Hypertrophic cardiomyopathy physical examination: Difference between revisions

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===Skin===
===Skin===
* Skin examination of patients with hypertrophic cardiomyopathy is usually normal.
* Skin examination of patients with hypertrophic cardiomyopathy is usually normal.
* they develop sever heart failure
*[[Cyanosis]]
*[[Jaundice]]
* [[Pallor]]
* Bruises
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UploadedImage-01.jpg | Description {{dermref}}
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===HEENT===
===HEENT===
* HEENT examination of patients with hypertrophic cardiomyopathy is usually normal.
* 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===
===Neck===
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===Lungs===
===Lungs===
* Pulmonary examination of patients with hypertrophic cardiomyopathy is usually normal.
* 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===
===Heart===
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===Abdomen===
===Abdomen===
* Abdominal examination of patients with hypertrophic cardiomyopathy is usually normal.
* Abdominal examination of patients with hypertrophic cardiomyopathy is usually normal.
OR
*[[Abdominal distension]]
*[[Abdominal tenderness]] in the right/left upper/lower abdominal quadrant
*[[Rebound tenderness]] (positive Blumberg sign)
*A palpable abdominal mass in the right/left upper/lower abdominal quadrant
*Guarding may be present
*[[Hepatomegaly]] / [[splenomegaly]] / [[hepatosplenomegaly]]
*Additional findings, such as obturator test, psoas test, McBurney point test, Murphy test


===Back===
===Back===
* Back examination of patients with hypertrophic cardiomyopathy is usually normal.
* 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===
* Genitourinary examination of patients with hypertrophic cardiomyopathy is usually normal.
* 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===
* Neuromuscular examination of patients with hypertrophic cardiomyopathy is usually normal.
* 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===
* Extremities examination of patients with hypertrophic cardiomyopathy is usually normal.
* Extremities examination of patients with hypertrophic cardiomyopathy is usually normal.
OR
 
*[[Clubbing]]  
* If they develop [[Congestive heart failure|heart failure]] the followings might be observed:
*[[Cyanosis]]  
 
*[[Clubbing]]
*[[Cyanosis]]
*Pitting/non-pitting [[edema]] of the upper/lower extremities
*Pitting/non-pitting [[edema]] of the upper/lower extremities
*Muscle atrophy
 
*Fasciculations in the upper/lower extremity




Revision as of 00:52, 22 January 2020

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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 normal.

Vital Signs

  • Tachycardia with regular pulse or (ir)regularly irregular pulse
  • Patients with hypertrophic cardiomyopathy are prone to arrhythmia

Skin

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

HEENT

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

Neck

Lungs

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

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.

Back

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

Genitourinary

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

Neuromuscular

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

Extremities

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


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.

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