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Diseases » Infantile Spasms » Causes

Causes of Infantile Spasms

Contents

Infantile Spasms Causes: Book Excerpts

Infantile Spasms as a symptom:

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

Medical news summaries relating to Infantile Spasms:

The following medical news items are relevant to causes of Infantile Spasms:

Related information on causes of Infantile Spasms:

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

Causes of Infantile Spasms: Online Medical Books

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

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

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
–S₁is 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

Seizures/Convulsions: Differential Diagnosis
(In a Page: Signs and Symptoms)

Partial seizure (involve only part of the brain)
–Simple (no altered consciousness)
–Complex (with altered consciousness)
Generalized seizure (involve both hemispheres)
–Tonic-clonic
–Atonic
–Tonic
–Myoclonic
–Absence
Epilepsy
–Recurrent unprovoked seizures of any or multiple types, which may be idiopathic or symptomatic
- Secondary seizure
  –Metabolic abnormalities (e.g., electrolyte disturbances, hypoglycemia)
  –Drug effects, intoxication, or withdrawal
  –Head injury/trauma
  –Febrile seizures in children
  –Structural lesions (e.g., tumor, subdural hematoma)
  –Cerebrovascular etiologies (e.g., cerebral infarct, intracerebral hemorrhage, subarachnoid hemorrhage
  –Hypoxic-ischemic encephalopathy
  –Infection (e.g., meningitis, encephalitis)
  –Hypoxia
- Nonepileptic seizure
  –Not associated with abnormal electrical activity in the brain
  –Patients with loss of consciousness secondary to cerebral hypoperfusion (fainting, syncope) may occasionally exhibit brief periods of twitching or convulsive movements resembling seizure activity
  –Psychological disturbances (pseudoseizure)
- Inborn errors of metabolism
  –Disorders of amino acid metabolism
  –Organic acidemias
  –Urea cycle disorders
  –Mitochondrial disorders
  –Peroxisomal disorders
  –Glycogen storage disorders
  –Disorders of sugar metabolism
- Rasmussen's encephalitis
  –Causes seizures and progressive hemispheric dysfunction in infants

» 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

Seizures – Childhood: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

Febrile seizure
Cerebral dysgenesis: Disorders of neuronal migration, heterotopias, lissencephaly
Epilepsy syndromes
–Childhood absence
–Juvenile absence
–Juvenile myoclonic epilepsy (JME)
–Benign rolandic epilepsy (BRE)
Meningitis/encephalitis (e.g., HSV)
Cerebral abscess
Postinfectious (e.g., ADEM)
Hyponatremia
Hypernatremia
Hypocalcemia
Hypoglycemia
Toxins: Ingestions or sedative withdrawal
Trauma
Pyridoxine deficiency
Neoplasm
Degenerative
–Alpers disease
–Rett syndrome
–Unterricht-Lundborg disease
–Lafora disease
–Neuronal ceroid lipofuscinosis
Genetic
–Angelman syndrome
–Aicardi syndrome

Metabolic
–Medium chain acyl-CoA dehydrogenase deficiency (MCAD)
–Myoclonus epilepsy and ragged-red fibers syndrome (MERRF)
–Sialidosis
–Glucose transporter deficiency
–Urea cycle defects

Vascular: Stroke, hemorrhage, vasculitis
Hashimoto encephalitis
Seizure mimics
–Breath-holding spells
–Syncope, convulsive syncope
–Gastroesophageal reflux
–Cardiac arrhythmia
–Movement disorder
–Migraine
–Benign paroxysmal vertigo
–Parasomnia
–Pseudo-seizure
–Rage attack

» READ BOOK EXCERPT ONLINE »

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

Seizures – Neonatal: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

Hypoxic ishemic encephalopathy
Bacterial meningitis/sepsis
Stroke
Cerebral dysgenesis
Electrolyte disturbances
–Hypoglycemia
–Hyponatremia
–Hypomagnesemia
–Hypocalcemia
Maternal drug use
–Drug withdrawal after delivery
–Direct effect of drugs, such as cocaine
Congenital infections (TORCH)
–Toxoplasmosis
–Syphilis
–Rubella
–CMV
–HSV
HSV encephalitis

Intracranial hemorrhage
–Subdural hemorrhage
–Intraparenchymal hemorrhage
–Intraventricular hemorrhage in the premature infant
–Subarachnoid hemorrhage

Urea cycle disturbances
Smith-Lemli-Opitz syndrome
Nonketotic hyperglycinemia
Pyridoxine deficiency
Fructose dysmetabolism
Amino acidurias
–Maple syrup urine disease
–Proprionic acidemia
Molybdenum cofactor deficiency
Mitochondrial encephalopathy
Glucose transporter deficiency

Benign etiologies
–Benign idiopathic neonatal seizures (fifth day fits)
–Benign familial neonatal seizures

Movements commonly mistaken for seizures
–Benign neonatal sleep myoclonus
–Jitteriness (may be secondary to hypoglycemia, drug withdrawal, or idiopathic)
–Gastroesophageal reflux (arching, writhing)
–Breath-holding spell

» 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

Seizures, absence: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Idiopathic epilepsy

Some forms of absence seizure are accompanied by learning disabilities.

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

Seizures, complex partial: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Brain abscess

If the brain abscess is in the temporal lobe, complex partial seizures commonly occur after the abscess disappears. Related problems may include a headache, nausea, vomiting, generalized seizures, and a decreased level of consciousness (LOC). The patient may also develop central facial weakness, auditory receptive aphasia, hemiparesis, and ocular disturbances.

Head trauma

Severe trauma to the temporal lobe (especially from a penetrating injury) can produce complex partial seizures months or years later. The seizures may decrease in frequency and eventually stop. Head trauma also causes generalized seizures and behavior and personality changes.

Herpes simplex encephalitis

The herpes simplex virus commonly attacks the temporal lobe, resulting in complex partial seizures. Other features include a fever, a headache, coma, and generalized seizures.

Temporal lobe tumor

Complex partial seizures may be the first sign of a temporal lobe tumor. Other signs and symptoms include a headache, pupillary changes, and mental dullness. Increased intracranial pressure may cause a decreased LOC, vomiting and, possibly, papilledema.

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

Seizures, generalized tonic-clonic: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Brain abscess

Generalized seizures may occur in the acute stage of abscess formation or after the abscess disappears. Depending on the size and location of the abscess, a decreased level of consciousness (LOC) varies from drowsiness to deep stupor. Early signs and symptoms reflect increased intracranial pressure (ICP) and include a constant headache, nausea, vomiting, and focal seizures. Typical later features include ocular disturbances, such as nystagmus, impaired vision, and unequal pupils. Other findings vary with the abscess, site but may include aphasia, hemiparesis, abnormal behavior, and personality changes.

Brain tumor

Generalized seizures may occur, depending on the tumor’s location and type. Other findings include a slowly decreasing LOC, a morning headache, dizziness, confusion, focal seizures, vision loss, motor and sensory disturbances, aphasia, and ataxia. Later findings include papilledema, vomiting, increased systolic blood pressure, widening pulse pressure and, eventually, a decorticate posture.

Chronic renal failure

End-stage renal failure produces the rapid onset of twitching, trembling, myoclonic jerks, and generalized seizures. Related signs and symptoms include anuria or oliguria, fatigue, malaise, irritability, decreased mental acuity, muscle cramps, peripheral neuropathies, anorexia, and constipation or diarrhea. Integumentary effects include skin color changes (yellow, brown, or bronze), pruritus, and uremic frost. Other effects include an ammonia breath odor, nausea and vomiting, ecchymoses, petechiae, GI bleeding, mouth and gum ulcers, hypertension, and Kussmaul’s respirations.

Eclampsia

Generalized seizures are a hallmark of eclampsia. Related findings include a severe frontal headache, nausea and vomiting, vision disturbances, increased blood pressure, a fever of up to 104° (40° C), peripheral edema, and sudden weight gain. The patient may also exhibit oliguria, irritability, hyperactive deep tendon reflexes (DTRs), and a decreased LOC.

Encephalitis

Seizures are an early sign of encephalitis, indicating a poor prognosis; they may also occur after recovery as a result of residual damage. Other findings include a fever, a headache, photophobia, nuchal rigidity, neck pain, vomiting, aphasia, ataxia, hemiparesis, nystagmus, irritability, cranial nerve palsies (causing facial weakness, ptosis, dysphagia), and myoclonic jerks.

Epilepsy (idiopathic)

In most cases, the cause of recurrent seizures is unknown.

Head trauma

In severe cases, generalized seizures may occur at the time of injury. (Months later, focal seizures may occur.) Severe head trauma may also cause a decreased LOC, leading to coma; soft-tissue injury of the face, head, or neck; clear or bloody drainage from the mouth, nose, or ears; facial edema; bony deformity of the face, head, or neck; Battle’s sign; and a lack of response to oculocephalic and oculovestibular stimulation. Motor and sensory deficits may occur along with altered respirations. Examination may reveal signs of increasing ICP, such as a decreased response to painful stimuli, nonreactive pupils, bradycardia, increased systolic pressure, and widening pulse pressure. If the patient is conscious, he may exhibit visual deficits, behavioral changes, and a headache.

Hepatic encephalopathy

Generalized seizures may occur late in hepatic encephalopathy. Associated late-stage findings in the comatose patient include fetor hepaticus, asterixis, hyperactive DTRs, and a positive Babinski’s sign.

Hypoglycemia

Generalized seizures usually occur with severe hypoglycemia, accompanied by blurred or double vision, motor weakness, hemiplegia, trembling, excessive diaphoresis, tachycardia, myoclonic twitching, and a decreased LOC.

Hyponatremia

Seizures develop when serum sodium levels fall below 125 mEq/L, especially if the decrease is rapid. Hyponatremia also causes orthostatic hypotension, a headache, muscle twitching and weakness, fatigue, oliguria or anuria, cold and clammy skin, decreased skin turgor, irritability, lethargy, confusion, and stupor or coma. Excessive thirst, tachycardia, nausea, vomiting, and abdominal cramps may also occur. Severe hyponatremia may cause cyanosis and vasomotor collapse, with a thready pulse.

Hypoparathyroidism

Worsening tetany causes generalized seizures. Chronic hypoparathyroidism produces neuromuscular irritability and hyperactive DTRs.

Hypoxic encephalopathy

Besides generalized seizures, hypoxic encephalopathy may produce myoclonic jerks and coma. Later, if the patient has recovered, dementia, visual agnosia, choreoathetosis, and ataxia may occur.

Neurofibromatosis

Multiple brain lesions from neurofibromatosis cause focal and generalized seizures. Inspection reveals café-au-lait spots, multiple skin tumors, scoliosis, and kyphoscoliosis. Related findings include dizziness, ataxia, monocular blindness, and nystagmus.

Stroke

Seizures (focal more commonly than generalized) may occur within 6 months of an ischemic stroke. Associated signs and symptoms vary with the location and extent of brain damage. They include a decreased LOC, contralateral hemiplegia, dysarthria, dysphagia, ataxia, unilateral sensory loss, apraxia, agnosia, and aphasia. The patient may also develop visual deficits, memory loss, poor judgment, personality changes, emotional lability, urine retention or urinary incontinence, constipation, a headache, and vomiting.

Other causes

Arsenic poisoning

Besides generalized seizures, arsenic poisoning may cause a garlicky breath odor, increased salivation, and generalized pruritus. GI effects include diarrhea, nausea, vomiting, and severe abdominal pain. Related effects include diffuse hyperpigmentation; sharply defined edema of the eyelids, face, and ankles; paresthesia of the extremities; alopecia; irritated mucous membranes; weakness; muscle aches; and peripheral neuropathy.

Barbiturate withdrawal

In chronically intoxicated patients, barbiturate withdrawal may produce generalized seizures 2 to 4 days after the last dose. Status epilepticus is possible.

Diagnostic tests

Contrast agents used in radiologic tests may cause generalized seizures.

Drugs

Toxic blood levels of some drugs, such as theophylline, lidocaine, meperidine, penicillins, and cimetidine, may cause generalized seizures. Phenothiazines, tricyclic antidepressants, amphetamines, isoniazid, and vincristine may cause seizures in patients with preexisting epilepsy.

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

Seizures, simple partial: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Brain abscess

Seizures can occur in the acute stage of abscess formation or after resolution of the abscess. A decreased LOC varies from drowsiness to deep stupor. Early signs and symptoms reflect increased intracranial pressure and include a constant, intractable headache; nausea; and vomiting. Later signs and symptoms include ocular disturbances, such as nystagmus, decreased visual acuity, and unequal pupils. Other findings vary according to the abscess site and may include aphasia, hemiparesis, and personality changes.

Brain tumor

Focal seizures are commonly the earliest indicators of a brain tumor. The patient may report a morning headache, dizziness, confusion, vision loss, and motor and sensory disturbances. He may also develop aphasia, generalized seizures, ataxia, a decreased LOC, papilledema, vomiting, increased systolic blood pressure, and widening pulse pressure. Eventually, he may assume a decorticate posture.

Head trauma

Any head injury can cause seizures, but penetrating wounds are characteristically associated with focal seizures. The seizures usually begin 3 to 15 months after injury, decrease in frequency after several years, and eventually stop. The patient may develop generalized seizures and a decreased LOC that may progress to coma.

Stroke

A major cause of seizures in patients older than age 50, a stroke may induce focal seizures up to 6 months after its onset. Related effects depend on the type and extent of the stroke, but may include a decreased LOC, contralateral hemiplegia, dysarthria, dysphagia, ataxia, unilateral sensory loss, apraxia, agnosia, and aphasia. A stroke may also cause visual deficits, memory loss, poor judgment, personality changes, emotional lability, a headache, urinary incontinence or retention, and vomiting. It may result in generalized seizures.

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

West Nile encephalitis: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

WNV is transmitted to humans by the bite of a mosquito (primarily the Culex species) infected with the virus. It's considered the primary vector for WNV and the source of the August 1999 outbreak in New York, New Jersey and Connecticut. Mosquitoes become infected by feeding on birds contaminated with the West Nile virus and then transmitting it to humans and animals during a blood meal or “bite.” (See Transmission routes of West Nile virus, page 256.)

Ticks have been found infected with WNV in Africa and Asia only. The role of ticks in the transmission and maintenance of the virus remains uncertain, and to date they aren't considered vectors for WNV in the United States.

The Centers for Disease Control and Prevention has reported that there is no evidence that a person can contract the virus from handling live or dead infected birds. However, avoid barehanded contact when handling dead animals, including birds, and use gloves or double plastic bags to dispose of a carcass. Report the finding to the local health department.

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

Epilepsy: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

In about half the cases of epilepsy, the cause is unknown. However, some possible causes of epilepsy include:

❑birth trauma (inadequate oxygen supply to the brain, blood incompatibility, or hemorrhage)

❑perinatal infection

❑anoxia (after respiratory or cardiac arrest)

❑infectious diseases (meningitis, encephalitis, or brain abscess)

❑ingestion of toxins (mercury, lead, or carbon monoxide)

❑tumors of the brain

❑inherited disorders or degenerative disease, such as phenylketonuria or tuberous sclerosis

❑head injury or trauma

❑metabolic disorders, such as hypoglycemia or hypoparathyroidism

❑stroke (hemorrhage, thrombosis, or embolism).

Alcohol withdrawal can cause nonep-ileptic seizures.

Epilepsy affects 1% to 2% of the population. However, 80% of patients have good seizure control if they strictly adhere to the prescribed treatment regimen.

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

X-linked infantile hypogammaglobulinemia: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

In this disease, B cells and B-cell precursors may be present in the bone marrow and peripheral blood, but a mutation in the B-cell protein tyrosine kinase causes failure of the B cells to mature and to secrete immunoglobulin. In the absence of protective immunoglobulins, the affected individual develops repeated infections. Worldwide, malnutrition is the primary cause of antibody disorders.

Humoral immune deficiencies account for 50% of all primary immunodeficiencies. IgA deficiency is the most common antibody deficiency symdrome, followed by common variable immunodeficiency (CVID). The incidence of these two disorders is 1 in 700 persons.Selective IgM deficiency is rare. IgG4 deficiency occurs in 10% to 15% of the population.

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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

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, S₂may 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

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

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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

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)

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

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

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 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

Seizures, absence: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Idiopathic epilepsy

Some forms of absence seizure are accompanied by learning disabilities.

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

Seizures, complex partial: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Brain abscess

If the brain abscess is in the temporal lobe, complex partial seizures commonly occur after the abscess disappears. Related problems may include headache, nausea, vomiting, generalized seizures, and a decreased level of consciousness (LOC). The patient may also develop central facial weakness, auditory receptive aphasia, hemiparesis, and ocular disturbances.

Head trauma

Herpes simplex encephalitis

The herpes simplex virus commonly attacks the temporal lobe, resulting in complex partial seizures. Other features include fever, headache, coma, and generalized seizures.

Temporal lobe tumor

Complex partial seizures may be the first sign of this disorder. Other signs and symptoms include headache, pupillary changes, and mental dullness. Increased intracranial pressure may cause a decreased LOC, vomiting and, possibly, papilledema.

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

Seizures, generalized tonic-clonic: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Alcohol withdrawal syndrome

i> Sudden withdrawal from alcohol dependence may cause seizures 7 to 48 hours later as well as status epilepticus. The patient may also be restless and exhibit hallucinations, profuse diaphoresis, and tachycardia.

Brain abscess

Generalized seizures may occur in the acute stage of abscess formation or after the abscess disappears. Depending on the size and location of the abscess, decreased level of consciousness (LOC) varies from drowsiness to deep stupor. Early signs and symptoms reflect increased intracranial pressure (ICP) and include constant headache, nausea, vomiting, and focal seizures. Typical later features include ocular disturbances, such as nystagmus, impaired vision, and unequal pupils. Other findings vary with the abscess site but may include aphasia, hemiparesis, abnormal behavior, and personality changes.

Brain tumor

Generalized seizures may occur, depending on the tumor’s location and type. Other findings include a slowly decreasing LOC, morning headache, dizziness, confusion, focal seizures, vision loss, motor and sensory disturbances, aphasia, and ataxia. Later findings include papilledema, vomiting, increased systolic blood pressure, widening pulse pressure, and (eventually) decorticate posture.

Cerebral aneurysm

Occasionally, generalized seizures may occur with an aneurysmal rupture. Premonitory signs and symptoms may last several days, but onset is typically abrupt with severe headache, nausea, vomiting, and decreased LOC. Depending on the site and amount of bleeding, related signs and symptoms vary but may include nuchal rigidity, irritability, hemiparesis, hemisensory defects, dysphagia, photophobia, diplopia, ptosis, and unilateral pupil dilation.

Chronic renal failure

End-stage renal failure produces rapid onset of twitching, trembling, myoclonic jerks, and generalized seizures. Related signs and symptoms include anuria or oliguria, fatigue, malaise, irritability, decreased mental acuity, muscle cramps, peripheral neuropathies, anorexia, and constipation or diarrhea. Integumentary effects include skin color changes (yellow, brown, or bronze), pruritus, and uremic frost. Other effects include ammonia breath odor, nausea and vomiting, ecchymoses, petechiae, GI bleeding, mouth and gum ulcers, hypertension, and Kussmaul’s respirations.

Eclampsia

Generalized seizures are a hallmark of this disorder. Related findings include severe frontal headache, nausea and vomiting, vision disturbances, increased blood pressure, fever of up to 104° F (40° C), peripheral edema, and sudden weight gain. The patient may also exhibit oliguria, irritability, hyperactive deep tendon reflexes (DTRs), and decreased LOC.

Encephalitis

Seizures are an early sign of this disorder, indicating a poor prognosis; they may also occur after recovery as a result of residual damage. Other findings include fever, headache, photophobia, nuchal rigidity, neck pain, vomiting, aphasia, ataxia, hemiparesis, nystagmus, irritability, cranial nerve palsies (causing facial weakness, ptosis, dysphagia), and myoclonic jerks.

Epilepsy (idiopathic)

In most cases, the cause of recurrent seizures is unknown.

Head trauma

In severe cases, generalized seizures may occur at the time of injury. (Months later, focal seizures may occur.) Severe head trauma may also cause a decreased LOC, leading to coma; soft-tissue injury of the face, head, or neck; clear or bloody drainage from the mouth, nose, or ears; facial edema; bony deformity of the face, head, or neck; Battle’s sign; and lack of response to oculocephalic and oculovestibular stimulation. Motor and sensory deficits may occur along with altered respirations. Examination may reveal signs of increasing ICP, such as decreased response to painful stimuli, nonreactive pupils, bradycardia, increased systolic pressure, and widening pulse pressure. If the patient is conscious, he may exhibit visual deficits, behavioral changes, and headache.

Hepatic encephalopathy

Generalized seizures may occur late in this disorder. Associated late-stage findings in the comatose patient include fetor hepaticus, asterixis, hyperactive DTRs, and a positive Babinski’s sign.

Hypertensive encephalopathy

This life-threatening disorder may cause seizures along with severely increased blood pressure, decreased LOC, intense headache, vomiting, transient blindness, paralysis, and (eventually) Cheyne-Stokes respirations.

Hypoglycemia

Hyponatremia

Seizures develop
when serum sodium levels fall below 125 mEq/L, especially if the decrease is rapid. Hyponatremia also causes orthostatic hypotension, headache, muscle twitching and weakness, fatigue, oliguria or anuria, cold and clammy skin, decreased skin turgor, irritability, lethargy, confusion, and stupor or coma. Excessive thirst, tachycardia, nausea, vomiting, and abdominal cramps may also occur. Severe hyponatremia may cause cyanosis and vasomotor collapse, with a thready pulse.

Hypoparathyroidism

Worsening tetany causes generalized seizures. Chronic hypoparathyroidism produces neuromuscular irritability and hyperactive DTRs.

Hypoxic encephalopathy

Besides generalized seizures, this disorder may produce myoclonic jerks and coma. Later, if the patient has recovered, dementia, visual agnosia, choreoathetosis, and ataxia may occur.

Multiple sclerosis

This disorder rarely produces generalized seizures. Characteristic findings include vision deficits, paresthesia, constipation, muscle weakness, paralysis, spasticity, hyperreflexia, intention tremor, ataxic gait, dysphagia, dysarthria, impotence, and emotional lability. Urinary frequency, urgency, and incontinence may also occur.

Neurofibromatosis

Multiple brain lesions from this disorder cause focal and generalized seizures. Inspection reveals café-au-lait spots, multiple skin tumors, scoliosis, and kyphoscoliosis. Related findings include dizziness, ataxia, monocular blindness, and nystagmus.

Porphyria (intermittent acute)

Generalized seizures are a late sign of this disorder, indicating severe CNS involvement. Acute porphyria also causes severe abdominal pain, tachycardia, psychotic behavior, muscle weakness, and sensory loss in the trunk.

Sarcoidosis

Lesions may affect the brain, causing generalized and focal seizures. Associated findings include a nonproductive cough with dyspnea, substernal pain, malaise, fatigue, arthralgia, myalgia, weight loss, tachypnea, dysphagia, skin lesions, and impaired vision.

Stroke

Seizures (focal more often than generalized) may occur within 6 months of an ischemic stroke. Associated signs and symptoms vary with the location and extent of brain damage. They include decreased LOC, contralateral hemiplegia, dysarthria, dysphagia, ataxia, unilateral sensory loss, apraxia, agnosia, and aphasia. The patient may also develop visual deficits, memory loss, poor judgment, personality changes, emotional lability, urine retention or urinary incontinence, constipation, headache, and vomiting.

Other causes

Arsenic poisoning

Barbiturate withdrawal

In chronically intoxicated patients, barbiturate withdrawal may produce generalized seizures 2 to 4 days after the last dose. Status epilepticus is possible.

Diagnostic tests

Contrast agents used in radiologic tests may cause generalized seizures.

Drugs

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

Seizures, simple partial: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Brain abscess

Seizures can occur in the acute stage of abscess formation or after resolution of the abscess. Decreased LOC varies from drowsiness to deep stupor. Early signs and symptoms reflect increased intracranial pressure and include a constant, intractable headache, nausea, and vomiting. Later signs and symptoms include ocular disturbances, such as nystagmus, decreased visual acuity, and unequal pupils. Other findings vary according to the abscess site and may include aphasia, hemiparesis, and personality changes.

Brain tumor

Focal seizures are commonly the earliest indicators of a brain tumor. The patient may report morning headache, dizziness, confusion, vision loss, and motor and sensory disturbances. He may also develop aphasia, generalized seizures, ataxia, decreased LOC, papilledema, vomiting, increased systolic blood pressure, and widening pulse pressure. Eventually, he may assume a decorticate posture.

Head trauma

Multiple sclerosis

Focal or generalized seizures may occur with this disorder, usually during the late stages. Other findings include visual deficits, paresthesia, constipation, muscle weakness, spasticity, paralysis, hyperreflexia, intention tremor, gait ataxia, dysphagia, dysarthria, emotional lability, impotence, and urinary frequency, urgency, and incontinence.

Neurofibromatosis

Multiple brain lesions cause focal seizures and, at times, generalized seizures. Inspection reveals café-au-lait spots, multiple skin tumors, scoliosis, and kyphoscoliosis. Related findings include dizziness, ataxia, progressive monocular blindness, nystagmus, and endocrine abnormalities.

Sarcoidosis

Multiple lesions from this disorder affect the brain, producing focal and generalized seizures. Associated findings include a nonproductive cough with dyspnea, substernal pain, malaise, fatigue, arthralgia, myalgia, weight loss, tachypnea, dysphagia, skin lesions, and impaired vision.

Stroke

A major cause of seizures in patients older than age 50, a stroke may induce focal seizures up to 6 months after its onset. Related effects depend on the type and extent of the stroke but may include decreased LOC, contralateral hemiplegia, dysarthria, dysphagia, ataxia, unilateral sensory loss, apraxia, agnosia, and aphasia. A stroke may also cause visual deficits, memory loss, poor judgment, personality changes, emotional lability, headache, urinary incontinence or retention, and vomiting. It may result in generalized seizures.

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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

Seizures: Differential Overview

(Field Guide to Bedside Diagnosis)

❑ Generalized (grand mal)

❑ Partial (focal)

❑ Complex partial (temporal lobe)

❑ Absence (petit mal)

❑ Vasovagal syncope

❑ Myoclonic

❑ Akinetic (drop attacks)

❑ Psychomotor

❑ Pseudoseizures

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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

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

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

West Nile encephalitis: Causes
(Handbook of Diseases)

WNV is transmitted to humans by the bite of an infected mosquito (primarily the Culex species). Mosquitoes become infected by feeding on infected birds.

Ticks infected with WNV have been found in Africa and Asia, but their role in transmission and maintenance of the virus is uncertain; they aren’t considered vectors for WNV in the United States.

The Centers for Disease Control and Prevention has reported that there’s no evidence that a person can contract the virus from handling live or dead infected birds. However, barehanded contact when handling dead animals, including dead birds, should be avoided; if a dead animal must be handled, gloves or other protective measures should be used to dispose of the carcass. A dead bird is a sign that there may be infected mosquitoes in the area; findings should be reported to the nearest Emergency Management Office.

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Source: Handbook of Diseases, 2003

Epilepsy: Causes
(Handbook of Diseases)

In about one-half of all epilepsy cases, the cause is unknown. Possible causes include:

❑ birth trauma (inadequate oxygen supply to the brain, blood incompatibility, or hemorrhage)

❑ perinatal infection

❑ anoxia

❑ infectious diseases (meningitis, encephalitis, or brain abscess)

❑ ingestion of toxins (mercury, lead, or carbon monoxide)

❑ brain tumors

❑ inherited disorders or degenerative disease, such as phenylketonuria or tuberous sclerosis

❑ head injury or trauma

❑ metabolic disorders, such as hypoglycemia and hypoparathyroidism

❑ stroke (hemorrhage, thrombosis, or embolism).

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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

Cervical spinal injury

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

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)

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

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

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 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 ventricular myxoma (rare) produces a systolic murmur, best heard at the lower left sternal border, arrhythmias, 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 stenosis

Other causes

Medical treatments

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

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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

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

Hypocalcemia

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

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.

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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

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

Seizures, generalized tonic-clonic: Medical causes
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Alcohol withdrawal syndrome

Seizures as well as status epilepticus may develop 7 to 48 hours after abrupt cessation of alcohol consumption by the individual with alcohol dependency. Restlessness, hallucinations, profuse diaphoresis, and tachycardia may also occur.

Brain abscess

Generalized seizures may occur in the acute stage of abscess formation or after the abscess disappears. Decreased level of consciousness (LOC) varies from drowsiness to deep stupor according to the size and location of the abscess. Early signs and symptoms reflect increased intracranial pressure (ICP) and include constant headache, nausea, vomiting, and focal seizures. Typical later features include ocular disturbances, such as nystagmus, impaired vision, and unequal pupils. Other findings vary with the abscess site, but may include aphasia, hemiparesis, abnormal behavior, and personality changes.

Brain tumor

Cerebral aneurysm

Occasionally, generalized seizures may occur with an aneurysm rupture. Premonitory signs and symptoms may last several days, but the onset is typically abrupt with severe headache, nausea, vomiting, and a decreased LOC. Related signs and symptoms vary according to the site and amount of bleeding, but may include nuchal rigidity, irritability, hemiparesis, hemisensory defects, dysphagia, photophobia, diplopia, ptosis, and unilateral pupil dilation.

Chronic renal failure

End-stage renal failure produces the rapid onset of twitching, trembling, myoclonic jerks, and generalized seizures. Related signs and symptoms include anuria or oliguria, fatigue, malaise, irritability, decreased mental acuity, muscle cramps, peripheral neuropathies, anorexia, and constipation or diarrhea. Integumentary effects include skin color changes (yellow, brown, or bronze), pruritus, and uremic frost. Other effects include ammonia breath odor, nausea and vomiting, ecchymoses, petechiae, GI bleeding, mouth and gum ulcers, hypertension, and Kussmaul’s respirations.

Eclampsia

Generalized seizures are a hallmark of eclampsia. Related findings include severe frontal headache, nausea and vomiting, vision disturbances, increased blood pressure, fever of up to 104° (40° C), peripheral edema, and sudden weight gain. The patient may also exhibit oliguria, irritability, hyperactive deep tendon reflexes (DTRs), and a decreased LOC.

Encephalitis

Seizures are an early sign of encephalitis, indicating a poor prognosis; they may also occur after recovery as a result of residual damage. Other findings include fever, headache, photophobia, nuchal rigidity, neck pain, vomiting, aphasia, ataxia, hemiparesis, nystagmus, irritability, cranial nerve palsies (causing facial weakness, ptosis, and dysphagia), and myoclonic jerks.

Epilepsy (idiopathic)

In most cases, the cause of recurrent seizures is unknown.

Head trauma

In severe cases, generalized seizures may occur at the time of injury. (Months later, focal seizures may occur.) Severe head trauma may also cause a decreased LOC, leading to coma. Other signs and symptoms may include soft-tissue injury of the face, head, or neck as well as facial edema and clear or bloody drainage from the mouth, nose, or ears. The patient may also exhibit Battle’s sign, lack of response to oculocephalic and oculovestibular stimulation, and bony deformity of the face, head, or neck. Motor and sensory deficits may occur along with altered respirations. Examination may reveal signs of increasing ICP, such as decreased response to painful stimuli, nonreactive pupils, bradycardia, increased systolic pressure, and widening pulse pressure. If the patient is conscious, he may exhibit visual deficits, behavioral changes, and headache.

Hepatic encephalopathy

Hypertensive encephalopathy

A life-threatening disorder, hypertensive encephalopathy may cause seizures along with severely increased blood pressure, a decreased LOC, intense headache, vomiting, transient blindness, paralysis and, eventually, Cheyne-Stokes respirations.

Hypoglycemia

Hyponatremia

Seizures develop when serum sodium levels fall below 125 mEq/L, especially if the decrease is rapid. Hyponatremia also causes orthostatic hypotension, headache, muscle twitching and weakness, fatigue, oliguria or anuria, cold and clammy skin, decreased skin turgor, irritability, lethargy, confusion, and stupor or coma. Excessive thirst, tachycardia, nausea, vomiting, and abdominal cramps may also occur. Severe hyponatremia may cause cyanosis and vasomotor collapse, with a thready pulse.

Hypoparathyroidism

Worsening tetany causes generalized seizures. Chronic hypoparathyroidism produces neuromuscular irritability and hyperactive DTRs.

Hypoxic encephalopathy

Besides generalized seizures, hypoxic encephalopathy may produce myoclonic jerks and coma. Later, if the patient has recovered, dementia, visual agnosia, choreoathetosis, and ataxia may occur.

Multiple sclerosis (MS)

MS rarely produces generalized seizures. Characteristic findings include vision deficits, paresthesia, constipation, muscle weakness, paralysis, spasticity, hyperreflexia, intention tremor, ataxic gait, dysphagia, dysarthria, impotence, and emotional lability. Urinary frequency, urgency, and incontinence may also occur.

Neurofibromatosis

Porphyria (intermittent acute)

Generalized seizures are a late sign of porphyria, indicating severe CNS involvement. Acute porphyria also causes severe abdominal pain, tachycardia, psychotic behavior, muscle weakness, and sensory loss in the trunk.

Sarcoidosis

Stroke

Seizures (focal more common than generalized) may occur within 6 months of an ischemic stroke. Associated signs and symptoms vary with the location and extent of brain damage. They include a decreased LOC, contralateral hemiplegia, dysarthria, dysphagia, ataxia, unilateral sensory loss, apraxia, agnosia, and aphasia. The patient may also develop visual deficits, memory loss, poor judgment, personality changes, emotional lability, urine retention or urinary incontinence, constipation, headache, and vomiting.

Other causes

Arsenic poisoning

Besides generalized seizures, arsenic poisoning may cause a garlicky breath odor, increased salivation, and generalized pruritus. GI effects include diarrhea, nausea, vomiting, and severe abdominal pain. Related effects include diffuse hyperpigmentation, paresthesia of the extremities, alopecia, irritated mucous membranes, weakness, muscle aches, peripheral neuropathy, and sharply defined edema of the eyelids, face, and ankles.

Barbiturate withdrawal

In chronically intoxicated patients, barbiturate withdrawal may produce generalized seizures 2 to 4 days after the last dose. Status epilepticus is possible.

Diagnostic tests

Contrast agents used in radiologic tests may cause generalized seizures.

Drugs

Toxic blood levels of some drugs, such as theophylline, lidocaine, Indocin, meperidine, penicillins, and cimetidine, may cause generalized seizures. Phenothiazines, tricyclic antidepressants, amphetamines, isoniazid, and vincristine may cause seizures in patients with preexisting epilepsy.

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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

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

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

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

Aortic insufficiency

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

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)

Mitral insufficiency

Mitral prolapse

Mitral stenosis

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

Other causes

Treatments

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

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

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

Anemia

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

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

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

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.

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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.

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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)

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 tamponade

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

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.

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

Seizures, complex partial: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Brain abscess

Head trauma

Temporal lobe tumor

Complex partial seizures may be the first sign of a tumor in the temporal lobe. Other signs and symptoms include headache, pupillary changes, and mental dullness. Increased intracranial pressure may cause a decreased LOC, vomiting and, possibly, papilledema.

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

Seizures, generalized tonic-clonic: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Alcohol withdrawal syndrome

Sudden withdrawal from alcohol dependence may cause seizures 7 to 48 hours later as well as status epilepticus. The patient may also be restless and exhibit hallucinations, profuse diaphoresis, and tachycardia.

Arsenic poisoning

Brain abscess

Brain tumor

Cerebral aneurysm

Eclampsia

Generalized seizures are a hallmark of eclampsia. Related findings include severe frontal headache, nausea and vomiting, vision disturbances, increased blood pressure, fever of up to 104° F (40° C), peripheral edema, and sudden weight gain. The patient may also exhibit oliguria, irritability, hyperactive deep tendon reflexes (DTRs), and decreased LOC.

Encephalitis

Head trauma

In severe cases, generalized seizures may occur at the time of injury. (Months later, focal seizures may occur.) Severe head trauma may also cause a decreased LOC, leading to coma; soft-tissue injury of the face, head, or neck; clear or bloody drainage from the mouth, nose, or ears; facial edema; bony deformity of the face, head, or neck; Battle’s sign; and lack of response to oculocephalic and oculovestibular stimulation. Motor and sensory deficits may occur along with altered respirations. Examination may reveal signs of increasing ICP, such as decreased response to painful stimuli, nonreactive pupils, bradycardia, increased systolic pressure, and widening pulse pressure. If the patient is conscious, he may exhibit vision deficits, behavioral changes, and headache.

Hepatic encephalopathy

Hypertensive encephalopathy

Hypertensive encephalopathy, a life-threatening disorder, may cause seizures along with severely increased blood pressure, decreased LOC, intense headache, vomiting, transient blindness, paralysis, and (eventually) Cheyne-Stokes respirations.

Hypoglycemia

Hyponatremia

Seizures develop when serum sodium levels fall below 125 mEq/L, especially if the decrease is rapid. Hyponatremia also causes orthostatic hypotension, headache, muscle twitching and weakness, fatigue, oliguria or anuria, cold and clammy skin, decreased skin turgor, irritability, lethargy, confusion, and stupor or coma. Excessive thirst, tachycardia, nausea, vomiting, and abdominal cramps may also occur. Severe hyponatremia may cause cyanosis and vasomotor collapse, with a thready pulse.

Hypoparathyroidism

Worsening tetany causes generalized seizures. Chronic hypoparathyroidism produces neuromuscular irritability, Chvostek’s sign, dysphagia, tetany, and hyperactive DTRs.

Hypoxic encephalopathy

Besides generalized seizures, hypoxic encephalopathy may produce myoclonic jerks and coma. Later, if the patient has recovered, dementia, visual agnosia, choreoathetosis, and ataxia may occur.

Neurofibromatosis

Renal failure (chronic)

Stroke

Other causes

Barbiturate withdrawal

In chronically intoxicated patients, barbiturate withdrawal may produce generalized seizures 2 to 4 days after the last dose. Status epilepticus is possible.

Diagnostic tests

Contrast agents used in radiologic tests may cause generalized seizures.

Drugs

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

Seizures, simple partial: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Brain abscess

Brain tumor

Head trauma

Multiple sclerosis

Focal or generalized seizures may occur with multiple sclerosis, usually during the late stages. Other findings include visual deficits, paresthesia, constipation, muscle weakness, spasticity, paralysis, hyperreflexia, intention tremor, gait ataxia, dysphagia, dysarthria, emotional lability, impotence, and urinary frequency, urgency, and incontinence.

Neurofibromatosis

With neurofibromatosis, multiple brain lesions cause focal seizures and, at times, generalized seizures. Inspection reveals café-au-lait spots, multiple skin tumors, scoliosis, and kyphoscoliosis. Related findings include dizziness, ataxia, progressive monocular blindness, nystagmus, and endocrine abnormalities.

Stroke

A major cause of seizures in patients older than age 50, a stroke may induce focal seizures up to 6 months after its onset. Related effects depend on the type and extent of the stroke but may include decreased LOC, contralateral hemiplegia, dysarthria, dysphagia, ataxia, unilateral sensory loss, apraxia, agnosia, and aphasia. A stroke may also cause vision deficits, memory loss, poor judgment, personality changes, emotional lability, headache, urinary incontinence or retention, and vomiting. It may result in generalized seizures.

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

Seizures: Principal Causes of Seizures
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

Febrileseizures
Hypoxic-ischemic encephalopathy
Brain disorders
1. Cerebralmalformations
2. Intracranial infection
3. Intracranial hemorrhage
4. Other
Hypertensive encephalopathy
Drugs and toxins
Metabolic disorders
1. Hypoglycemia
2. Hypocalcemia
3. Hypomagnesemia
4. Hyponatremia
5. Hypernatremia
6. Uremia
7. Bilirubin encephalopathy (kernicterus)
8. Pyridoxine dependency
9. Inborn errors of metabolism
Selected epileptic syndromes
1. Neonatalseizures
2. Benign neonatal epilepsy
3. Infantile spasms (West syndrome)
4. Lennox-Gastaut syndrome
5. Benign focal epilepsy with centrotemporalspikes
6. Temporal lobe epilepsy
7. Juvenile myoclonic epilepsy
8. Posttraumatic epilepsy
9. Childhood absence epilepsy
Unknown

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

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

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
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

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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.

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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 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.

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

Seizures, absence: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Idiopathic epilepsy.Some forms of absence seizure are accompanied by learning disabilities.

Other causes

Drugs.Drugs that lower the threshold for seizures, such as alcohol, cocaine, penicillin in high doses, isoniazid, and phenothiazines may trigger seizures in patients with preexisting epilepsy.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Seizures, complex partial: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Brain abscess.If the brain abscess is in the temporal lobe, complex partial seizures commonly occur after the abscess disappears. Related problems may include headache, nausea, vomiting, generalized seizures, and decreased level of consciousness (LOC). The patient may also develop central facial weakness, auditory receptive aphasia, hemiparesis, and ocular disturbances.

Head trauma.Severe trauma to the temporal lobe (especially from a penetrating injury) can produce complex partial seizures months or years later. The seizures may decrease in frequency and eventually stop. Head trauma also causes generalized seizures and behavior and personality changes.

Herpes simplex encephalitis.Herpes simplex virus commonly attacks the temporal lobe, resulting in complex partial seizures. Other features include fever, headache, coma, and generalized seizures.

Temporal lobe tumor.Complex partial seizures may be the first sign of a temporal lobe tumor. Other signs and symptoms include headache, pupillary changes, and mental dullness. Increased intracranial pressure may cause decreased LOC, vomiting and, possibly, papilledema.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Seizures, generalized tonic-clonic: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Brain abscess.Generalized seizures may occur in the acute stage of a brain abscess formation or after the abscess disappears. Depending on the size and location of the abscess, a decreased LOC varies from drowsiness to deep stupor. Early signs and symptoms reflect increased intracranial pressure (ICP) and include a constant headache, nausea, vomiting, and focal seizures. Typical later features include ocular disturbances, such as nystagmus, impaired vision, and unequal pupils. Other findings vary with the abscess site but may include aphasia, hemiparesis, abnormal behavior, and personality changes.

Brain tumor.Generalized seizures may occur with a brain tumor, depending on it's location and type. Other findings include a slowly decreasing LOC, a morning headache, dizziness, confusion, focal seizures, vision loss, motor and sensory disturbances, aphasia, and ataxia. Later findings include papilledema, vomiting, increased systolic blood pressure, widening pulse pressure and, eventually, a decorticate posture.

Chronic renal failure.End-stage renal failure produces the rapid onset of twitching, trembling, myoclonic jerks, and generalized seizures. Related signs and symptoms include anuria or oliguria, fatigue, malaise, irritability, decreased mental acuity, muscle cramps, peripheral neuropathies, anorexia, and constipation or diarrhea. Integumentary effects include skin color changes (yellow, brown, or bronze), pruritus, and uremic frost. Other effects include an ammonia breath odor, nausea and vomiting, ecchymoses, petechiae, GI bleeding, mouth and gum ulcers, hypertension, and Kussmaul's respirations.

Eclampsia.Generalized seizures are a hallmark of eclampsia. Related findings include a severe frontal headache, nausea and vomiting, vision disturbances, increased blood pressure, a fever of up to 104° F (40° C), peripheral edema, and sudden weight gain. The patient may also exhibit oliguria, irritability, hyperactive deep tendon reflexes (DTRs), and decreased LOC.

Encephalitis.Seizures are an early sign of encephalitis, indicating a poor prognosis; they may also occur after recovery as a result of residual damage. Other findings include fever, headache, photophobia, nuchal rigidity, neck pain, vomiting, aphasia, ataxia, hemiparesis, nystagmus, irritability, cranial nerve palsies (causing facial weakness, ptosis, and dysphagia), and myoclonic jerks.

Epilepsy (idiopathic).In most cases, the cause of recurrent seizures is unknown.

Head trauma.With severe head trauma, generalized seizures may occur at the time of injury. (Months later, focal seizures may occur.) Severe head trauma may also cause decreased LOC, leading to coma; soft-tissue injury of the face, head, or neck; clear or bloody drainage from the mouth, nose, or ears; facial edema; bony deformity of the face, head, or neck; Battle's sign; and a lack of response to oculocephalic and oculovestibular stimulation. Motor and sensory deficits may occur along with altered respirations. Examination may reveal signs of increasing ICP, such as a decreased response to painful stimuli, nonreactive pupils, bradycardia, increased systolic pressure, and widening pulse pressure. If the patient is conscious, he may exhibit visual deficits, behavioral changes, and headache.

Hepatic encephalopathy.Generalized seizures may occur latein hepatic encephalopathy. Associated late-stage findings in the comatose patient include fetor hepaticus, asterixis, hyperactive DTRs, and a positive Babinski's sign.

Hypoglycemia.Generalized seizures usually occur with severe hypoglycemia, accompanied by blurred or double vision, motor weakness, hemiplegia, trembling, excessive diaphoresis, tachycardia, myoclonic twitching, and decreased LOC.

Hyponatremia.Seizures may develop when the serum sodium level falls below 125 mEq/L, especially if the sodium loss is rapid. Hyponatremia also causes orthostatic hypotension, headache, muscle twitching and weakness, fatigue, oliguria or anuria, cold and clammy skin, decreased skin turgor, irritability, lethargy, confusion, and stupor or coma. Excessive thirst, tachycardia, nausea, vomiting, and abdominal cramps may also occur. Severe hyponatremia may cause cyanosis and vasomotor collapse, with a thready pulse.

Hypoparathyroidism.Chronic hypoparathyroidism produces neuromuscular irritability and hyperactive DTRs. Worsening tetany causes generalized seizures.

Hypoxic encephalopathy.Besidesgeneralized seizures, hypoxic encephalopathy may produce myoclonic jerks and coma. Later, if the patient has recovered, dementia, visual agnosia, choreoathetosis, and ataxia may occur.

Neurofibromatosis.Multiple brain lesions from neurofibromatosis cause focal and generalized seizures. Inspection reveals café-au-lait spots, multiple skin tumors, scoliosis, and kyphoscoliosis. Related findings include dizziness, ataxia, monocular blindness, and nystagmus.

Stroke.Seizures (focal more commonly than generalized) may occur within 6 months of an ischemic stroke. Associated signs and symptoms vary with the location and extent of brain damage. They include decreased LOC, contralateral hemiplegia, dysarthria, dysphagia, ataxia, unilateral sensory loss, apraxia, agnosia, and aphasia. The patient may also develop visual deficits, memory loss, poor judgment, personality changes, emotional lability, urine retention or urinary incontinence, constipation, headache, and vomiting.

Other causes

Arsenic poisoning.Besides generalized seizures, arsenic poisoning may cause a garlicky breath odor, increased salivation, and generalized pruritus. GI effects include diarrhea, nausea, vomiting, and severe abdominal pain. Related effects include diffuse hyperpigmentation; sharply defined edema of the eyelids, face, and ankles; paresthesia of the extremities; alopecia; irritated mucous membranes; weakness; muscle aches; and peripheral neuropathy.

Barbiturate withdrawal.In chronically intoxicated patients, barbiturate withdrawal may produce generalized seizures 2 to 4 days after the last dose. Status epilepticus is possible.

Diagnostic tests.Contrast agents used in radiologic tests may cause generalized seizures.

Drugs.Toxic blood levels of some drugs, such as theophylline, lidocaine, meperidine, penicillins, and cimetidine, may cause generalized seizures. Phenothiazines, tricyclic antidepressants, amphetamines, isoniazid, and vincristine may cause seizures in patients with preexisting epilepsy.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Seizures, simple partial: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Brain abscess.Seizures can occur in the acute stage of a brain abscess formation or after resolution of the abscess. A decreased LOC varies from drowsiness to deep stupor. Early signs and symptoms reflect increased intracranial pressure and include a constant, intractable headache; nausea; and vomiting. Later signs and symptoms include ocular disturbances, such as nystagmus, decreased visual acuity, and unequal pupils. Other findings vary according to the abscess site and may include aphasia, hemiparesis, and personality changes.

Brain tumor.Focal seizures are commonly the earliest indicators of a brain tumor. The patient may report a morning headache, dizziness, confusion, vision loss, and motor and sensory disturbances. He may also develop aphasia, generalized seizures, ataxia, decreased LOC, papilledema, vomiting, increased systolic blood pressure, and widening pulse pressure. Eventually, he may assume a decorticate posture.

Head trauma.Any head injury can cause seizures, but penetrating wounds are characteristically associated with focal seizures. The seizures usually begin 3 to 15 months after injury, decrease in frequency after several years, and eventually stop. The patient may develop generalized seizures and decreased LOC that may progress to coma.

Stroke.A major cause of seizures, a stroke may induce focal seizures up to 6 months after its onset. Related effects depend on the type and extent of the stroke, but may include decreased LOC, contralateral hemiplegia, dysarthria, dysphagia, ataxia, unilateral sensory loss, apraxia, agnosia, and aphasia. A stroke may also cause visual deficits, memory loss, poor judgment, personality changes, emotional lability, headache, urinary incontinence or urine retention, and vomiting. It may result in generalized seizures.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

» Next page: Risk Factors for Infantile Spasms

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

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

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

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

Seizures/Convulsions: Differential Diagnosis (In a Page: Signs and Symptoms)

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

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

Seizures – Childhood: Differential Diagnosis (In A Page: Pediatric Signs and Symptoms)

Seizures – Neonatal: Differential Diagnosis (In A Page: Pediatric Signs and Symptoms)

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

Other causes

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

Aortic insufficiency

Aortic stenosis

Cardiomyopathy (hypertrophic)

Mitral insufficiency

Mitral prolapse

Mitral stenosis

Myxomas

Papillary muscle rupture

Rheumatic fever with pericarditis

Tricuspid insufficiency

Tricuspid stenosis

Other causes

Treatments

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

Anxiety attack (acute)

Cardiac arrhythmias

Hypertension

Hypocalcemia

Mitral prolapse

Mitral stenosis

Thyrotoxicosis

Other causes

Drugs

Herb Alert

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

Arrhythmias

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

Aortic aneurysm (dissecting)

Aortic arch syndrome (Takayasu’s arteritis)

Aortic bifurcation occlusion (acute)

Aortic stenosis

Arrhythmias

Arterial occlusion

Cardiac tamponade

Coarctation of the aorta

Peripheral vascular disease

Pulmonary embolism

Shock

Thoracic outlet syndrome

Other causes

Treatments

Seizures, absence: Medical causes (Handbook of Signs & Symptoms (Third Edition))

Idiopathic epilepsy

Seizures, complex partial: Medical causes (Handbook of Signs & Symptoms (Third Edition))

Brain abscess

Head trauma

Herpes simplex encephalitis

Temporal lobe tumor

Seizures, generalized tonic-clonic: Medical causes (Handbook of Signs & Symptoms (Third Edition))

Brain abscess

Brain tumor

Chronic renal failure

Eclampsia

Encephalitis

Epilepsy (idiopathic)

Head trauma

Hepatic encephalopathy

Hypoglycemia

Hyponatremia

Hypoparathyroidism

TREATMENTS &
RESEARCH

Dr. Huntley's
Diagnosis
Checklist

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

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

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

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

Seizures/Convulsions: Differential Diagnosis
(In a Page: Signs and Symptoms)

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

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

Seizures – Childhood: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

Seizures – Neonatal: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

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

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

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

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

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

Seizures, absence: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Seizures, complex partial: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Seizures, generalized tonic-clonic: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Seizures, simple partial: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

West Nile encephalitis: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

Epilepsy: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

X-linked infantile hypogammaglobulinemia: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

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

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

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

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

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