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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3230_Библиотеки_им_академика_М_И_Перельмана
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CHAPTER 7 Cardiovascular signs
162
Unilateral leg and ankle swelling
Main differential diagnoses and typical outline evidence
Deep vein
thrombosis
Suggested by: immobility, prominent dilated veins,
warm, tender, swollen calf and positive Homan’s sign
Confirmed by: reduced flow on compression Doppler,
blockage seen on venography
Ruptured
Baker’s cyst
Suggested by: sudden onset while straightening knee,
warm, tender, swollen calf
Confirmed by: D-dimer titers not raised, normal flow
on compression Doppler, no blockage seen on
venography. Leaking from joint capsule on
arthrography
Cellulitis
from infection
secondary or
primarily due to
insect bites
Suggested by: tender, hot, red leg and fever
Confirmed by: resolution on antibiotics
Unilateral
varicose veins
Suggested by: distended and tortuous veins made
worse when standing
Confirmed by: Doppler ultrasound probe to confirm
where incompetence is present
Chronic venous
insufficiency
from old deep
vein thromboses
Suggested by: past history, veins distended and made
worse on standing
Confirmed by: Doppler ultrasound probe to where
incompetence is present
Venous
insufficiency
from obstruction
by tumor or
lymph node
Suggested by: onset over weeks, veins distended
Confirmed by: Doppler ultrasound and venography to
explore where obstruction is present
Lymphedema
from lymphatic
obstruction due
to primary
lymphatic
hypoplasia
Suggested by: unilateral swelling that is worse premen-
strually, in warm weather, and with immobility.
No venous dilatation
Confirmed by: Doppler ultrasound to show normal
venous flow. MRI or CT or lymphangiogram (rarely)
to show hypoplastic lymphatics
UNILATERAL LEG AND ANKLE SWELLING1
163
Subacute
lymphatic
obstruction
secondary to
neoplastic
obstruction
Suggested by: unilateral swelling developing over
months. No venous dilatation
Confirmed by: Doppler ultrasound to show normal
venous flow. MRI or CT or lymphangiogram (rarely)
to show site of obstruction
Acute lymphatic
obstruction
due to
streptococcal
lymphangitis
Suggested by: sudden unilateral swelling developing
over hours. No venous dilatation but lymphangitic
streaks
Confirmed by: clinical features and response to
penicillin. Doppler ultrasound to show normal
venous flow
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
CHAPTER 7 Cardiovascular signs
164
Bilateral leg and ankle swelling
Main differential diagnoses and typical outline evidence
Bilateral
varicose veins or
old deep vein
thromboses
Suggested by: veins distended and tortuous made
worse when standing
Confirmed by: Doppler ultrasound probe to confirm
where incompetence is present
Low albumin
due to poor
nutrition, mal-
absorption, liver
failure, nephrotic
syndrome,
protein-losing
enteropathy
Suggested by: history of facial puffiness in morning and
evidence of possible cause of low albumin
Confirmed by: low serum albumin (<3.0 g/dL to be
significant)
Congestive
cardiac failure
(i.e., right heart
failure due to left
heart failure)
caused by
ischemic heart
disease, mitral
stenosis, cardio-
myopathy, etc.
Suggested by: raised JVP, large liver, fine rales at lung
bases or higher, third heart sound. Echocardiogram
showing systolic or diastolic dysfunction or valve
dysfunction
Confirmed by: CXR: large heart, distension of veins in
upper lobes of lung, and fluffy lung infiltrates.
Echocardiogram: ventricular dysfunction
Cor pulmonale
(right heart
failure)
from pulmonary
hypertension due
to long-standing
lung disease, old
pulmonary
emboli, etc.)
Suggested by: raised JVP, large liver, third heart sound,
loud pulmonary second sound, and RV heave
Confirmed by: CXR showing pulmonary disease, ECG
showing right axis deviation. Echocardiogram: right
ventricular dysfunction
Lymphedema
due to primary
lymphatic
hypoplasia
Suggested by: bilateral swelling that is worse premenstru-
ally, in warm weather, and with immobility. No venous
dilatation.
Confirmed by: Doppler ultrasound to show normal
venous flow. Occasional lymphangiography to show
hypoplastic lymphatics
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CHAPTER 7 Cardiovascular signs
166
Raised jugular venous pressure
This is measured with the patient lying at 45*. It is undetectably low if the
external jugular empties when the compressing finger is released. An
elevated JVP with a and v waves that is accurately assessed means that
right atrial pressure is abnormally high.
Main differential diagnoses and typical outline evidence
Fluid overload
due to excessive
IV or oral fluids
Suggested by: elevated double pulsations JVP
with a
and v waves. History of high input of IV
or oral fluids.
Renal insufficiency or failure. Echocardiogram showing
normal or hyperdynamic systolic function
Confirmed by: response to reduced fluid intake and
spontaneous diuresis (or diuretics) or fluid removal
Congestive
cardiac failure
(i.e., right-sided
failure due to
left-sided failure)
Suggested by: elevated JVP
with a and v waves. Dysp-
nea, rales on pulmonary exam. CXR consistent with
pulmonary edema. Echocardiogram showing LV
systolic or diastolic dysfunction or valve dysfunction
Confirmed by: echocardiogram showing ventricular
dysfunction, right heart catheterization showing
elevated RA and pulmonary capillary wedge pressure,
decreased cardiac output
Cor pulmonale
Right heart
failure due to
pulmonary
vascular disease
Suggested by: elevated JVP; large a waves may be
present. Pulmonary exam with hyperresonance and
low diaphragms. Sometimes wheezing or rhonchi,
but not rales. ECG showing tall P wave in lead 2
Confirmed by: echocardiogram showing dilated RV with
reduced systolic function, flattened intraventricular
septum indicating elevation of RV pressure, no LV
systolic or diastolic dysfunction or valve dysfunction.
Right heart catheterization showing elevation of RA,
RV, and PA systolic pressure, elevation of pulmonary
vascular resistance, but normal pulmonary capillary
wedge pressure
Right-sided
congestive heart
failure with
atrial fibrillation
Suggested by: elevated JVP with a single pulsation,
a waves absent, irregularly irregular pulse
Confirmed by: ECG
showing no P waves and normal
QRS complexes. Other findings of congestive heart
failure mentioned above
Complete heart
block
Suggested by: intermittent elevations of JVP when the
atria contract when AV valves are closed. Bradycardia
Confirmed by: ECG
showing no association between
P waves and QRS complexes
RAISED JUGULAR VENOUS PRESSURE1
167
Tricuspid
regurgitation
Suggested by: elevated JVP with single pulsation, large
v waves in mid-systole. Holosystolic murmur present
in the low sternal area
Confirmed by: echocardiogram showing large right
atrium and tricuspid incompetence
Pericardial
effusion
sufficient to
compromise
heart function
Suggested by: pulsatile JVP with a wave and rapid
descent. Very breathless. Quiet heart sounds. Globular
heart shadow on CXR
. Low-voltage QRS complexes
on ECG
Confirmed by: Echocardiogram showing moderate or
large pericardial effusion, excessive respiratory
variation of the inflow velocity of mitral and
tricuspid valves, diastolic collapse of the RA or RV
Constrictive
pericarditis
Suggested by: JVP rising with inspiration (Kussmaul
sign), a waves have rapid descent. Quiet heart sounds.
Large liver and ascites.
Confirmed by: small heart shadow on CXR.
Echocardiogram shows small cavity and little
contraction
Jugular vein
obstruction
Suggested by: no JVP pulsation, external jugular vein
also distended
Confirmed by: ultrasound scan to explore site of
obstruction
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CHAPTER 7 Cardiovascular signs
168
Abnormal apical impulse
Look for displacement from normal site in mid-clavicular line, heave, and
character of impulse (tapping, double).
Main differential diagnoses and typical outline evidence
Obesity,
emphysema,
pleural effusion,
pericardial
effusion or
dextrocardia
Suggested by: impalpable apical impulse
Confirmed by: evidence of intervening factors or
apical impulse palpable on right (dextrocardia)
Large left
ventricle
due to mitral
incompetence,
aortic incompe-
tence, right-to-
left VSD shunt
Suggested by: apical impulse displaced to the left and
heaving
Confirmed by: large left ventricle on echocardiogram
with corresponding valve lesion
Hypertrophied
left ventricle
due to
hypertension or
aortic stenosis
Suggested by: apex not displaced but heaving. ECG
meeting voltage criteria for LVH
Confirmed by: hypertrophied left ventricular wall on
echocardiogram
Hypertrophic
cardiomyopathy
Suggested by: double apex beat, angina, breathlessness,
syncope on exercise, jerky pulse, high JVP with a wave,
thrill and murmur best at left sternal edge. Rapid and
notched carotid upstroke
Confirmed by: echocardiogram showing hypertrophied
septum and left ventricular walls with small left
ventricular cavity
Ventricular
aneurysm
Suggested by: double apical impulse. Persistently raised
ST
segments on ECG
Confirmed by: thinning and paradoxical movement of
ventricular wall on echocardiogram
ABNORMAL APICAL IMPULSE1
169
Mitral stenosis Suggested by: tapping left ventricular impulse (palpable
first heart sound) and rumbling diastolic murmur
radiating to the axilla. ECG showing left atrial
enlargement without LVH
Confirmed by: echocardiogram and cardiac
catheterization
Right ventricular
hypertrophy
due to pulmonic
stenosis
or pulmonary
hypertension
Suggested by: upper sternal heave
Confirmed by: ECG
findings and echocardiogram.
Major valve
stenosis or
regurgitation
or muscular
outflow tract
obstruction
Suggested by: palpable thrill or loud murmur
Confirmed by: ECG findings and echocardiogram and
cardiac catheterization
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CHAPTER 7 Cardiovascular signs
170
Extra heart sounds
The third and fourth heart sounds (S3 and S4), respectively, are early and
late diastolic ventricular filling sounds. S3 can be heard in healthy chil-
dren, but S4 is abnormal even in children.
Main differential diagnoses and typical outline evidence
LVH
due to
hypertension,
aortic stenosis,
or hypertrophic
cardiomyopathy
Suggested by: fourth heart sound. Increased LV voltage
on ECG
Confirmed by: LV hypertrophy on echocardiogram
Decompensated
heart failure in
cardiomyopathy,
constrictive
pericarditis
Suggested by: third heart sound
Confirmed by: Elevated JVP, pulmonary rales, CXR
findings of CHF
Severe heart
failure
Suggested by: third and fourth heart sound giving gallop
Confirmed by: raised JVP, crackles at lung bases,
pulmonary edema on CXR
and systolic or diastolic
dysfunction or valve dysfunction on echocardiogram
DIASTOLIC MURMUR1
171
Diastolic murmur
Find where it is heard best (e.g., at the apex or left sternal edge).
Main differential diagnoses and typical outline evidence
Mitral stenosis Suggested by: mitral facies, tapping apex beat, loud first
heart sound, rumbling diasystolic murmur best at apex
with patient lying on left side
Confirmed by: echocardiogram and cardiac catheter
displaying valve lesion
Mitral stenosis
with pliable
valve
Suggested by: opening snap
Aortic
insufficency
Suggested by: high BP, wide pulse pressure, laterally
displaced apex beat, early diasystolic murmur best at
left or right sternal edge
Confirmed by: echocardiogram and cardiac
catheterization displaying valve lesion
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
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