Physical Diagnosis
Palpitation
Introduction
? Palpitation is an unpleasant awareness of
the heart beating,
? Not necessary associated with organic heart
disease,
Mechanism
? Heart contractility,Augmentation
? Heart rhythm,Regular Irregular
? Heart rate,Normal fast or slow
Etiology
I,Forceful Contraction of Heart
1,Physiological type
— strenuous physical effort
— sudden emotional tension,
— use of coffee,tea,alcohol,tobacco and some
drugs
2,Pathological type
1),Ventricular hypertrophy
— Hypertensive heart disease,
— Rheumatic heart disease,
2),Disorders causing augmentation of cardiac
output — Anemia,High fever,Hyperthyroidism,
Hypoglycemia,Pheochromocytoma,
II,Cardiac arrhythmias,
1.Tachycardia,tachyarrhythmia
— paroxysmal tacycardia,
— atrial flutter,
— atrial fibrillation,
2,Bradycardia,bradyarrhythmia
— high degree AV block,
— sick sinus syndrome and so on,
3,Premature beat of heart
III,Cardiac neurosis
Disturbance of autonomic nervous system,and no organic
lesion in heart,Chief symptoms are palpitation and those of
anxiety state,
— Menopausal syndrome,
— Syndrome of increased ?-adrenergic receptor responsiveness
Approach to Patients with Palpitation
History
1,Use of coffee,tabacco,alcohol,drugs etc;
2,Onset and duration of palpitation;
3,Anxiety state;
4,Accompanied symptoms
+ Precordial pain,Organic heart disease
or Cardiac neurosis
+ Anemia or fever,may be the cause of palpitation
+ Weight loss,sweating, Hyperthyroidism
Physical examination
— Heart rate,
— Rhythm,
— Murmurs
Laboratory examination
— Electrocardiography (ECG),
— Echocardiography
— Ambulatory ECG (Holter Monitoring)
Physical Diagnosis
Cyanosis
Definition of cyanosis
A bluish color of skin and mucous
membranes,in lips,nail beds and malar
eminences,caused by increased amount
of reduced hemoglobin(Hb) or abnormal
Hb derivatives in blood,
15
5
20
5 5 5
0
2
4
6
8
10
12
14
16
18
20
Total Hb
R-Hb
Normal Polycythemia Anemia
g/dl
Mechanisms of Cyanosis
Caused by absolute increase of amount of reduced
Hb in blood,usually > 5g/dl (capillary)
The higher the hemoglobin concentration,
The greater tendency toward cyanosis,
Clinical Classification & Etiology
? True Cyanosis (increased amount of reduced Hb)
— Central Type
— Peripheral Type
— Mixed Type
? Cyanosis due to abnormal Hb derivatives
— Methemoglobinemia
— Sulfhemoglobinemia
Impaired pulmonary
function
1,Airway obstruction
2,Pulmonary diseases
3,Pleural diseases
Right-to-left shunting
of blood
Tetralogy of Fallot
Central Cyanosis
Peripheral Cyanosis
Caused by increased oxygen consumption in
peripheral tissue,
Vasoconstriction
Low cardiac output
Exposure to cold air or water
Slowing of blood flow
Right heart failure
Mixed Cyanosis
(Central + Peripheral)
Cardiogenic
Shock
Pulmonary
Edema
Cyanosis due to abnormal Hb derivatives
? Methemoglobinemia
— Hereditary,very rare
— Acquired,>3g/dl in blood
- intake or exposure to some drugs or
chemicals,such as sulfa drugs,nitrite
salt., enterogenic cyanosis,
? Sulfhemoglobinemia
— Caused by some drugs or chemicals,
— Sulfhemoglobin > 0.5g/dl in blood
Approach to Patients with Cyanosis
? Differentiation of central as opposed to peripheral
Cyanosis Skin temp,Massage or warming
Central Warm No change
Peripheral Cool Cyanosis fade
? Cyanosis + Dyspnea
Disorders of respiratory or cardiovascular system
? Cyanosis with mild or no dyspnea
Methemoglobinemia
Sulfhemoglobinemia,Spectroscopy helpful
? Cyanosis + clubbing
Severe,long duration
? Determination of arterial oxygen saturation
Physical Diagnosis
Bleeding in Skin & Mucous Membranes
Introduction of BSMM
BSMM is caused by the abnormalities of hemostasis and
/or coagulation mechanisms,and characterized by local or
extensive mucocutaneous hemorrhage spontaneously or
following slight trauma
Type and Clinical Manifestation
? Petechia,pinpoint hemorrhage
? Purpura,> 5mm in diameter
? Ecchymosis,common bruise,>10mm
? Hematoma,local elevation and fluctuation
bleeding in skin,mucous membrane,joint cavity
and viscera,
Petechiae
Purpura
Ecchymosis
(Bruise)
Hematoma
Etiology & Pathogenesis
? Defects on the capillary wall
? Abnormalities of blood platelets
— Quantitative platelets defects
— Qualitative platelets defects
? Disturbance of coagulation
— Deficiency of coagulation factors
— Increase of anti-coagulation substances
Defects on Capillary Wall
Fragile,or failure to constriction after
damage
? Allergic purpura,
? Hereditary telangioectasia
? Non- thrombocytopenic purpura
— Severe infection
— Vitamin C deficiency
— Uremia
Abnormalities of Blood Platelets
? Quantitative platelets defects
— BPC is low,as thrombocytopenia with
various causes
? Qualitative platelets defects
— Platelets dysfunction,as thrombasthenia
Disturbance of Coagulation
I,Formation of activated thrombokinase
II,Prothrombin Thrombin
III,Fibrinogen Fibrin
? Deficiency of coagulation factors
— Congenital, Hemophilia
— Acquired, Severe liver disease
? Increase of anti-coagulation substances
— During anti-coagulation therapy
Approach to Patients with BSMM
? History
— Bleeding whether spontaneously or after trauma
— Past history of bleeding tendency
— Liver disease
? Physical Examination
— Jaundice,
— Size of liver and spleen,
— Joints
? Laboratory Tests
— Blood routine,blood platelet count,bleeding time,
— Coagulation time,bone marrow study
— Coagulation factors determination