Hypertrophic cardiomyopathy physical examination: Difference between revisions

Jump to navigation Jump to search
VisualWikitext
No edit summary
Line 1: Line 1:
{{Hypertrophic cardiomyopathy}}
{{Hypertrophic cardiomyopathy}}


{{CMG}}
{{CMG}} {{AE}} {{Soroush}}


==Overview==
==Overview==
There are numerous teachers on physical examination that allow one to distinguish hypertrophic cardiomyopathy from other conditions such as [[aortic stenosis]].
There are numerous teachers on physical examination that allow one to distinguish hypertrophic cardiomyopathy from other conditions such as [[aortic stenosis]]. On physical examination, (as shown in the table below) maneuvers that decrease left ventricular filling augment the [[murmur]] and maneuvers that increase afterload or filling decrease the murmur.


==Overview==
==Physical Examination==
On physical examination, (as shown in the table below) maneuvers that decrease left ventricular filling augment the [[murmur]] and maneuvers that increase afterload or filling decrease the murmur.


==Physical Examination==
* The physical findings of HCM are associated with the dynamic outflow obstruction that is often present with this disease.<ref name=":0">Maron BJ. Hypertrophic cardiomyopathy. Lancet 1997;350:127–33.</ref><ref name=":1">Maron BJ. Hypertrophic cardiomyopathy. A systematic review. JAMA 2002;287:1308–20.</ref><ref name=":2">Maki S, Ikeda H, Muro A et al. Predictors of sudden cardiac death in
* The physical findings of HCM are associated with the dynamic outflow obstruction that is often present with this disease.<ref name=":0">Maron BJ. Hypertrophic cardiomyopathy. Lancet 1997;350:127–33.</ref><ref name=":1">Maron BJ. Hypertrophic cardiomyopathy. A systematic review. JAMA 2002;287:1308–20.</ref><ref name=":2">Maki S, Ikeda H, Muro A et al. Predictors of sudden cardiac death in
hypertrophic cardiomyopathy. Am J Cardiol 1998;82:774–8.</ref><ref name=":3">Maron BJ, Casey SA, Poliac LC, Gohman TE, Almquist AK, Aeppli DM. Clinical course of hypertrophic cardiomyopathy in a regional United
hypertrophic cardiomyopathy. Am J Cardiol 1998;82:774–8.</ref><ref name=":3">Maron BJ, Casey SA, Poliac LC, Gohman TE, Almquist AK, Aeppli DM. Clinical course of hypertrophic cardiomyopathy in a regional United
States cohort. JAMA 1999;281:650–5.</ref><ref name=":4">Maron BJ, Olivotto I, Bellone P et al. Clinical profile of stroke in 900 patients with hypertrophic cardiomyopathy. J Am Coll Cardiol 2002;39:301–7.</ref> <ref name=":5">Maron BJ. Hypertrophic cardiomyopathy. A systematic review. JAMA 2002;287:1308–20.</ref><ref name=":6">Maron BJ, Casey SA, Poliac LC, Gohman TE, Almquist AK, Aeppli DM. Clinical course of hypertrophic cardiomyopathy in a regional United States cohort. JAMA 1999;281:650–5.</ref><ref name=":7">Fay WP, Taliercio CP, Ilstrup DM, Tajik AJ, Gersh BJ. Natural history of hypertrophic cardiomyopathy in the elderly. J Am Coll Cardiol 1990;16:821–6.</ref><ref name=":8">Takagi E, Yamakado T, Nakano T. Prognosis of completely asymptomatic adult patients with hypertrophic cardiomyopathy. J Am Coll Cardiol 1999;33:206–11.</ref>
States cohort. JAMA 1999;281:650–5.</ref><ref name=":4">Maron BJ, Olivotto I, Bellone P et al. Clinical profile of stroke in 900 patients with hypertrophic cardiomyopathy. J Am Coll Cardiol 2002;39:301–7.</ref> <ref name=":5">Maron BJ. Hypertrophic cardiomyopathy. A systematic review. JAMA 2002;287:1308–20.</ref><ref name=":6">Maron BJ, Casey SA, Poliac LC, Gohman TE, Almquist AK, Aeppli DM. Clinical course of hypertrophic cardiomyopathy in a regional United States cohort. JAMA 1999;281:650–5.</ref><ref name=":7">Fay WP, Taliercio CP, Ilstrup DM, Tajik AJ, Gersh BJ. Natural history of hypertrophic cardiomyopathy in the elderly. J Am Coll Cardiol 1990;16:821–6.</ref><ref name=":8">Takagi E, Yamakado T, Nakano T. Prognosis of completely asymptomatic adult patients with hypertrophic cardiomyopathy. J Am Coll Cardiol 1999;33:206–11.</ref>
===Neck===
* "[[A wave]]" is prominent on [[JVP]].
* Double carotid arterial pulse may be present.
===Heart===
* If dynamic outflow obstruction exists, physical examination findings that can be elicited include the pulsus bisferiens and the double apical impulse with each ventricular contraction. These findings, when present, can help differentiate HCM from [[aortic stenosis]].
* In addition, if the individual has [[premature ventricular contraction]]s (PVCs), the change in the carotid pulse intensity in the beat after the PVC can help differentiate HCM from aortic stenosis.
* In individuals with HCM, the pulse pressure will decrease in the beat after the PVC, while in aortic stenosis, the pulse pressure will increase.
====Palpation====
* Powerful apical precordial impulse is present which may be shifted laterally.
====Auscultation====
=====Heart Sounds=====
* [[S1]] is normal.
* There may be paradoxically split S2 in severe cases
* S3 gallop or S4 may also be present.
* S2 is louder in HCM than Aortic Stenosis.
=====Murmurs=====
* The murmur is characteristically a crescendo-decrescendo [[systolic murmur]].
* Best heard between the apex and left sternal border.
* It radiates to the suprasternal notch but not to the carotid arteries or neck thus differentiating it from aortic stenosis.
* The cardiac [[heart murmur|murmur]] of HCM will sound similar to the murmur of [[aortic stenosis]]. However, this murmur will:
:* increase in intensity with any maneuver that decreases the volume of blood in the left ventricle (such as standing, [[valsalva maneuver]], amyl nitrate, diuretic administration or vasodilator administration).
:* decrease in intensity with any maneuver that increases the volume of blood in the left ventricle (such as mueller maneuver, squatting or handgrip).
* [[Hypertrophic cardiomyopathy]](HCM) can be differentiated from aortic stenosis by the fact that the murmur of aortic stenosis does not change substantially with maneuvers.
* The character of the pulse in Aortic Stenosis is [[Pulsus parvus et tardus|parvus et tardus]], while a [[Pulsus bisferiens|bisferiens]] pulse is noted in HCM.
* Associated murmurs:
:* 10% patients of HCM will also present with aortic regurgitation and in that case a diastolic decrescendo murmur may be present.
:* If mitral regurgitation co exists with HCM then a holosystolic murmur will be beast heard at the caridac apex and left axilla.
{| border="1" style="background:LightSkyBlue"
|+ '''Differentiating hypertrophic cardiomyopathy and valvular aortic stenosis'''
|-
! scope="col" style="width: 33%" | &nbsp;
! scope="col" style="width: 33%" | Aortic stenosis
! scope="col" style="width: 33%" | Hypertrophic cardiomyopathy
|- style="background:#dfefff;"
| colspan="3" | Echocardiography
|-
! scope="row" | Aortic valve calcification
| Common || No
|-
! scope="row" | Dilated ascending aorta
| Common || Rare
|-
! scope="row" | Ventricular hypertrophy
| Concentric [[left ventricular hypertrophy|LVH]]
| Asymmetric, often involving the septum
|-
| colspan="3" style="background:#dfefff;" | Physical examination
|-
! scope="row" | Murmur of [[Aortic insufficiency|AI]]
| Common || No
|-
! scope="row" | Pulse pressure after [[premature ventricular contraction|PVC]]
| Increased || Decreased
|-
! scope="row" | [[Valsalva maneuver]]
| Decreased intensity of murmur || Increased intensity of murmur
|-
! scope="row" | Carotid pulsation
| Normal or [[Pulsus tardus et parvus|tardus et parvus]]
| Brisk, jerky, or bisferiens pulse (a collapse of the pulse followed by a secondary rise)
|}
==Overview==
Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].
OR
Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].
OR
The presence of [finding(s)] on physical examination is diagnostic of [disease name].
OR
The presence of [finding(s)] on physical examination is highly suggestive of [disease name].
There are numerous teachers on physical examination that allow one to distinguish hypertrophic cardiomyopathy from other conditions such as [[aortic stenosis]]. On physical examination, maneuvers that decrease left ventricular filling augment the [[murmur]] and maneuvers that increase afterload or filling decrease the murmur.
==Physical Examination==
Physical examination of patients with [disease name] is usually normal.
OR
Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].
OR
The presence of [finding(s)] on physical examination is diagnostic of [disease name].
OR
The presence of [finding(s)] on physical examination is highly suggestive of [disease name].


===Appearance of the Patient===
===Appearance of the Patient===
*Patients with [disease name] usually appear [general appearance].  
*Patients with hypertrophic cardiomyopathy usually appear [general appearance].


===Vital Signs===
===Vital Signs===
Line 128: Line 27:


===Skin===
===Skin===
* Skin examination of patients with [disease name] is usually normal.
* Skin examination of patients with hypertrophic cardiomyopathy is usually normal.
OR
OR
*[[Cyanosis]]  
*[[Cyanosis]]  
Line 143: Line 42:


===HEENT===
===HEENT===
* HEENT examination of patients with [disease name] is usually normal.
* HEENT examination of patients with hypertrophic cardiomyopathy is usually normal.
OR
OR
* Abnormalities of the head/hair may include ___
* Abnormalities of the head/hair may include ___
Line 171: Line 70:


===Lungs===
===Lungs===
* Pulmonary examination of patients with [disease name] is usually normal.
* Pulmonary examination of patients with hypertrophic cardiomyopathy is usually normal.
OR
OR
* Asymmetric chest expansion OR decreased chest expansion
* Asymmetric chest expansion OR decreased chest expansion
Line 209: Line 108:
* Associated murmurs:
* Associated murmurs:
:* 10% of the patients with HCM will also present with aortic regurgitation and in that case, a diastolic decrescendo murmur may be present.
:* 10% of the patients with HCM will also present with aortic regurgitation and in that case, a diastolic decrescendo murmur may be present.
:* If mitral regurgitation co-exists with HCM then a holosystolic murmur will be beast heard at the cardiac apex and left axilla.
:* If mitral regurgitation co exists with HCM then a holosystolic murmur will be beast heard at the caridac apex and left axilla.
 
{| border="1" style="background:LightSkyBlue"
|+ '''Differentiating hypertrophic cardiomyopathy and valvular aortic stenosis'''
|-
! scope="col" style="width: 33%" | &nbsp;
! scope="col" style="width: 33%" | Aortic stenosis
! scope="col" style="width: 33%" | Hypertrophic cardiomyopathy
|- style="background:#dfefff;"
| colspan="3" | Echocardiography
|-
! scope="row" | Aortic valve calcification
| Common || No
|-
! scope="row" | Dilated ascending aorta
| Common || Rare
|-
! scope="row" | Ventricular hypertrophy
| Concentric [[left ventricular hypertrophy|LVH]]
| Asymmetric, often involving the septum
|-
| colspan="3" style="background:#dfefff;" | Physical examination
|-
! scope="row" | Murmur of [[Aortic insufficiency|AI]]
| Common || No
|-
! scope="row" | Pulse pressure after [[premature ventricular contraction|PVC]]
| Increased || Decreased
|-
! scope="row" | [[Valsalva maneuver]]
| Decreased intensity of murmur || Increased intensity of murmur
|-
! scope="row" | Carotid pulsation
| Normal or [[Pulsus tardus et parvus|tardus et parvus]]
| Brisk, jerky, or bisferiens pulse (a collapse of the pulse followed by a secondary rise)
|}
 
<br />
===Abdomen===
===Abdomen===
* Abdominal examination of patients with [disease name] is usually normal.
* Abdominal examination of patients with hypertrophic cardiomyopathy is usually normal.
OR
OR
*[[Abdominal distension]]  
*[[Abdominal distension]]  
Line 222: Line 158:


===Back===
===Back===
* Back examination of patients with [disease name] is usually normal.
* Back examination of patients with hypertrophic cardiomyopathy is usually normal.
OR
OR
*Point tenderness over __ vertebrae (e.g. L3-L4)
*Point tenderness over __ vertebrae (e.g. L3-L4)
Line 230: Line 166:


===Genitourinary===
===Genitourinary===
* Genitourinary examination of patients with [disease name] is usually normal.
* Genitourinary examination of patients with hypertrophic cardiomyopathy is usually normal.
OR
OR
*A pelvic/adnexal mass may be palpated
*A pelvic/adnexal mass may be palpated
Line 237: Line 173:


===Neuromuscular===
===Neuromuscular===
* Neuromuscular examination of patients with [disease name] is usually normal.
* Neuromuscular examination of patients with hypertrophic cardiomyopathy is usually normal.
OR
OR
*Patient is usually oriented to persons, place, and time
*Patient is usually oriented to persons, place, and time
Line 258: Line 194:


===Extremities===
===Extremities===
* Extremities examination of patients with [disease name] is usually normal.
* Extremities examination of patients with hypertrophic cardiomyopathy is usually normal.
OR
OR
*[[Clubbing]]  
*[[Clubbing]]  

Revision as of 00:48, 22 January 2020

Hypertrophic Cardiomyopathy Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Hypertrophic Cardiomyopathy from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Study of Choice

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

X Ray

Echocardiography and Ultrasound

CT scan

MRI

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Interventions

Surgery

Primary Prevention

Secondary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Case Studies

Case #1

Hypertrophic cardiomyopathy physical examination On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Hypertrophic cardiomyopathy physical examination

CDC on Hypertrophic cardiomyopathy physical examination

Hypertrophic cardiomyopathy physical examination in the news

Blogs on Hypertrophic cardiomyopathy physical examination

Directions to Hospitals Treating Hypertrophic cardiomyopathy

Risk calculators and risk factors for Hypertrophic cardiomyopathy physical examination

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Soroush Seifirad, M.D.[2]

Overview

There are numerous teachers on physical examination that allow one to distinguish hypertrophic cardiomyopathy from other conditions such as aortic stenosis. On physical examination, (as shown in the table below) maneuvers that decrease left ventricular filling augment the murmur and maneuvers that increase afterload or filling decrease the murmur.

Physical Examination

  • The physical findings of HCM are associated with the dynamic outflow obstruction that is often present with this disease.[1][2][3][4][5] [6][7][8][9]

Appearance of the Patient

  • Patients with hypertrophic cardiomyopathy usually appear [general appearance].

Vital Signs

  • High-grade / low-grade fever
  • Hypothermia / hyperthermia may be present
  • Tachycardia with regular pulse or (ir)regularly irregular pulse
  • Bradycardia with regular pulse or (ir)regularly irregular pulse
  • Tachypnea / bradypnea
  • Kussmal respirations may be present in _____ (advanced disease state)
  • Weak/bounding pulse / pulsus alternans / paradoxical pulse / asymmetric pulse
  • High/low blood pressure with normal pulse pressure / wide pulse pressure / narrow pulse pressure

Skin

  • Skin examination of patients with hypertrophic cardiomyopathy is usually normal.

OR

HEENT

  • HEENT examination of patients with hypertrophic cardiomyopathy is usually normal.

OR

  • Abnormalities of the head/hair may include ___
  • Evidence of trauma
  • Icteric sclera
  • Nystagmus
  • Extra-ocular movements may be abnormal
  • Pupils non-reactive to light / non-reactive to accommodation / non-reactive to neither light nor accommodation
  • Ophthalmoscopic exam may be abnormal with findings of ___
  • Hearing acuity may be reduced
  • Weber test may be abnormal (Note: A positive Weber test is considered a normal finding / A negative Weber test is considered an abnormal finding. To avoid confusion, you may write "abnormal Weber test".)
  • Rinne test may be positive (Note: A positive Rinne test is considered a normal finding / A negative Rinne test is considered an abnormal finding. To avoid confusion, you may write "abnormal Rinne test".)
  • Exudate from the ear canal
  • Tenderness upon palpation of the ear pinnae/tragus (anterior to ear canal)
  • Inflamed nares / congested nares
  • Purulent exudate from the nares
  • Facial tenderness
  • Erythematous throat with/without tonsillar swelling, exudates, and/or petechiae

Neck

Lungs

  • Pulmonary examination of patients with hypertrophic cardiomyopathy is usually normal.

OR

  • Asymmetric chest expansion OR decreased chest expansion
  • Lungs are hyporesonant OR hyperresonant
  • Fine/coarse crackles upon auscultation of the lung bases/apices unilaterally/bilaterally
  • Rhonchi
  • Vesicular breath sounds OR distant breath sounds
  • Expiratory wheezing OR inspiratory wheezing with normal OR delayed expiratory phase
  • Wheezing may be present
  • Egophony present/absent
  • Bronchophony present/absent
  • Normal/reduced tactile fremitus

Heart

  • If dynamic outflow obstruction exists, physical examination findings that can be elicited include the pulsus bisferiens and the double apical impulse with each ventricular contraction. These findings, when present, can help differentiate HCM from aortic stenosis.
  • In addition, if the individual has premature ventricular contractions (PVCs), the change in the carotid pulse intensity in the beat after the PVC can help differentiate HCM from aortic stenosis.
  • In individuals with HCM, the pulse pressure will decrease in the beat after the PVC, while in aortic stenosis, the pulse pressure will increase.

Palpation

  • Powerful apical precordial impulse is present which may be shifted laterally.

Auscultation

Heart Sounds
  • S1 is normal.
  • There may be paradoxically split S2 in severe cases
  • S3 gallop or S4 may also be present.
  • S2 is louder in HCM than Aortic Stenosis.
Murmurs
  • The murmur is characteristically a crescendo-decrescendo systolic murmur.
  • Best heard between the apex and left sternal border.
  • It radiates to the suprasternal notch but not to the carotid arteries or neck thus differentiating it from aortic stenosis.
  • The cardiac murmur of HCM will sound similar to the murmur of aortic stenosis. However, this murmur will:
  • increase in intensity with any maneuver that decreases the volume of blood in the left ventricle (such as standing, valsalva maneuver, amyl nitrate, diuretic administration or vasodilator administration).
  • decrease in intensity with any maneuver that increases the volume of blood in the left ventricle (such as Mueller maneuver, squatting or handgrip).
  • Hypertrophic cardiomyopathy(HCM) can be differentiated from aortic stenosis by the fact that the murmur of aortic stenosis does not change substantially with maneuvers.
  • The character of the pulse in Aortic Stenosis is parvus et tardus, while a bisferiens pulse is noted in HCM.
  • Associated murmurs:
  • 10% of the patients with HCM will also present with aortic regurgitation and in that case, a diastolic decrescendo murmur may be present.
  • If mitral regurgitation co exists with HCM then a holosystolic murmur will be beast heard at the caridac apex and left axilla.
Differentiating hypertrophic cardiomyopathy and valvular aortic stenosis
  Aortic stenosis Hypertrophic cardiomyopathy
Echocardiography
Aortic valve calcification Common No
Dilated ascending aorta Common Rare
Ventricular hypertrophy Concentric LVH Asymmetric, often involving the septum
Physical examination
Murmur of AI Common No
Pulse pressure after PVC Increased Decreased
Valsalva maneuver Decreased intensity of murmur Increased intensity of murmur
Carotid pulsation Normal or tardus et parvus Brisk, jerky, or bisferiens pulse (a collapse of the pulse followed by a secondary rise)


Abdomen

  • Abdominal examination of patients with hypertrophic cardiomyopathy is usually normal.

OR

Back

  • Back examination of patients with hypertrophic cardiomyopathy is usually normal.

OR

  • Point tenderness over __ vertebrae (e.g. L3-L4)
  • Sacral edema
  • Costovertebral angle tenderness bilaterally/unilaterally
  • Buffalo hump

Genitourinary

  • Genitourinary examination of patients with hypertrophic cardiomyopathy is usually normal.

OR

  • A pelvic/adnexal mass may be palpated
  • Inflamed mucosa
  • Clear/(color), foul-smelling/odorless penile/vaginal discharge

Neuromuscular

  • Neuromuscular examination of patients with hypertrophic cardiomyopathy is usually normal.

OR

  • Patient is usually oriented to persons, place, and time
  • Altered mental status
  • Glasgow coma scale is ___ / 15
  • Clonus may be present
  • Hyperreflexia / hyporeflexia / areflexia
  • Positive (abnormal) Babinski / plantar reflex unilaterally/bilaterally
  • Muscle rigidity
  • Proximal/distal muscle weakness unilaterally/bilaterally
  • ____ (finding) suggestive of cranial nerve ___ (roman numerical) deficit (e.g. Dilated pupils suggestive of CN III deficit)
  • Unilateral/bilateral upper/lower extremity weakness
  • Unilateral/bilateral sensory loss in the upper/lower extremity
  • Positive straight leg raise test
  • Abnormal gait (describe gait: e.g. ataxic (cerebellar) gait / steppage gait / waddling gait / choeiform gait / Parkinsonian gait / sensory gait)
  • Positive/negative Trendelenburg sign
  • Unilateral/bilateral tremor (describe tremor, e.g. at rest, pill-rolling)
  • Normal finger-to-nose test / Dysmetria
  • Absent/present dysdiadochokinesia (palm tapping test)

Extremities

  • Extremities examination of patients with hypertrophic cardiomyopathy is usually normal.

OR

  • Clubbing
  • Cyanosis
  • Pitting/non-pitting edema of the upper/lower extremities
  • Muscle atrophy
  • Fasciculations in the upper/lower extremity


References

  1. ↑ Maron BJ. Hypertrophic cardiomyopathy. Lancet 1997;350:127–33.
  2. ↑ Maron BJ. Hypertrophic cardiomyopathy. A systematic review. JAMA 2002;287:1308–20.
  3. ↑ Maki S, Ikeda H, Muro A et al. Predictors of sudden cardiac death in hypertrophic cardiomyopathy. Am J Cardiol 1998;82:774–8.
  4. ↑ Maron BJ, Casey SA, Poliac LC, Gohman TE, Almquist AK, Aeppli DM. Clinical course of hypertrophic cardiomyopathy in a regional United States cohort. JAMA 1999;281:650–5.
  5. ↑ Maron BJ, Olivotto I, Bellone P et al. Clinical profile of stroke in 900 patients with hypertrophic cardiomyopathy. J Am Coll Cardiol 2002;39:301–7.
  6. ↑ Maron BJ. Hypertrophic cardiomyopathy. A systematic review. JAMA 2002;287:1308–20.
  7. ↑ Maron BJ, Casey SA, Poliac LC, Gohman TE, Almquist AK, Aeppli DM. Clinical course of hypertrophic cardiomyopathy in a regional United States cohort. JAMA 1999;281:650–5.
  8. ↑ Fay WP, Taliercio CP, Ilstrup DM, Tajik AJ, Gersh BJ. Natural history of hypertrophic cardiomyopathy in the elderly. J Am Coll Cardiol 1990;16:821–6.
  9. ↑ Takagi E, Yamakado T, Nakano T. Prognosis of completely asymptomatic adult patients with hypertrophic cardiomyopathy. J Am Coll Cardiol 1999;33:206–11.

Template:WH Template:WS

Retrieved from "https://www.wikidoc.org/index.php?title=Hypertrophic_cardiomyopathy_physical_examination&oldid=1596042"