Diagnostic Tests for Heart Murmur
Heart Murmur: Diagnostic Tests
The list of diagnostic tests
mentioned in various sources as
used in the diagnosis of Heart Murmur
includes:
Heart Murmur Tests: Book Excerpts
Home Diagnostic Testing
These home medical tests may be relevant to Heart Murmur:
- High Blood Pressure: Home Testing
- Heart Health: Home Testing:
Heart Murmur Diagnosis: Book Excerpts
Diagnosis of Heart Murmur: medical news summaries:
The following medical news items
are relevant to diagnosis of Heart Murmur:
Diagnostic Tests for Heart Murmur: Online Medical Books
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Review excerpts from medical books online, free, without registration,
for more information about the diagnostic tests for Heart Murmur.
PALPITATIONS:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
Before initiating an expensive workup, the patient should eliminate use of all drugs, alcohol, caffeine, and nicotine, if possible, for several days. If this does not eliminate the palpitations, a careful inquiry into the dietary habits should be made, and a CBC should be done to eliminate anemia. In the presence of tachycardia, weight loss, and increased appetite, it is obvious that a thyroid profile should be drawn. If there are palpitations and fever, a workup for an infectious disease, particularly rheumatic fever and bacterial endocarditis, is in order. Blood cultures, ASO titers, sedimentation rate, and echocardiography are useful. If the palpitations are intermittent, a pheochromocytoma should be considered, and 24-hr urine collection for VMA or metanephrines should be ordered. A drug screen may be necessary to ensure patient cooperation in eliminating all drugs. Twenty-four-hr blood pressure monitoring is also useful. In addition, 24-hr or 48-hr Holter monitoring is very useful in the diagnosis of intermittent palpitations. Newer technology involving a continuous-loop event recorder allows monitoring for 2 weeks at a time. Arm-to-tongue circulation times as well as spirometry may diagnose early congestive heart failure.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
CARDIAC MURMURS:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
If the murmur is believed to be organic, the most cost-effective approach would be to consult a cardiologist at the outset. If the astute clinician wishes to pursue the diagnostic workup on his own, it is suggested that a CBC, sedimentation rate, chemistry panel, VDRL test, and thyroid profile should be done for the initial blood work. In addition, a chest x-ray including obliques, congestive heart failure, phonocardiograms, and EKG should be performed. These findings may provide a diagnosis. If there is fever, a streptozyme test, antistreptolysin-O (ASO) titer, and serial blood culture should be performed. If congestive heart failure is suspected, venous pressure and circulation time should be determined. Pulmonary function studies are also helpful. Echocardiography will be extremely helpful in diagnosing the various forms of valvular disease and will also help in identifying a pericardial effusion, congestive heart failure, or the various cardiomyopathies. Cardiac catheterization and angiography and angiocardiography will identify the various congenital heart lesions and valvular disease. These studies, however, are most important when surgery is being considered.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Bruits:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
If you detect bruits over the abdominal aorta, check for a pulsating mass or a bluish discoloration around the umbilicus (Cullen's sign). Either of these signs — or severe, tearing pain in the abdomen, flank, or lower back — may signal life-threatening dissection of an aortic aneurysm. Also, check peripheral pulses, comparing intensity in the upper versus lower extremities.
If you suspect dissection, monitor the patient's vital signs constantly, and withhold food and fluids until a definitive diagnosis is made. Watch for signs and symptoms of hypovolemic shock, such as thirst; hypotension; tachycardia; a weak, thready pulse; tachypnea; an altered level of consciousness (LOC); mottled knees and elbows; and cool, clammy skin.
If you detect bruits over the thyroid gland, ask the patient if he has a history of hyperthyroidism or signs and symptoms of it, such as nervousness, tremors, weight loss, palpitations, heat intolerance, and (in females) amenorrhea. Watch for signs and symptoms of life-threatening thyroid storm, such as tremor, restlessness, diarrhea, abdominal pain, and hepatomegaly.
If you detect carotid artery bruits, be alert for signs and symptoms of a transient ischemic attack (TIA), including dizziness, diplopia, slurred speech, flashing lights, and syncope. These findings may indicate an impending stroke. Be sure to evaluate the patient frequently for changes in LOC and muscle function.
If you detect bruits over the femoral, popliteal, or subclavian artery, watch for signs and symptoms of decreased or absent peripheral circulation — edema, weakness, and paresthesia. Ask the patient if he has a history of intermittent claudication. Frequently check distal pulses and skin color and temperature. Also, watch for the sudden absence of pulse, pallor, or coolness, which may indicate a threat to the affected limb.
If you detect a bruit, make sure to check for further vascular damage and perform a thorough cardiac assessment.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Murmurs:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
If you discover a murmur, try to determine its type through careful auscultation. (See Identifying common murmurs, page 406.) Use the bell of your stethoscope for low-pitched murmurs and the diaphragm for high-pitched murmurs.
Next, obtain a patient history. Ask if the murmur is a new discovery or if it has been known since birth or childhood. Find out if the patient has experienced associated symptoms, particularly palpitations, dizziness, syncope, chest pain, dyspnea, and fatigue. Explore the patient’s medical history, noting especially an incidence of rheumatic fever, recent dental work, heart disease, or heart surgery, particularly prosthetic valve replacement.
Perform a systematic physical examination. Note especially the presence of cardiac arrhythmias, jugular vein distention, and such pulmonary signs and symptoms as dyspnea, orthopnea, and crackles. Is the patient’s liver tender or palpable? Does he have peripheral edema?
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Palpitations:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
If the patient isn’t in distress, perform a complete cardiac history and physical examination. Ask if he has a cardiovascular or pulmonary disorder, which may produce arrhythmias. Does the patient have a history of hypertension or hypoglycemia? Make sure to obtain a drug history. Has the patient recently started cardiac glycoside therapy? Also, ask about caffeine, tobacco, and alcohol consumption.
Then explore associated symptoms, such as weakness, fatigue, and angina. Finally, auscultate for gallops, murmurs, and abnormal breath sounds.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Bruits:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If you detect bruits over the abdominal aorta, check for a pulsating mass or a bluish discoloration around the umbilicus (Cullen’s sign). Either of these signs—or severe, tearing pain in the abdomen, flank, or lower back—may signal life-threatening dissection of an aortic aneurysm. Also check peripheral pulses, comparing intensity in the upper and lower extremities.
If you suspect dissection, monitor the patient’s vital signs continuously, and withhold food and fluids until a definitive diagnosis is made. Watch for signs and symptoms of hypovolemic shock, such as thirst; hypotension; tachycardia; weak, thready pulse; tachypnea; altered level of consciousness (LOC); mottled knees and elbows; and cool, clammy skin.
If you detect bruits over the thyroid gland, ask the patient if he has a history of hyperthyroidism or signs and symptoms of it, such as nervousness, tremors, weight loss, palpitations, heat intolerance, and (in females) amenorrhea. Watch for signs and symptoms of life-threatening thyroid storm, such as tremor, restlessness, diarrhea, abdominal pain, and hepatomegaly.
If you detect carotid artery bruits, be alert for signs and symptoms of a transient ischemic attack (TIA), including dizziness, diplopia, slurred speech, flashing lights, and syncope. These findings may indicate an impending stroke. Be sure to evaluate the patient frequently for changes in LOC and muscle function.
If you detect bruits over the femoral, popliteal, or subclavian artery, watch for signs and symptoms of decreased or absent peripheral circulation—edema, weakness, and paresthesia. Ask the patient if he has a history of intermittent claudication. Frequently check distal pulses and skin color and temperature. Pallor, coolness, or the sudden absence of a pulse may indicate a threat to the affected limb.
If you detect a bruit, be sure to check for further vascular damage and perform a thorough cardiac assessment.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Murmurs:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If you discover a murmur, try to determine its type through careful auscultation. (See Identifying common murmurs, page 517.) Use the bell of your stethoscope for low-pitched murmurs; the diaphragm for high-pitched murmurs.
Next, obtain a patient history. Ask if the murmur is a new discovery, or if it has been known since birth or childhood. Find out if the patient has experienced any associated symptoms, particularly palpitations, dizziness, syncope, chest pain, dyspnea, and fatigue. (See Differential diagnosis: Murmurs, pages 518 and 519.) Explore the patient’s medical history, noting especially any incidence of rheumatic fever, recent dental work, heart disease, or heart surgery, particularly prosthetic valve replacement.
Perform a systematic physical examination. Note especially the presence of cardiac arrhythmias, jugular vein distention, and such pulmonary signs and symptoms as dyspnea, orthopnea, and crackles. Is the patient’s liver tender or palpable? Does he have peripheral edema?
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Palpitations:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If the patient isn’t in distress, perform a complete cardiac history and physical examination. Ask if he has a cardiovascular or pulmonary disorder, which may produce arrhythmias. Does the patient have a history of hypertension or hypoglycemia? Be sure to obtain a drug history. Has the patient recently started cardiac glycoside therapy? Ask about caffeine, tobacco, and alcohol consumption.
Explore associated symptoms, such as weakness, fatigue, and angina. Auscultate for gallops, murmurs, and abnormal breath sounds.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Palpitations:
Physical examination (PE)
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
If the patient is not seen during an episode, aim the PE at detecting abnormalities that are associated with PPTs. Midsystolic click and murmur (mitral valve prolapse), harsh holosystolic murmur (hypertrophic cardiomyopathy), diastolic murmur (aortic regurgitation), or signs of congestive heart failure may aid in diagnosis. Look for stigmata of hyperthyroidism and other conditions noted above (II.E) (Chapter 14.8).
Testing
A. 12-lead electrocardiogram (ECG). All patients with PPTs should have an ECG. The presence of an arrhythmia may be diagnostic. Findings between episodes can include short PR interval and delta waves (preexcitation),
Q waves (VT, PVCs), long QT interval (drugs, long QT syndrome), left ventricular hypertrophy with left atrial abnormality (AF), and complete heart block (PVCs, torsades de pointes) (3).
B. Laboratory testing. Initial laboratory testing consists of serum potassium, hemoglobin and hematocrit, and thyroid-stimulating hormone; serum glucose can be added with a suspicion of hypoglycemia.
C. Ambulatory ECG recording (AECG). For patients in whom a diagnosis has not been made with the initial evaluation, AECG monitoring is indicated. A Holter monitor (24- or 48-hour continuous ECG) should be the initial study for patients with daily symptoms. In those with less frequent episodes, a continuous-loop event recorder worn for a duration of 2 weeks is more cost-effective (4,5).
Diagnostic assessment
The history, PE, and ECG are important steps in the evaluation of PPTs, although many patients will require ambulatory ECG testing to reach a diagnosis. If symptoms correlate with arrhythmias on AECG monitoring, a diagnosis can be made and treatment begun, if appropriate. If no arrhythmia occurs and the patient has typical PPTs, a benign cause is likely. When no symptoms and no arrhythmias are found, the AECG is nondiagnostic and repeat testing or referral may be necessary, especially with underlying heart disease or poorly tolerated PPTs.
References
1. Weber BE, Kapoor WN. Evaluation and outcomes of patients with palpitations. Am J Med 1996;100:138–148.
2. Barsky AJ, Cleary PD, Coeytaux RR, Ruskin JN. The clinical course of palpitations in medical outpatients. Arch Intern Med 1995;155:1782–1788.
3. Zimetbaum P, Josephson ME. Evaluation of patients with palpitations. N Engl
J Med 1998;338:1369–1373.
4. Kinlay S, Leitch JW, Neil A, Chapman BL, Hardy DB, Fletcher PJ. Cardiac event recorders yield more diagnoses and are more cost-effective than 48-hour Holter monitoring in patients with palpitations. Ann Intern Med 1996;124:16–20.
5. Zimetbaum PJ, Kim KY, Josephson ME, Goldberger AL, Cohen DJ. Diagnostic yield and optimal duration of continuous-loop event monitoring for the diagnosis of palpitations. Ann Intern Med 1998;128:890–895.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Heart Murmur, Diastolic:
Physical examination (PE)
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Table 7.3 lists characteristic PE findings of diastolic murmurs.
B. Fine points of the physical examination
1. Is the murmur of AR louder at the right sternal border? If so, consider aortic root dilation. Remember, whereas the duration of the chronic AR murmur is directly proportional to the severity of the regurgitation, the duration of the acute AR murmur may not predict its severity (3).
2. Is the murmur of MS shorter, or does it extend closer to S2? The length of this murmur, not its intensity, is directly proportional to the severity of the stenosis (3). In addition, the murmur may not be audible with increased heart rates because of shortening of diastole.
3. Does the murmur of MS vary from examination to examination? If so, and especially if it is introduced by a “plop” sound, consider atrial myxoma.
Testing
Echocardiogram is the essential test for confirming the anatomic location of the murmur and its severity. Transthoracic echocardiography (ECHO) is generally sufficient, unless endocarditis is suspected, in which case a transesophageal ECHO is preferred to evaluate for vegetations. If aortic root dilatation is present on ECHO, a computed tomography or magnetic resonance imaging scan may help to delineate the anatomy further. Additional laboratory testing may be warranted to further evaluate the underlying cause (e.g., serologic studies for collagen vascular disease, serologic test for syphilis, and so on).
Diagnostic assessment
With a careful examination and thorough history, the valve causing the murmur and the probable cause of the valvular lesion can be identified prior to ordering the definitive test (ECHO). The most common cause of all diastolic murmurs is still rheumatic heart disease, even though the incidence of acute rheumatic fever has decreased. Mitral stenosis is almost invariably caused by rheumatic heart disease (98% in one study of excised valves) (3,4), with the remainder caused by vegetations (from endocarditis) or congenital factors (4). Tricuspid stenosis is also predominantly rheumatic in origin and is rarely an isolated lesion. Other causes of TS include carcinoid and congenital malformations. Rheumatic heart disease is the leading cause of chronic AR, followed by congenital bicuspid valves and aortic root dilatation (Marfan’s syndrome, Ehlers-Danlos syndrome, ankylosing spondylitis, and syphilitic aortitis). If chronic, AR can result in LV dilation and compensation; if acute, it can be associated with severe LV overload and significant symptoms. Acute AR is most often related to endocarditis, aortic dissection, and trauma. Pulmonary regurgitation without hypertension has multiple causes, including pulmonary trunk dilation, endocarditis, carcinoid, trauma (from balloon-tipped catheters), and rheumatic fever. The nonstenotic physiologic murmurs are related to high-flow states across an otherwise normal mitral
or tricuspid valve. For a mitral flow murmur, the primary lesions are usually mitral regurgitation, ventricular septal defects, or patent ductus arteriosus. For a tricuspid flow murmur, an atrial septal defect or severe tricuspid regurgitation is the most common cause. The Austin–Flint murmur, caused by increasing left ventricular pressure pushing the anterior mitral leaflet into the flow of blood coming from the atrium, is the result of significant aortic regurgitation.
References
1. Chizner MA, ed. Classical teachings in clinical cardiology. Chatham, New Jersey: Laennec Publishing, 1996.
2. Coblyn JS, Weinblatt ME. Rheumatic disease and the heart. In: Braunwald E, ed. Heart disease: a textbook of cardiovascular medicine, 5th ed. Philadelphia: WB Saunders, 1997:1776–1785.
3. Abrams J, ed. Synopsis of cardiac physical diagnosis. Philadelphia: Lea & Febiger, 1989.
4. Olson LJ, Subramanian MB, Ackermann DM, Orszulak TA, Edwards WM. Surgical pathology of the mitral valve: a study of 712 cases spanning 21 years. Mayo Clin Proc 1987;62:22–34.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Heart Murmur, Systolic:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Technique. Auscultate the heart with the bell to best detect lower frequencies and the heart sounds (S1-S4). The quality of the murmur is best heard with the diaphragm. Inspiration increases the audibility of right ventricular sounds.
B. Murmur characteristics. Table 7.4 presents a summary of the characteristics of different causes of systolic murmurs (2,3). Etchell et al. (3) have prepared a comprehensive review on the usefulness of specific physical examination findings in the diagnosis of systolic murmurs.
Testing
Testing of an undiagnosed cardiac murmur can include an electrocardiogram (ECG), a chest x-ray study (CXR), and an echocardiogram. Echocardiograms, although useful for quantification of stenotic valvular disease, can overestimate the degree of regurgitation.
A. Aortic stenosis. Specific ECG findings in aortic stenosis can include left ventricular hypertrophy (LVH), left axis deviation, conduction disturbances, and atrial hypertrophy. On CXR, cardiac size remains normal until stenosis is severe, then signs of CHF may be present. The echocardiogram may reveal thickened or calcified aortic leaflets, bicuspid valve, and LVH. The size of
the valve can be estimated and the pressure gradient across the valve can
be assessed. Cardiac catheterization can also be used to assess the size of the valve and the gradient. Even though echocardiography is accurate in measuring valve area and gradient, catheterization is usually indicated because 50% of patients above age 40 years have coronary artery disease.
B. Mitral regurgitation. In mitral regurgitation, the ECG may reveal LVH with left atrial enlargement and later in the course, atrial fibrillation. In severe disease, CXR usually reveals cardiomegaly without pulmonary venous congestion. The echocardiogram reveals valvular anatomy, but can overestimate the severity of the regurgitation. Exercise testing can be used to determine clinical deterioration in mitral regurgitation. Catheterization is used to assess the contractile state of the ventricle as well as the regurgitant and forward stroke volume.
C. Other disease processes. The ECG with tricuspid insufficiency often reveals atrial fibrillation. The CXR may show right atrial hypertrophy, and the echocardiogram shows valvular anatomy. Pulmonic stenosis will lead to ECG findings consistent with right ventricular hypertrophy. Hypertrophic cardiomyopathy is best diagnosed by echocardiography. ECG may reveal LVH and occasionally a shortened PR interval is seen. Cardiac catheterization can be used to quantify the gradient caused by the hypertrophic lesion.
Diagnostic assessment
The history and physical examination with special emphasis on auscultation are the keys to the diagnosis of systolic murmurs. Those with symptomatic murmurs or in whom valvular disease is suspected should have an ECG, CXR, and echocardiogram. Murmurs of unknown duration or new murmurs should be worked up promptly with consideration of acute infarction in mind. If aortic stenosis is suspected, the workup should be expedited because sudden death can be the first clinical presentation. Valvular disease must always be considered with new onset congestive heart failure. Table 7.5 lists some of the online resources available to assist in the evaluation of heart murmurs.
References
1. Rackley C. Valvular heart disease. In: Bennett JC, Plum F, eds. Cecil textbook of medicine, 20th ed. Philadelphia: WB Saunders, 1996.
2. O’Connor D. The art of auscultation. Patient Care 1998;38:56–60.
3. Etchells E, Bell C, Robb K. Does this patient have an abnormal systolic murmur? JAMA 1997;277:564–571.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Diastolic Murmur:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
A diastolic murmur is always abnormal. An early diastolic murmur, caused by aortic or pulmonic regurgitation, is high-pitched and decrescendo. The duration of the murmur is an index of severity. A mid-diastolic murmur suggests mitral or tricuspid stenosis.
The murmur of mitral stenosis decreases or does not change with inspiration whereas the murmur of tricuspid stenosis increases.
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Source: Field Guide to Bedside Diagnosis, 2007
Continuous Murmur:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
Continuous murmurs begin in systole and extend into diastole without interruption. The murmur results from blood flow from a higher pressure chamber or vessel to a lower pressure system, with the gradient maintained during both systole and diastole, for example with aortopulmonary and arteriovenous connections.
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Source: Field Guide to Bedside Diagnosis, 2007
Systolic Murmur:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
The intensity of the murmur is proportional to the degree of stenosis until flow decreases markedly. Intensity can be expressed semiquantitatively, from grade 1/6, heard only with concentration, to grade 4/6, a loud murmur associated with a palpable thrill, to grade 6/6 with a thrill and murmur heard with the stethoscope off the chest. The duration of the murmur is proportional to the pressure differential between the two chambers.
An early systolic murmur, decrescendo at the apex, occurs in acute, severe mitral regurgitation (MR) with papillary muscle rupture, endocarditis, ruptured chordae tendineae, or blunt chest trauma. A midsystolic murmur is typical of aortic stenosis (AS). It can also be found with hypertrophic obstructive cardiomyopathy (HOC) and with hyperdynamic states. A late systolic murmur is usually heard with mitral valve prolapse (MVP) in association with a midsystolic click. A holosystolic murmur can be produced by severe MR or tricuspid regurgitation (TR), or by a ventricular septal defect (VSD), when the pressure differential between chambers persists throughout systole. Holosystolic murmurs are almost never innocent.
Handgrip decreases AS and HOC murmurs but increases MR, aortic regurgitation (AR), VSD, and mitral stenosis (MS). Transient arterial occlusion by a blood pressure cuff 20 mm above systolic increases left-sided murmurs. Valsalva decreases most murmurs (decreased right and left ventricular filling), except HOC and MVP, which increase.
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Source: Field Guide to Bedside Diagnosis, 2007
Carotid Bruit:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
Carotid bruits are imperfect markers of increased stroke risk because stroke is usually not due to progressive carotid stenosis, but rather to ruptured plaque, cardiac emboli from atrial fibrillation, emboli from aortic sources, or watershed ischemia due to decreased flow. A bruit is, however, an important marker of generalized atherosclerosis. The annual incidence of stroke in the territory of a carotid bruit is 1.7%/year and increases to 5.5%/year as stenosis exceeds 75%. The risk of death (usually cardiac) in a patient with a carotid bruit is 4%/yr. Bruits are clinically significant when associated with transient ipsilateral anterior circulation symptoms such as amaurosis fugax (transient monocular blindness), contralateral homonymous hemianopsia, hemiparesis, and hemisensory defect. Left hemispheric lesions are associated with aphasia, and right with visuospatial neglect and constructional apraxia.
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Source: Field Guide to Bedside Diagnosis, 2007
Palpitations/Tachycardia:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
A disquieting awareness of the heartbeat described as pounding, skipping, racing, flopping, or fluttering is usually due to an arrhythmia, or a change in rhythm, rate, or contractility.
Arrhythmia should be approached both from the standpoint of determining the specific rhythm disturbance and recognizing it as a marker for other potentially serious disorders. Signs of underlying heart disease such as ischemia (exertional chest pain), cardiomyopathy (rales, S3 gallop, diffuse PMI), or syncope must be searched for because they alter the prognostic implications of the rhythm disorder.
A sensation of pounding in the neck is associated with jugular cannon a waves. Presence of a cannon a wave implies atrial contraction and can rule out atrial fibrillation. Intermittent cannon a waves result from atrioventricular dissociation.
Carotid massage will suddenly halve the rate with atrial flutter, but there is a gradual slowing of the pulse with sinus tachycardia. Supraventricular tachycardia either continues or terminates abruptly with carotid massage.
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Source: Field Guide to Bedside Diagnosis, 2007
Discrete Heart Sounds:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
The A2-P2 interval normally increases with inspiration due to decreased intrathoracic pressure and increased venous return, which leads to increased stroke volume.
In my southern medical school I was taught that the cadence of the S3 gallop matches that of the spoken word Kentucky, and of S4, Tennessee.
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Source: Field Guide to Bedside Diagnosis, 2007
Bruits:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
If you detect bruits over the abdominal aorta, check for a pulsating mass or a bluish discoloration around the umbilicus (Cullen’s sign). Either of these signs — or severe, tearing pain in the abdomen, flank, or lower back — may signal life-threatening dissection of an aortic aneurysm. Also, check peripheral pulses, comparing intensity in the upper versus lower extremities.
If you suspect dissection, monitor the patient’s vital signs constantly, and withhold food and fluids until a definitive diagnosis is made. Watch for signs and symptoms of hypovolemic shock, such as thirst; hypotension; tachycardia; weak, thready pulse; tachypnea; altered level of consciousness (LOC); mottled knees and elbows; and cool, clammy skin.
If you detect bruits over the thyroid gland, ask the patient if he has a history of hyperthyroidism or signs and symptoms of it, such as nervousness, tremors, weight loss, palpitations, heat intolerance, and (in females) amenorrhea. Watch for signs and symptoms of life-threatening thyroid storm, such as tremor, restlessness, diarrhea, abdominal pain, and hepatomegaly.
If you detect carotid artery bruits, be alert for signs and symptoms of a transient ischemic attack (TIA), including dizziness, diplopia, slurred speech, flashing lights, and syncope. These findings may indicate an impending stroke. Be sure to evaluate the patient frequently for changes in LOC and muscle function.
If you detect bruits over the femoral, popliteal, or subclavian artery, watch for signs and symptoms of decreased or absent peripheral circulation — edema, weakness, and paresthesia. Ask the patient if he has a history of intermittent claudication. Frequently check distal pulses and skin color and temperature. Also, watch for the sudden absence of pulse, pallor, or coolness, which may indicate a threat to the affected limb.
If you detect a bruit, be sure to check for further vascular damage and perform a thorough cardiac assessment.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Murmurs:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Perform a systematic physical assessment. Note especially the presence of cardiac arrhythmias, jugular vein distention, and such pulmonary signs and symptoms as dyspnea, orthopnea, and crackles. Is the patient’s liver tender or palpable? Does he have peripheral edema?
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Palpitations:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Perform a complete cardiac and pulmonary assessment. Then explore associated symptoms, such as weakness, fatigue, and angina. Be sure to auscultate for gallops, murmurs, and abnormal breath sounds.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Heart Murmurs (Asymptomatic):
Diagnostic Approach
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
To distinguisha normal from a pathologic murmur, physicians must rely on theirskill in physical exam of cardiovascular system; on their interpretationof chest radiograph, ECG, and 2-D echocardiogram; and on their knowledgeof the diagnostic possibilities that each murmur suggests.In most cases, cardiovascular examat bedside can distinguish a normal from a pathologic murmur.With a normalmurmur, no tests are needed. Physicians can reassure parents andexplain that the murmur is a normal phenomenon due to normal turbulenceof blood flow. They can also emphasize that the murmur is not indicativeof mild heart disease, nor is it of any importance whether it disappears.With a pathologic murmur, precise diagnosismust be made because subsequent management depends on it. Diagnosisof pathologic murmurs is based on cardiovascular exam in conjunctionwith chest radiograph and ECG and sometimes 2-D echocardiogram. Only rarely are cardiac catheterizationand angiography needed to clarify etiology of murmurs in asymptomaticchildren.
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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Bruits:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If you detect bruits over the abdominal aorta, check for a pulsating mass or a bluish discoloration around the umbilicus (Cullen's sign). Either of these signs—or severe, tearing pain in the abdomen, flank, or lower back—may signal life-threatening dissection of an aortic aneurysm. Check peripheral pulses, comparing intensity in the upper versus lower extremities.
If you suspect dissection, monitor the patient's vital signs constantly, and withhold food and fluids until a definitive diagnosis is made. Watch for signs and symptoms of hypovolemic shock, such as thirst; hypotension; tachycardia; a weak, thready pulse; tachypnea; an altered level of consciousness (LOC); mottled knees and elbows; and cool, clammy skin.
If you detect bruits over the thyroid gland, ask the patient if he has a history of hyperthyroidism or signs and symptoms of it, such as nervousness, tremors, weight loss, palpitations, heat intolerance, and (in females) amenorrhea. Watch for signs and symptoms of life-threatening thyroid storm, such as tremor, restlessness, diarrhea, abdominal pain, and hepatomegaly.
If you detect carotid artery bruits, be alert for signs and symptoms of a transient ischemic attack (TIA), including dizziness, diplopia, slurred speech, flashing lights, and syncope. These findings may indicate an impending stroke. Be sure to evaluate the patient frequently for changes in LOC and muscle function.
If you detect bruits over the femoral, popliteal, or subclavian artery, watch for signs and symptoms of decreased or absent peripheral circulation, such as edema, weakness, and paresthesia. Ask the patient if he has a history of intermittent claudication. Frequently check distal pulses and skin color and temperature. Watch for the sudden absence of pulse, pallor, or coolness, which may indicate a threat to the affected limb.
If you detect a bruit, make sure to check for further vascular damage and perform a thorough cardiac assessment.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Murmurs:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If you discover a murmur, try to determine its type through careful auscultation. (See Identifying common murmurs, page 398.) Use the bell of your stethoscope for low-pitched murmurs and the diaphragm for high-pitched murmurs.
Next, obtain a patient history. Ask if the murmur is a new discovery or if it has been known since birth or childhood. Find out if the patient has experienced associated symptoms, particularly palpitations, dizziness, syncope, chest pain, dyspnea, and fatigue. Explore the patient's medical history, noting especially an incidence of rheumatic fever, recent dental work, heart disease, or heart surgery, particularly prosthetic valve replacement.
Perform a systematic physical examination. Note especially the presence of cardiac arrhythmias, jugular vein distention, and such pulmonary signs and symptoms as dyspnea, orthopnea, and crackles. Is the patient's liver tender or palpable? Does he have peripheral edema?
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Palpitations:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If the patient isn't in distress, perform a complete cardiac history and physical examination. Ask if he has a cardiovascular or pulmonary disorder, which may produce arrhythmias. Does the patient have a history of hypertension or hypoglycemia? Be sure to obtain a drug history. Has the patient recently started cardiac glycoside therapy? Also, ask about caffeine, tobacco, and alcohol consumption.
Then explore associated symptoms, such as weakness, fatigue, and angina. Finally, auscultate for gallops, murmurs, and abnormal breath sounds.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
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