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Valvular Heart Disease and Heart Failure
Published in Andreas P. Kalogeropoulos, Hal A. Skopicki, Javed Butler, Heart Failure, 2023
Kali Polytarchou, Constantina Aggeli
First heart sound (S1) may be reduced or even silent in cases of LV dysfunction or premature mitral valve closure. Second heart sound may be paradoxically split due to prolonged ejection time. Fourth heart sound is a usual clinical finding in patients with AR, while S3 is heard when LVEF is reduced. A diastolic decrescendo blowing murmur following the aortic component of S2 and heard at the left third or fourth intercostal space parasternal, with radiation to the apex, is typical for AR. The murmur increases in duration when AR becomes more severe. However, at the end stage of the disease the murmur decreases because of increase in LV end-diastolic pressure. The Austin-Flint murmur is a mid-to-end diastolic low-pitched rumble that results from the direction of the regurgitant jet toward the anterior mitral leaflet. A mid-systolic ejection murmur may be heard at the base of the heart with radiation to the neck, due to an increased SV.10
Cardiovascular Disease
Published in John S. Axford, Chris A. O'Callaghan, Medicine for Finals and Beyond, 2023
A third heart sound (S3) occurs after the second heart sound and is produced by high left atrial and LV filling pressures including volume overload and/or pressure overloaded ventricle. A left-sided S3 indicates LV failure, but it can be a normal finding in children, young adults and pregnant women.
Coronary Artery Disease
Published in Jahangir Moini, Matthew Adams, Anthony LoGalbo, Complications of Diabetes Mellitus, 2022
Jahangir Moini, Matthew Adams, Anthony LoGalbo
Female patients often have atypical chest discomfort, and older patients may have more dyspnea than ischemic-related chest pain. If there is severe ischemia, the pain may be extreme and the patient becomes apprehensive and restless. Nausea and vomiting are more common with inferior MI. For some patients, the primary symptoms are dyspnea and weakness (from LV failure), pulmonary edema, significant arrhythmia, and shock. The patient’s skin may be moist, pale, and cool, and peripheral or central cyanosis may be seen. Blood pressure can be varied, but many patients first experience early hypertension when the pain manifests. The pulse is often described as thready. Heart sounds are often slightly distant, and a fourth heart sound is nearly always present. In some cases, there is a soft systolic blowing apical murmur, which indicates dysfunction of the papillary muscle of the heart. Upon first examination, a preexisting heart condition or another type of condition may be suggested by a friction rub or more significant murmurs. If a friction rub is found within several hours after MI symptoms begin, acute pericarditis is more likely than MI. Even so, friction rubs described usually as evanescent. In about 15% of patients, the chest wall is tender when it is palpated. Signs of RV infarction include distended jugular veins, often with the Kussmaul sign, elevated RV filling pressure, lung fields that are clear, and hypotension.
Management of congenitally corrected transposition from fetal diagnosis to adulthood
Published in Expert Review of Cardiovascular Therapy, 2023
Patients diagnosed early in the adulthood usually have isolated ccTGA or well-balanced complex anomaly (ccTGA with VSD and PS with mild cyanosis). They might be identified with abnormal findings on the physical examination, such as heart murmur (in the presence of tricuspid regurgitation or other concomitant lesions), loud second heart sound (due to location of the aortic valve close to the chest wall) or cardiac arrhythmia. Abnormalities found on cardiovascular testing (electrocardiogram, chest radiograph, echocardiography, or advanced cardiac imaging tests) performed for other indications (Figure 1) can also lead to the recognition of ccTGA. In some cases, the correct diagnosis is not established despite a prior cardiology consultation with cardiac imaging [17]. Occasionally, ccTGA is diagnosed in athletes [18] or adults with very advanced age [19].
Pathophysiology and clinical evaluation of the patient with unexplained persistent dyspnea
Published in Expert Review of Respiratory Medicine, 2022
Andi Hudler, Fernando Holguin, Meghan Althoff, Anne Fuhlbrigge, Sunita Sharma
Physical examination is not sensitive and therefore the absence of physical findings cannot rule out conditions causing dyspnea but can be very useful for making specific diagnoses when abnormal exam findings are present. The clinical examination should look for evidence of lung sounds that indicate airway obstruction or parenchymal disease. Cardiac exam should evaluate for the presence of abnormal heart sounds with particular focus on identifying signs of heart failure, such as SIII, distended jugular veins, and peripheral edema. In addition to a careful cardiopulmonary exam, it is important to assess neuromuscular function. Point of care ultrasound can provide additional value in detecting abnormal lung parenchyma, pleural effusions, reduced cardiac function, or poor diaphragmatic excursion if any of these abnormalities are present [7,26].
Use of Anakinra in steroid dependent recurrent pericarditis: a case report and review of literature
Published in Journal of Community Hospital Internal Medicine Perspectives, 2021
Vinay Kumar Thallapally, Sonia Gupta, Sai Giridhar Gundepalli, Joseph Nahas
A 44-year-old male with a past medical history significant for gout initially presented to the primary care clinic with complaints of persistent shortness of breath with mild chest tightness after recovering from a recent upper respiratory tract infection. Physical examination revealed lungs clear to auscultation bilaterally, normal s1, s2 heart sounds with no abnormal rubs, murmurs or gallops. ECG showed normal sinus rhythm with no ST or Q wave changes. CT scan of the chest followed by an echocardiogram was done which showed a small posterior pericardial effusion. He was diagnosed with idiopathic pericarditis presenting as pericardial effusion and was started on naproxen 500 mg twice daily and colchicine 0.6 mg daily. However, he continued to have progressively worsening shortness of breath over the next two weeks and presented to the emergency department with the same. He received high-dose methylprednisolone 125 mg in the Emergency Department with rapid improvement in the symptoms. Laboratory workup revealed elevated ESR at 74 mm/hour (normal range 0–25 mm/hour) and CRP at 181 mg//L (normal range ≤9.00 mg/L). Other workup includes normal ferritin, α1-antitrypsin, IgG subclasses I, II, III, and IV. Angiotensin-converting enzyme, SPEP, antinuclear antibody, rheumatoid factor, hepatitis panel, Lyme serology, and tuberculosis screen were unremarkable. A repeat echocardiogram showed a moderate increase in the size of pericardial effusion with some evidence of thickened pericardium.