Cardiovascular System



Cardiovascular System





2-A. Chest Pain

Skin and subcutaneous lesions [including adiposis dolorosa, thrombophlebitis of thoracoepigastric vein (Mondor disease)]

Breast lesions



  • Fibroadenosis


  • Chronic cystic mastitis


  • Acute breast abscess or mastitis


  • Carcinoma


  • Trauma and hematoma

Musculoskeletal disorders



  • Bruised or fractured rib


  • Periostitis


  • Periosteal hematoma


  • Costochondritis (Tietze syndrome)


  • Slipping costal cartilage


  • Intercostal muscle “stitch” or cramp


  • Intercostal myositis


  • Pectoral or other muscular strain


  • Shoulder girdle disorders (e.g., subacromial bursitis)


  • Cervical disc herniation


  • Dorsal spine osteoarthritis


  • Thoracic outlet syndrome


  • Fibromyalgia


Neuralgia



  • Herpes zoster


  • Tabes dorsalis


  • Neurofibroma


  • Neoplasm

Pericardial disease



  • Pericarditis (see 2-H)


  • Neoplasm


  • Congenital absence of left pericardium

Mediastinal disease



  • Mediastinal emphysema


  • Neoplasm


  • Mediastinitis

Cardiovascular disease



  • Coronary heart diseases



    • Acute coronary syndrome


    • Acute myocardial infarction


    • Angina pectoris


  • Aortic valvular disease


  • Hypertrophic cardiomyopathy


  • Cardiomyopathy (see 2-G)


  • Mitral valve prolapse


  • Acute aortic dissection


  • Thoracic aortic aneurysm


  • Myocarditis


  • Cardiac rupture


  • Ruptured sinus of Valsalva aneurysm

Pleural or pulmonary disease



  • Pleuritis of any etiology (e.g., pneumothorax; see 11-K)


  • Tracheobronchitis


  • Pneumonia


  • Pulmonary hypertension (see 11-O)


  • Pulmonary thromboembolism


  • Pulmonary artery rupture


  • Neoplasm



    • Bronchogenic carcinoma


    • Metastatic tumor


    • Mesothelioma


    • Other parenchymal lesions

Gastrointestinal disease



  • Esophageal lesions



    • Esophagitis


    • Esophageal spasm



    • Mallory-Weiss syndrome


    • Esophageal rupture


    • Foreign body


    • Carcinoma


    • Zenker diverticulum


    • Plummer-Vinson syndrome


    • Hyperalgesia

Peptic ulcer disease (with or without perforation)

Gastric distention

Gastritis



  • Biliary disease


  • Acute cholecystitis


  • Biliary colic

Distention of the liver



  • Pancreatitis


  • Subphrenic abscess


  • Splenic infarct


  • Splenic flexure syndrome

Thyroiditis

Psychogenic causes



  • Hyperventilation


  • Anxiety-panic disorders


  • Depression


  • Somatization disorders



References

1. Braunwald E. Examination of the patient. See Bibliography, 5.

2. Simel DL. Approach to the patient: history and physical examination. See Bibliography, 2.


2-B. Edema


Localized

Acute venous thrombosis

Chronic venous insufficiency

Baker cyst

Tumor invasion or compression of veins and/or lymphatics (e.g., superior vena cava syndrome)

Surgical or radiation damage

Inflammatory disease (e.g., cellulitis)

Allergic process (e.g., angioneurotic edema)

Physical or chemical trauma


Stings and bites

Immobilized or paralyzed limb

Congenital lymphedema

Filariasis


Generalized

Biventricular congestive heart failure (see 2-F)

Tricuspid stenosis and other valvular lesions

Right atrial myxoma

Cor pulmonale (e.g., obstructive sleep apnea) (see 11-M)

Pericardial disease (see 2-H, 2-I)



  • Chronic constrictive pericarditis


  • Pericardial effusion

Hypoalbuminemic states



  • Hepatic cirrhosis


  • Nephrotic syndrome


  • Protein-losing enteropathy


  • Malnutrition


  • Severe chronic disease

Acute and chronic renal failure with volume overload

Myxedema

Pregnancy

Iatrogenic salt overload



  • Enteral feeding


  • Intravenous fluid administration


  • Drugs



    • Sirolimus


    • Tamoxifen, letrozole (Femara), and similar drugs


    • Thiazolidiones (e.g., pioglitazone)


    • Estrogens


    • Corticosteroids


    • Minoxidil


    • Calcium channel blockers (e.g., nifedipine)


    • Nonsteroidal anti-inflammatory drugs

Trichinosis

Idiopathic and/or cyclic edema

Hereditary angioneurotic edema



References

1. Braunwald E. Examination of the patient. See Bibliography, 5.

2. Friedman HH. Edema, p. 1. See Bibliography, 1.



2-C. Palpitation


Palpitation without Arrhythmia

Noncardiac disorders



  • Anxiety


  • Exercise


  • Anemia


  • Fever


  • Volume depletion


  • Postural hypotension


  • Thyrotoxicosis


  • Menopausal syndrome


  • Hypoglycemia


  • Pheochromocytoma


  • Aortic aneurysm


  • Migraine syndrome


  • Arteriovenous fistula


  • Diaphragmatic flutter


  • Drugs



    • Sympathomimetic agents


    • Monoamine oxidase (MAO) inhibitors


    • Digitalis


    • Nitrates


    • Theophylline


    • Atropine


    • Coffee, tea


    • Tobacco


    • Alcohol


    • Thyroid preparations

Cardiac disorders



  • Aortic regurgitation


  • Aortic stenosis


  • Patent ductus arteriosus


  • Ventricular septal defect


  • Atrial septal defect


  • Marked cardiomegaly


  • Acute left ventricular failure


  • Hyperkinetic heart syndrome


  • Tricuspid insufficiency


  • Pericarditis


  • Prosthetic heart valve


  • Electronic pacemaker



Palpitation with Arrhythmia (see 2-N)

Extrasystoles

Bradyarrhythmias

Tachyarrhythmias



References

1. Braunwald E. Examination of the patient. See Bibliography, 5.

2. Shander D. Palpitation and disorders of the heartbeat, p. 111. See Bibliography, 1.


2-D. Hypertension


Systolic and Diastolic

Pseudohypertension (e.g., wrong-sized cuff)

Primary (essential)

Renal causes (see 5-J, 5-L)



  • Parenchymal


  • Vascular


  • Renoprival (after bilateral nephrectomy)


  • Renin-producing tumor


  • Liddle syndrome

Endocrine causes



  • Obesity


  • Acromegaly


  • Hypothyroidism


  • Hypercalcemia (e.g., hyperparathyroidism)


  • Hypoglycemia


  • Adrenal causes



    • Glucocorticoid-remediable aldosteronism (GRA; and other inherited syndromes)


    • Congenital adrenal hyperplasia


    • Cushing syndrome


    • Primary aldosteronism


    • Pheochromocytoma


    • Licorice

Extra-adrenal chromaffin tumors (e.g., carcinoid tumor)

Exogenous



  • Oral contraceptives


  • Estrogens


  • Glucocorticoids


  • Mineralocorticoids (e.g., licorice)


  • Sympathomimetic agents


  • Tyramine-containing foods and MAO inhibitors


Coarctation of aorta

Pregnancy-induced

Neurogenic causes



  • Increased intracranial pressure (e.g., brain neoplasm)


  • Intracranial hemorrhage


  • Postoperative state


  • Stress


  • Acute porphyria


  • Lead poisoning


  • Quadriplegia (acute)


  • Diencephalic syndrome


  • Familial dysautonomia


  • Bulbar polio

Increased intravascular volume



  • Polycythemia vera


  • Iatrogenic causes (e.g., perioperative, postresuscitative)

Burns

Sleep apnea

Psychogenic causes

Drug withdrawal

Other drugs



  • Cocaine


  • Cyclosporine


  • Tacrolimus


  • Erythropoietin

Vasculitis



  • Sickle cell crisis


Systolic

Aortic rigidity (e.g., atherosclerosis)

Increased cardiac output or stroke volume, or both



  • Aortic valvular regurgitation


  • Fever


  • Arteriovenous fistula, patent ductus arteriosus


  • Paget disease


  • Beriberi


  • Thyrotoxicosis (endogenous or exogenous)


  • Anemia


  • Hyperkinetic circulation



    • Anxiety


    • Complete heart block




References

1. Friedman HH. Arterial hypertension, p. 53. See Bibliography, 1.

2. Kaplan NM. Systemic hypertension. See Bibliography, 5.

3. Victor R. Arterial hypertension. See Bibliography, 2.


2-E. Heart Murmurs (see also 2-M)


Systolic

Early systolic



  • Physiologic (innocent)


  • Small ventricular septal defect


  • Large ventricular septal defect with pulmonary hypertension


  • Severe acute mitral or tricuspid regurgitation


  • Tricuspid regurgitation without pulmonary hypertension

Midsystolic



  • Physiologic (innocent)



    • Vibratory murmur


    • Hyperkinetic states


    • Pulmonary ejection murmur


    • Aortic ejection murmur of old age


  • Obstruction to left ventricular outflow



    • Valvular aortic stenosis


    • Supravalvular aortic stenosis


    • Hypertrophic cardiomyopathy


    • Aortic valve prosthesis

Aortic dilatation



  • Murmurs of mitral regurgitation (occasionally)


  • Aortic flow murmur in aortic regurgitation


  • Coarctation of aorta


  • Supraclavicular arterial bruit


  • Obstruction to right ventricular outflow



    • Supravalvular pulmonary arterial stenosis


    • Pulmonic valvular stenosis


    • Subpulmonic (infundibular) stenosis


  • Flow murmur of atrial septal defect


  • Idiopathic dilatation of pulmonary artery

Pulmonary hypertension of any cause (occasionally)

Late systolic



  • Mitral valve prolapse


  • Tricuspid valve prolapse

Holosystolic



  • Mitral regurgitation


  • Tricuspid regurgitation secondary to pulmonary hypertension



  • Ventricular septal defect


  • Patent ductus arteriosus or aorticopulmonary window with pulmonary hypertension


Diastolic

Early diastolic



  • Aortic regurgitation


  • Pulmonic regurgitation associated with pulmonary hypertension, congenital or valvular disease

Middiastolic



  • Mitral stenosis


  • Mitral valve prosthesis


  • Tricuspid stenosis


  • Atrial myxoma


  • Left atrial ball-valve thrombus


  • Austin Flint murmur


  • Increased diastolic atrioventricular flow



    • Hyperkinetic states


    • Mitral and tricuspid regurgitation


    • Left-to-right shunt (e.g., ventricular septal defect)


    • Acute rheumatic valvulitis (Carey-Coombs murmur)


    • Complete heart block


    • Anomalous pulmonary venous return


  • Coronary artery stenosis

Presystolic or late diastolic



  • Mitral stenosis


  • Tricuspid stenosis


  • Atrial myxoma


  • Left-to-right shunt


  • Complete heart block


  • Severe pulmonic stenosis


  • Severe aortic insufficiency (Austin Flint)


Continuous

Pseudomurmur (e.g., pericardial friction rub)

Coronary arteriovenous fistula

Patent ductus arteriosus

Surgically created aorticopulmonary fistula

Pulmonary embolism

Ruptured sinus of Valsalva aneurysm

Coarctation of aorta

Bronchial or intercostal artery collateral circulation

Anomalous left coronary artery


Intercostal arteriovenous fistula

Cervical venous hum

Mammary souffle

Aortic arch syndrome

Pulmonary artery branch stenosis or partial occlusion



References

1. Braunwald E. Approach to the patient with cardiovascular disease. See Bibliography, 5.

2. Braunwald E, Perloff JK. Physical examination of the heart and circulations. See Bibliography, 3.

3. Friedman HH. Heart murmurs, p. 70. See Bibliography, 1.


2-F. Congestive Heart Failure


Left Heart Failure

Hypertensive heart disease

Coronary artery disease

Left ventricular diastolic dysfunction

Acute myocardial infarction

Aortic and mitral valvular disease

Cardiomyopathy (see 2-G)

Pericardial disease (see 2-H, 2-I)

Arrhythmias

Congenital heart disease

Endocarditis

Cardiotoxic drugs (e.g., Adriamycin, Herceptin, cocaine, alcohol)

Myocarditis

Acute rheumatic fever

Traumatic heart disease

Thyrotoxicosis

Thiamine deficiency

Anemia

Arteriovenous fistula (e.g., Paget disease)

Neoplastic heart disease

Toxic shock syndrome

Pulmonary thromboembolism

Postcardioversion

Pregnancy

Left atrial thrombus

Salt-retaining drugs (e.g., NSAIDs)



Right Heart Failure1

Associated with pulmonary hypertension (see 11-O)

Pulmonary venous disease

Vascular disease

Without pulmonary hypertension



  • Pulmonic stenosis


  • Tricuspid stenosis (nonrheumatic)


  • Tricuspid regurgitation not associated with pulmonary hypertension


  • Decreased right ventricular compliance


  • Ebstein anomaly


  • Right atrial myxoma



Reference

1. Givertz MM, Colucci WS, Braunwald E. Clinical aspects of heart failure; pulmonary edema, high-output failure. See Bibliography, 5.

2. Massie BM. Heart failure: pathophysiology and diagnosis. See Bibliography, 2.


2-G. Cardiomyopathy1


Dilated

Congenital



  • Familial


  • Duchenne and Becker muscular dystrophy


  • Facioscapulohumeral muscular dystrophy


  • Limb-girdle muscular dystrophy


  • Myotonic dystrophy


  • Refsum disease


  • Friedreich ataxia


  • Fabry disease


  • Hunter disease


  • Gaucher disease


  • Glycogen storage disease


  • Hypertrophic pseudoxanthoma elasticum

Acquired



  • Idiopathic


  • Inflammatory



    • Infective myocarditis (e.g., Chagas disease, coxsackie virus)


    • Acquired immunodeficiency syndrome (AIDS)



    • Noninfective



      • Collagen diseases


      • Giant cell myocarditis


      • Kawasaki disease

Metabolic



  • Hypoxia


  • Nutritional



    • Fatty infiltration


    • Thiamine deficiency


    • Kwashiorkor


    • Pellagra


    • Scurvy


    • Hypervitaminosis D


    • Obesity


    • Selenium deficiency


    • Carnitine deficiency


  • Endocrine



    • Acromegaly


    • Thyrotoxicosis


    • Myxedema


    • Uremia


    • Cushing disease


    • Pheochromocytoma


    • Diabetes


    • Hypophosphatemia


    • Hypocalcemia


    • Gout


    • Porphyria


    • Oxalosis


    • Electrolyte imbalance

Toxins, drugs



  • Alcohol


  • Disopyramide


  • Daunorubicin


  • Doxorubicin (Adriamycin)


  • Cyclophosphamide


  • Cocaine


  • Bleomycin


  • 5-Fluorouracil


  • Phosphate (poisoning)


  • Phenothiazines and antidepressants


  • Lithium


  • Carbon monoxide



  • Emetine


  • Chloroquine


  • Acetaminophen, paracetamol


  • Lead


  • Arsenic


  • Hydrocarbons


  • Antimony


  • Cobalt


  • Snake or insect bites

Infiltrative

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Jun 19, 2016 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Cardiovascular System

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