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Chapter 10: THE HISTORY, PHYSICAL EXAMINATION, AND CARDIAC AUSCULTATION

PHYSICAL EXAMINATION OF THE CHEST, ABDOMEN, AND EXTREMITIES

Physical examination of the lungs is an important noninvasive technique requiring only a stethoscope.202 Wheezing and a pleural friction rub are detected only by the clinical evaluation. The pleural friction rub may be a clue to the diagnosis of pulmonary infarction. Pleural fluid due to heart failure is usually located in the right pleural space. When pleural fluid is localized predominately to the left, a cause other than or in addition to heart failure, such as pulmonary infarction, should be considered.

A pneumothorax may develop as a consequence of spontaneous mediastinal emphysema or may be iatrogenic, due to procedures.202 Hyperresonance and diminished breath sounds may be due to pulmonary emphysema. Signs of pulmonary consolidation may be due to pneumonia or pulmonary infarction. Wheezing and rales may be due to bronchial disease. Heart failure may be associated with rales in the lung bases, wheezing, and pleural fluid. Importantly, heart failure frequently is not associated with rales, since interstitial pulmonary edema usually does not produce rales.202

The diameter of the abdominal aorta should be determined in every patient202 (see Chap. 88). An abdominal aortic aneurysm may be missed if the examiner fails to assess the area above the umbilicus.

Specific abnormalities of the abdomen may be secondary to heart disease. A large, tender liver is common in patients with heart failure or constrictive pericarditis. Systolic hepatic pulsations are frequent in patients with tricuspid regurgitation. A palpable spleen is a common but late sign in patients with severe heart failure and is also often present in patients with infective endocarditis.

Although hepatic cirrhosis is the most common cause of ascites, the latter may occur with heart failure alone, although it is less common with the use of diuretic therapy. Severe tricuspid regurgitation, as caused by infective endocarditis in drug addicts, may produce prominent systolic pulsation of the internal jugular veins in the neck, a large, moving, and pulsating liver, and ascites. Constrictive pericarditis should be considered when the ascites is out of proportion to peripheral edema. In many such patients, the heart is normal in size or only slightly enlarged, a pericardial "knock" is heard, and there is a rapid x and/or y descent in the internal jugular vein pulsation.202 Restrictive cardiomyopathy can mimic constrictive pericarditis, but the heart is usually moderately large in patients with restrictive cardiomyopathy. When there is an arteriovenous fistula in the abdomen, a continuous murmur may be heard over the abdomen. Fistulas due to trauma and surgery may occur.

A systolic bruit may be heard over the kidney areas and may signify renal artery stenosis, particularly in patients with systemic hypertension. A systolic bruit often is auscultated over the abdominal aorta, but its presence does not indicate the severity of disease of the aorta.202

Examination of the upper and lower extremities may provide important diagnostic information (see Chap. 90). The clinical detection of arterial disease and thrombophlebitis is important. Atherosclerosis of the peripheral arteries may produce intermittent claudication of the buttock, calf, thigh, or foot, with severe disease resulting in tissue damage of the toes. Peripheral atherosclerosis is an important risk factor for ischemic heart disease, and its presence increases the likelihood of coronary atherosclerosis. Thrombophlebitis often causes pain in the calf or thigh or edema, and its presence should raise the consideration of pulmonary emboli as well. Edema is a late sign of heart failure, and its predictive value as a diagnostic sign is poor. It frequently involves the right leg prior to the left. Considerable heart failure and a resulting weight gain may be present without edema being present. Edema of the lower extremities may be secondary to local factors such as varicose veins or thrombophlebitis or the removal of veins at CABG surgery. Under such circumstances, the edema often occurs in only one leg.

Edema may result from restrictive garments, and venous stasis often is secondary to a long trip in a car or airplane.202 Edema may be due to salt and water retention in patients with primary renal disease. In the differential diagnosis of edema, local factors should be considered first. If local factors can be excluded, the cause of the salt and water retention should be determined with an assessment for evidence of primary renal disease. Rarely, peripheral edema can be an early sign of lymphatic obstruction produced by metastatic disease in the pelvis or abdomen.

Since the invention of the stethoscope by Laennec in 1826, cardiac auscultation has played a key role in the evaluation of patients with cardiovascular disease. New diagnostic techniques developed in recent years have led to a better understanding of the relationship between intracardiac pressure, flow, and valve motion and the resulting sound phenomena on the other. The analysis of heart sounds and murmurs by phonocardiography, together with information obtained by cardiac catheterization, angiography, echocardiography, and cardiac surgery, has made cardiac auscultation a precise discipline based on firm physiologic principles.203

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