Congestive heart failure physical examination

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Specific Groups: Special Populations Patients who have concomitant disorders Obstructive Sleep Apnea in the Patient with CHF NSTEMI with Heart Failure and Cardiogenic Shock
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S. [2]

Overview

Physical examination is of utmost important in the suspicion, diagnosis and follow up of heart failure. Focus should be targeted mainly on the evaluation of the fluid status, blood pressure and weight changes.

Physical Examination

General

• The patient's weight should be recorded to ascertain how far they are from their "dry" weight.
• Tachycardia
• Tachypnea (an increased rate of breathing) and an increased work of breathing
• Narrow pulse pressure (systolic blood pressure minus diastolic blood pressure is < 25 mm Hg)

Appearance

• The patient is often sitting upright and had labored breathing during an acute episode.

Skin

• The skin is cool and clammy consistent with hypoperfusion or cardiogenic shock
• Cyanosis is observed if severe hypoxemia is present
• Anasarca

Neck

• Jugular vein distention
• Central venous pressure > 16 cm H₂O

Lungs

• Pleural effusion with dullness to percussion at the bases
• Rales

Abdomen

• Hepatojugular reflux
• Hepatomegaly
• Ascites

Heart

• Third heart sound (S3) and a gallop rhythm
• A displaced point of maximum impulse (PMI) consistent with an enlarged left ventrile
• If the right ventricular pressure is increased, a parasternal heave may be present, signifying the compensatory increase in contraction strength.
• A functional holosystolic murmur of mitral regurgitation may be heard if the heart dilates excessively
• Underlying valvular heart disease causes of congestive heart failure such as aortic stenosis,

aortic regurgitation and mitral regurgitation may be auscultated.

Extremities

• Bilateral ankle edema

Neurologic

• Confusion and altered mentation

Signs that represent left sided failure include cool clammy skin, cyanosis, rales, a gallop rhythm, and a laterally displaced PMI. Signs that represent right sided failure include an elevated JVP, pedal edema, ascites, hepatomegaly, a parasternal heave and hepatojugular reflux. Commonly signs of both left and right sided failure are present.

2009 ACC/AHA Focused Update and 2005 Guidelines for the Diagnosis and Management of Chronic Heart Failure in the Adult (DO NOT EDIT)

Initial Clinical Assessment of Patients Presenting With Heart Failure (DO NOT EDIT)

Class I

"1. A thorough history and physical examination should be obtained/performed in patients presenting with heart failure to identify cardiac and noncardiac disorders or behaviors that might cause or accelerate the development or progression of heart failure. (Level of Evidence: C) "

"2. In patients presenting with heart failure, initial assessment should be made of the patient’s ability to perform routine and desired activities of daily living. (Level of Evidence: C) "

"3. Initial examination of patients presenting with heart failure should include assessment of the patient’s volume status, orthostatic blood pressure changes, measurement of weight and height, and calculation of body mass index. (Level of Evidence: C) "

Serial Clinical Assessment of Patients Presenting With Heart Failure (DO NOT EDIT)

Class I

"1. Assessment should be made at each visit of the ability of a patient with heart failure to perform routine and desired activities of daily living. (Level of Evidence: C) "

"2. Assessment should be made at each visit of the volume status and weight of a patient with heart failure. (Level of Evidence: C) "

Vote on and Suggest Revisions to the Current Guidelines

• The CHF Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines

Sources

• The ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult

• 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation

References

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