associated findings vary with the underlying cause and may include moderate tachycardia, a cervical venous hum, and widened pulse pressure.

    Hypertrophic obstructive cardiomyopathy.About 40% of patients with hypertrophic obstructive cardiomyopathy have pulsus bisferiens because of a pressure gradient in the left ventricular outflow tract. Recorded more often than it's palpated, the pulse rises rapidly, and the first wave is the more forceful one. Associated findings include a systolic murmur, dyspnea, angina, fatigue, and syncope.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Tachycardia: Medical causes
    (Nursing: Interpreting Signs and Symptoms)

    Acute respiratory distress syndrome (ARDS).Besides tachycardia, ARDS causes crackles, rhonchi, dyspnea, tachypnea, nasal flaring, and grunting respirations. Other findings include cyanosis, anxiety, decreased LOC, and abnormal chest X-ray findings.

    Adrenocortical insufficiency.With adrenocortical insufficiency, tachycardia commonly occurs with a weak pulse as well as progressive weakness and fatigue, which may become so severe that the patient requires bed rest. Other signs and symptoms include abdominal pain, nausea and vomiting, altered bowel habits, weight loss, orthostatic hypotension, irritability, bronze skin, decreased libido, and syncope. Some patients report an enhanced sense of taste, smell, and hearing.

    Anaphylactic shock.With life-threatening anaphylactic shock, tachycardia and hypotension develop within minutes after exposure to an allergen, such as penicillin or an insect sting. Typically, the patient is visibly anxious and has severe pruritus, perhaps with urticaria and a pounding headache. Other findings may include flushed and clammy skin, cough, dyspnea, nausea, abdominal cramps, seizures, stridor, change or loss of voice associated with laryngeal edema, and urinary urgency and incontinence.

    Anemia.Tachycardia and bounding pulse are characteristics of anemia. Associated signs and symptoms include fatigue, pallor, dyspnea and, possibly, bleeding tendencies. Auscultation may reveal an atrial gallop, a systolic bruit over the carotid arteries, and crackles.

    Aortic insufficiency.Accompanying tachycardia with aortic insufficiency are a “water-hammer” bounding pulse and a large, diffuse apical heave. With severe insufficiency, widened pulse pressure occurs. Auscultation reveals a hallmark diastolic murmur that starts with the second heart sound; is decrescendo, high-pitched, and blowing; and is heard best at the left sternal border of the second and third intercostal spaces. An atrial or ventricular gallop, an early systolic murmur, an Austin Flint murmur (apical diastolic rumble), or Duroziez's sign (a murmur over the femoral artery during systole and diastole) may also be heard. Other findings include angina, dyspnea, palpitations, strong and abrupt carotid pulsations, pallor, and signs of heart failure, such as crackles and jugular vein distention.

    Aortic stenosis.Typically, aortic stenosis causes tachycardia, a weak, thready pulse, and an atrial gallop. Its chief features are exertional dyspnea, angina, dizziness, and syncope. Aortic stenosis also causes a harsh, crescendo-decrescendo systolic ejection murmur that's loudest at the right sternal border of the second intercostal space. Other findings include palpitations, crackles, and fatigue.

    Cardiac arrhythmias.Tachycardia may occur with an irregular heart rhythm. The patient may be hypotensive and report dizziness, palpitations, weakness, and fatigue. Depending on his heart rate, he may also exhibit tachypnea, decreased LOC, and pale, cool, clammy skin.

    Cardiac contusion.Cardiac contusion may cause tachycardia, substernal pain, dyspnea, and palpitations. Assessment may detect sternal ecchymoses and a pericardial friction rub.

    Cardiac tamponade.With life-threatening cardiac tamponade, tachycardia is commonly accompanied by paradoxical pulse, dyspnea, and tachypnea. The patient is visibly anxious and restless and has cyanotic, clammy skin and distended jugular veins. He may develop muffled heart sounds, pericardial friction rub, chest pain, hypotension, narrowed pulse pressure, and hepatomegaly.

    Cardiogenic shock.With cardiogenic shock, tachycardia is accompanied by a weak, thready pulse; narrowing pulse pressure; hypotension; tachypnea; cold, pale, clammy, and cyanotic skin; oliguria; restlessness; and altered LOC.

    Cholera.Cholera causes abrupt watery diarrhea and vomiting, which leads to severe fluid and electrolyte loss, causing tachycardia, thirst, weakness, muscle cramps, decreased skin turgor, oliguria, and hypotension. Without treatment, death can occur within hours.

    Chronic obstructive pulmonary disease (COPD).Although the clinical picture varies widely with COPD, tachycardia is a common sign. Other characteristic findings include cough, tachypnea, dyspnea, pursed-lip breathing, accessory muscle use, cyanosis, diminished breath sounds, rhonchi, crackles, and wheezing. Clubbing and barrel chest are usually late findings.

    Diabetic ketoacidosis.Life-threatening diabetic ketoacidosis commonly produces tachycardia and a thready pulse. Its cardinal sign, however, is Kussmaul's respirations—abnormally rapid, deep breathing. Other signs and symptoms of acidosis include fruity breath odor, orthostatic hypotension, generalized weakness, anorexia, nausea, vomiting, and abdominal pain. The patient's LOC may vary from lethargy to coma.

    Heart failure.Especially common with left-sided heart failure, tachycardia may be accompanied by a ventricular gallop, fatigue, dyspnea (exertional and paroxysmal nocturnal), orthopnea, and leg edema. Eventually, the patient develops widespread signs and symptoms, such as palpitations, narrowed pulse pressure, hypotension, tachypnea, crackles, dependent edema, weight gain, slowed mental response, diaphoresis, pallor and, possibly, oliguria. Late signs include hemoptysis, cyanosis, and marked hepatomegaly and pitting edema.

    Hyperosmolar hyperglycemic nonketotic syndrome (HHNS).With HHNS, a rapidly deteriorating LOC is commonly accompanied by tachycardia, hypotension, tachypnea, seizures, oliguria, and severe dehydration with poor skin turgor and dry mucous membranes.

    Hypertensive crisis.Life-threatening hypertensive crisis is characterized by tachycardia, tachypnea, diastolic blood pressure that exceeds 120 mm Hg, and systolic blood pressure that may exceed 200 mm Hg. Typically, the patient develops pulmonary edema with jugular vein distention, dyspnea, and pink, frothy sputum. Related findings include chest pain, severe headache, drowsiness, confusion, anxiety, tinnitus, epistaxis, muscle twitching, seizures, nausea, and vomiting. Focal neurologic signs, such as paresthesia, may also occur.

    Hypoglycemia.A common sign of hypoglycemia, tachycardia accompanies hypothermia, nervousness, trembling, fatigue, malaise, weakness, headache, hunger, nausea, diaphoresis, and moist, clammy skin. Central nervous system effects include blurred or double vision, motor weakness, hemiplegia, seizures, and decreased LOC.

    Hypovolemia.Tachycardia occurs with hypovolemia. Associated findings include hypotension, decreased skin turgor, sunken eyeballs, thirst, syncope, and dry skin and tongue.

    Hypovolemic shock.Mild tachycardia, an early sign of life-threatening hypovolemic shock, may be accompanied by tachypnea, restlessness, thirst, and pale, cool skin. As shock progresses, the patient's skin becomes clammy and his pulse becomes increasingly rapid and thready. He may also develop hypotension, narrowed pulse pressure, oliguria, subnormal body temperature, and decreased LOC.

    Neurogenic shock.Tachycardia or bradycardia may accompany tachypnea, apprehension, oliguria, variable body temperature, decreased LOC, and warm, dry skin.

    Orthostatic hypotension.Tachycardia accompanies the characteristic signs and symptoms of orthostatic hypotension, which include dizziness, syncope, pallor, blurred vision, diaphoresis, and nausea.

    Pneumothorax.Life-threatening pneumothorax causes tachycardia and other signs and symptoms of distress, such as severe dyspnea and chest pain, tachypnea, and cyanosis. Related findings include dry cough, subcutaneous crepitation, absent or decreased breath sounds, cessation of normal chest movement on the affected side, and decreased vocal fremitus.

    Pulmonary embolism.With pulmonary embolism, tachycardia is usually preceded by sudden dyspnea, angina, or pleuritic chest pain. Common associated signs and symptoms include weak peripheral pulses, cyanosis, tachypnea, low-grade fever, restlessness, diaphoresis, and a dry cough or a cough with blood-tinged sputum.

    Thyrotoxicosis.Tachycardia is a classic feature of thyrotoxicosis—a thyroid disorder. Others include an enlarged thyroid, nervousness, heat intolerance, weight loss despite increased appetite, diaphoresis, diarrhea, tremors, and palpitations. Although also considered characteristic, exophthalmos is sometimes absent.

    Because thyrotoxicosis affects virtually every body system, its associated features are diverse and numerous. Some examples include full and bounding pulse, widened pulse pressure, dyspnea, anorexia, nausea, vomiting, altered bowel habits, hepatomegaly, and muscle weakness, fatigue, and atrophy. The patient's skin is smooth, warm, and flushed; his hair is fine and soft and may gray prematurely or fall out. The female patient may have a reduced libido and oligomenorrhea or amenorrhea; the male patient may exhibit a reduced libido and gynecomastia.

    Other causes

    Diagnostic tests.Cardiac catheterization and electrophysiologic studies may induce transient tachycardia.

    Drugs and alcohol.Various drugs affect the nervous system, circulatory system, or heart muscle, resulting in tachycardia. Examples of these include sympathomimetics; phenothiazines; anticholinergics, such as atropine; thyroid drugs; vasodilators, such as hydralazine; acetylcholinesterase inhibitors, such as captopril; nitrates, such as nitroglycerin; alpha-adrenergic blockers, such as phentolamine; and beta-adrenergic bronchodilators, such as albuterol. Excessive caffeine intake and alcohol intoxication may also cause tachycardia.

    Surgery and pacemakers.Cardiac surgery and pacemaker malfunction or wire irritation may cause tachycardia.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007


     » Next page: Risk Factors for Arrhythmias

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