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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
172
Systolic murmur
Main differential diagnoses and typical outline evidence
Aortic stenosis Suggested by: crescendo–decrescendo systolic murmur
at upper right sternal border radiating to the carotid
arteries. Cool extremities, slowly rising carotid pulse,
low
BP and pulse pressure, heaving apex and soft or
absent aortic component of the second heart sound
(A
2
). ECG with criteria for LVH
Confirmed by: echocardiogram and cardiac
catheterization showing stenosed aortic valve
Hypertrophic
cardiomyopathy
Suggested by: angina, breathlessness, syncope on
exercise, double peaked carotid pulse, high JVP
with
a wave, double apex beat, normal aortic component
of second heart sound (A
2
), and systolic murmur best
at left sternal edge
Confirmed by: echocardiogram showing hypertrophied
septum and lef
t
ventricular walls with small ventricular
cavity showing evidence of subvalvular outflow
obstruction
Aortic sclerosis Suggested by: normal pulse and BP ± no heaving apex.
Normal ECG
Confirmed by: echocardiogram showing thickening of
aortic valve leaflets but not stenosis
Pulmonary
high flow
Suggested by: normal pulse and BP, normal JVP, and no
left parasternal heave. Normal ECG
Confirmed by: Normal echocardiogram
Atrial septal
defect (rare)
causing high
pulmonary flow
Suggested by: normal pulse and BP, normal JVP and left
parasternal heave present. ECG: peaked P waves, right
axis deviation in secundum defect, left-axis devia
t
ion in
primum defect.
Confirmed by: echocardiogram and cardiac
catheterization findings
Pulmonary
stenosis
Suggested by: low pulse, high JVP, and left parasternal
heave. Right bundle branch block (RBBB) and right-
axis deviation on ECG
Confirmed by: echocardiogram and cardiac
catheterization
SYSTOLIC MURMUR1
173
Mitral
incompetence
due to rheumatic
heart disease,
valve dysfunction
after myocardial
infarction
Suggested by: holosystolic murmur at apex with
radiation to axilla. No large JVP v waves. Displaced
heaving apex beat
Confirmed by: CXR: large, round opacity “behind
heart” (big left atrium). ECG: M-shaped P wave.
Echocardiogram and cardiac catheterization
Tricuspid
incompetence
(rare alone)
sometimes
alone in severe
cor pulmonale or
after pulmonary
embolus
Suggested by: holosystolic murmur at left sternal
edge (louder on inspiration), no radiation to axilla.
Large JVP
with mid-systolic v waves. Left parasternal
heave. ECG: tall-peaked P waves, right-axis deviation
and RBBB
Confirmed by: Echocardiogram and cardiac
catheterization showing tricuspid valve incompetence
Mitral and
tricuspid
incompetence
due to rheumatic
heart disease or
dilated ventricles
in severe heart
failure
Suggested by: holosystolic murmur with radiation to
axilla. Large JVP v waves. Displaced heaving apex beat
Confirmed by: normal ECG
and echocardiogram
showing mitral and tricuspid valve incompetence
Ventricular
septal defect
(VSD)
usually
congenital,
sometimes
rupture of
septum after
infarction
Suggested by: holosystolic murmur loud and rough.
Raised JVP. Central cyanosis if right-to-left shunt.
Displaced heaving apex beat. RBBB and right-axis
deviation on ECG
Confirmed by: echocardiogram and cardiac
catheterization showing defect
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CHAPTER 7 Cardiovascular signs
174
Murmurs not entirely in systole
or diastole
Main differential diagnoses and typical outline evidence
Patent ductus
arteriosus
Suggested by: newborn infant, high pulse volume,
diastolic and systolic murmurs to give continuous,
“mechanical” murmur: “shee-shoo, shee-shoo”
Confirmed by: echocardiogram and cardiac
catheterization
Pericarditis
with pericardial
friction rub
(not true
murmur)
Suggested by: “scratching murmur” heard in systole
± diastole. Chest pain worse when lying back and
relieved by lying forward. Raised ST segments or
T-wave inversion on ECG
Confirmed by: echocardiographic findings of pericardial
effusion
Chapter 8
175
Respiratory symptoms
Sudden breathlessness 176
Orthopnea and paroxysmal nocturnal
dyspnea (PND) 177
Acute breathlessness, wheeze ± cough 178
Frank hemoptysis (blood-streaked sputum) 180
Cough with sputum 182
Persistent dry cough (no sputum) 183
Hoarseness 184
Unilateral calf or leg swelling 186
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CHAPTER 8 Respiratory symptoms
176
Sudden breathlessness
This situation may be life threatening; the severity of the underlying
condition often creates helpful diagnostic information.
Some differential diagnoses and typical outline evidence
Pulmonary
embolus (PE)
arising from DVT
in leg, pelvic vein,
or right atrium
Suggested by: central chest pain also with abrupt
shortness of breath, cyanosis, tachycardia, loud second
sound in pulmonary area, associated DVT or risk
factors of silent DVT. PO
2
low, PCO
2
normal or low
Confirmed by: Spiral CT showing filling defect (best) or
V/Q scan showing ventilation/perfusion mismatch.
When spiral CT is not available (rare today) and
confirmatory test required, pulmonary angiogram
may be done (shows filling defect)
Pneumothorax Suggested by: pain in center or side of chest with
abrupt breathlessness. Resonance to percussion over
same side, especially lung apex
Confirmed by: expiratory CXR showing loss of lung
markings outside sharp line (see Fig. 19.20)
Anaphylaxis Suggested by: dramatic onset over minutes, history of
prior allergen exposure, tachycardia and hypotension,
acute bronchospasm with wheeze and dyspnea, flush-
ing and/or sweating, feeling of dread, facial edema,
urticaria, warm but clammy extremities
Confirmed by: clinical presentation and by controlled
allergen exposure and examination. Response to
intramuscular (IM) adrenaline
Inhalation of
foreign body
Suggested by: history of putting an object in mouth,
e.g., peanut. Sudden stridor, severe cough, low-
pitched, monophonic wheeze
Confirmed by: relief in extremis by performing Heimlich
maneuver, etc., or if not in extremis, foreign body seen
on CXR/CT or bronchoscopy
ORTHOPNEA AND PAROXYSMAL NOCTURNAL DYSPNEA (PND)1
177
Orthopnea and paroxysmal nocturnal
dyspnea (PND)
Orthopnea is shortness of breath when lying flat. (Try to confirm by
observing patient lying flat.) This can be explained by increased venous
return or less efficient lung movement when the abdominal contents press
against the diaphragm. PND is shortness of breath that awakens a patient
from sleep; PND usually has similar pathophysiology to orthopnea, but
may also occur with nocturnal bronchospasm (e.g., in asthma).
Some differential diagnoses and typical outline evidence
Pulmonary
edema
from
congestive
(chronic) LV
failure (due to
ischemic heart
disease, mitral
stenosis)
Suggested by: displaced apex beat, third
heart sound,
bilateral basal fine crackles
Confirmed by: CXR appearances (see Fig. 19.13).
Impaired LV function on echocardiogram. Abnormal
ECG reflecting underlying heart disease
COPD Suggested by: dry cough and white sputum, wheeze.
Smoking history of ≥10 pack-years. Chest hyperinfla-
tion, pursed lips. Reduced breath sounds, accessory
muscles of respiration used. Reduced peak flow rate
Confirmed by: CXR: oyperexpanded, radiolucent lungs;
bullae. Spirometry: <12% reversibility, reduced ratio of
forced expiratory volume in 1 second to forced vital
capacity (FEV
1
/FVC ratio), reduced carbon dioxide
diffusing capacity (
DL
CO
). Hypoxia ± hypercapnia.
Rarely (young patients, family history): reduced
α
1
-antitrypsin levels
Asthma Suggested by: wheeze or dry cough. Other specific
triggers to breathlessness. Other allergies. Past history
of similar attacks unless first
presentation
Confirmed by: reduced peak flows, FEV
1
that improves
>12% with treatment and symptomatic response to
treatment
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CHAPTER 8 Respiratory symptoms
178
Acute breathlessness, wheeze ± cough
This symptom suggests airway narrowing due to a foreign body, bron-
chospasm, inflammation or hydrostatic edema.
Some differential diagnoses and typical outline evidence
Asthma Suggested by: wheeze with exacerbations over hours
(silent chest if very severe). Anxiety, tachypnea, tachy-
cardia, prolonged expiration, use of accessory muscles.
Usually known asthmatic
Confirmed by: reduced peak flows, FEV
1
that
improve by >12% with treatment
COPD Suggested by: wheeze with exacerbations over hours
to days often with pursed lips. Long history of cough,
breathlessness and wheeze
Confirmed by: response to bronchodilators, spirometry
showing low FEV
1
/FVC and little reversibility of FEV
1
(improves by <12%)
Acute viral
or bacterial
bronchitis
Suggested by: onset of wheeze over days. No dramatic
progression. Fever, mucopurulent sputum, dyspnea
Confirmed by: sputum culture and sensitivities,
response to antibiotics (if bacterial)
Acute left
ventricular
failure
Suggested by: onset over minutes or hours of breath-
lessness and wheeze, displaced tapping apex beat,
third heart sound, bilateral basal late, fine inspiratory
crackles and wheeze
Confirmed by: CXR: fluffy opacification greatest around
the hilum, fine horizontal linear opacities (Kerley lines),
peripherally, large heart. Impaired LV function on
echocardiogram (see Fig. 19.13)
Anaphylaxis Suggested by: dramatic onset over minutes, acute
bronchospasm with wheeze and dyspnea, flushing,
sweating and a feeling of dread, facial edema, urticaria
and warm but clammy extremities. Tachycardia and
hypotension
Confirmed by: clinical presentation and later by
controlled allergen exposure and examination.
Response to adrenaline IM
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CHAPTER 8 Respiratory symptoms
180
Frank hemoptysis (blood-streaked
sputum)
This may have a sinister cause that requires urgent diagnosis and treatment.
Some differential diagnoses and typical outline evidence
Acute viral or
bacterial
bronchitis
Suggested by: days of fever, mucopurulent sputum,
dyspnea
Confirmed by: sputum culture and sensitivities,
response to appropriate antibiotics
Pulmonary
infarction
due to embolus
from DVT in leg,
pelvis, or right
atrium
Suggested by: sudden shortness of breath, pleural rub,
cyanosis, tachycardia, loud P2, associated DVT or risk
factors such as recent surgery, childbirth, immobility,
etc.
Confirmed by: V/Q scan mismatch, spiral CT scan
showing clot in artery, pulmonary angiogram showing
filling defect
Carcinoma
of lung
Suggested by: weeks or months of weight loss, smoking
history, new or worsening cough
Confirmed by: opacity on CXR and/or CT
scan (see Fig.
19.6). Tumor cells on sputum cytology or broncho-
scopic biopsy
Pulmonary
tuberculosis
Suggested by: weeks or months of fever, malaise,
weight loss, and a contact history. CXR: opacification,
especially in apical segments.
Confirmed by: AFB on smear sputum, culture
and/or response to treatment (when cultures
negative and no other explanation for symptoms)
Upper respira-
tory infection
(URI)
abnormalities
and bleeding
e.g., nasal
polyps, laryngeal
carcinoma,
pharyngeal
tumors
Suggested by: days of purulent rhinorrhea (blood from
URI swallowed or inhaled and coughed back up).
Confirmed by: fiber-optic rhinoscopy, CT/MRI, surgery
and biopsy
FRANK HEMOPTYSIS (BLOOD-STREAKED SPUTUM) 1
181
Lung abscess Suggested by: days or weeks of copious and
foul-smelling sputum, fever, chest pain
Confirmed by: CXR: circular opacity with fluid level,
sputum culture
Bronchiectasis Suggested by: months of copious (often cupfuls) of
purulent sputum daily. Coarse, late inspiratory crackles,
digital clubbing
Confirmed by: CXR: cystic shadowing; high-resolution
CT chest: honeycombing and thickened, dilated
bronchi (see Fig. 19.18)
Wegener’s
granulomatosis
Suggested by: months of cough, breathless, hematuria.
Classic triad of URT, LRT, and renal abnormalities.
Multisystem vasculitis, e.g., arthritis, myalgia, skin
rashes, and nasal bridge collapse
Confirmed by: ititers of cytoplasmic anti-neutrophil
cytoplasmic antibody (cANCA) antibody and
microscopic arteritis on biopsy (see Fig. 19.8)
Goodpastures’
syndrome
(very rare)
Suggested by: profuse hemoptysis, months or years of
ill health, renal failure, iBP
, chest pain
Confirmed by: anti-glomerular basement antibody
(anti-GBM) in serum and/or on renal biopsy
Pulmonary
arteriovenous
malformation
Suggested by: hemoptysis alone. No other symptoms.
CXR normal
Confirmed by: vascular red-blue lesion on bronchoscopy,
enhancing lesion on CT chest with contrast, pulmonary
angiography showing feeding blood vessels
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