Examination Medicine: A Guide to Physician Training

Examination Medicine: A Guide to Physician Training by Nicholas J. Talley, Simon O’connor

Book: Examination Medicine: A Guide to Physician Training by Nicholas J. Talley, Simon O’connor Read Free Book Online
Authors: Nicholas J. Talley, Simon O’connor
Tags: Medical, Internal Medicine, Diagnosis
bat’s wing appearance. These changes are usually superimposed on interstitial oedema. A lamellar pleural effusion (arrow) is seen at the right costophrenic angle where Kerley ‘B’ lines are also evident. The Canberra Hospital X-Ray Library, reproduced with permission. 
    2.  ECG . Look for arrhythmias, signs of ischaemia or recent or old infarction ( Fig 5.6 ), left ventricular hypertrophy and persisting ST elevation (aneurysm). Left bundle branch block is a common ECG finding in these patients ( Fig 5.7 ). The ECG is rarely entirely normal in a patient with heart failure.

FIGURE 5.6  Sinus rhythm. There are Q waves from V1 to V5. This is diagnostic of an extensive old anterior infarct, which is likely to be the cause of this patient’s heart failure.

FIGURE 5.7  Sinus rhythm. Left bundle branch block (LBBB). The QRS complexes may widen further as heart failure progresses. LBBB is a common finding in heart failure but is not diagnostic.
    3.  Electrolytes and creatinine levels . To exclude hypokalaemia (as a cause of arrhythmia), hyponatraemia (which may indicate severe longstanding cardiac failure, a poor prognostic sign) and renal failure.
    4.  B-type natriuretic peptide level (BNP; previously called brain natriuretic peptide) . Although there is doubt about the reference range, a definitely elevated level may help distinguish cardiac from non-cardiac dyspnoea. Since BNP falls when heart failure is treated, trials of monitoring BNP are underway as a means of assessing the adequacy of cardiac treatment.
    5.  Haemoglobin value . To exclude anaemia as a precipitating cause.
    If the diagnosis is not already obvious, consider dilated cardiomyopathy . Investigations for this include those outlined below.

    1.  Echocardiography ( Fig 5.8 ). This will show generalised or segmental wall motion abnormalities and reduced fractional shortening. An estimate of the left ventricular ejection fraction can be made. Segmental hypokinesia suggests that ischaemia is thecause of the cardiac failure. Doppler echocardiography will usually show at least some mitral and tricuspid regurgitation in these patients. The presence of more severe valvular disease suggests a different aetiology for the cardiac failure. Serial echocardiograph measurements of left and right ventricular dimensions can be useful for following the patient’s progress.

FIGURE 5.8  Echocardiography report in a patient with cardiac failure caused by anterior myocardial infarction.

FIGURE 5.9  (a) Achilles tendon xanthoma. (b) Xanthelasma. (c) Palmar xanthoma. (d) Eruptive xanthomas. (a) courtesy A F Lant, J Dequeker, London; (b) M Yanoff, J Duker. Opthamology  . 3rd edn. Fig 12-9-18. Mosby, Elsevier, 2009, with permission; (c) and (d) courtesy R A Marsden, St George’s Hospital, London.
    2.  A gated blood pool scan for the ejection fraction . The right ventricular ejection fraction is normally >45% and the left ventricular ejection fraction is >50%. The scan will also show whether hypokinesis is global or segmental and to what extent the right ventricle is affected.
    3.  Coronary angiography . This is often necessary to exclude coronary artery disease.
    4.  Right ventricular biopsy . This may help determine the aetiology in selected patients.


    1. Remove precipitating causes. Atrial fibrillation and other incessant tachycardias can be a cause of cardiac failure – tachycardia-induced cardiomyopathy. The prognosis is good if normal heart rate can be restored.
    2. Correct underlying causes if possible (e.g. thrombolysis for an acute infarct or coronary artery bypass grafting or angioplasty for ischaemia) (see Table 5.2 ).
    Table 5.2
    Causes of ventricular failure

    3. Control the failure.
    a. Decrease physical activity (e.g. bed rest for the acutely ill patient).
    b. Control fluid retention (e.g. by diuretics, low-salt diet, fluid restriction (1000–1500 mL for severe failure)).
• Patients should be advised to weigh themselves daily. An

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