Diagnosis
Table 3. History and Physical Examination in HF (continued)
History
Comments
History of discontinuation of
medications for HF
Determine whether lack of GDMT in patients
with HFrEF reflects intolerance, an adverse
event, or perceived contraindication to use.
Withdrawal of these medications has been
associated with adverse prognosis.
Medications that may exacerbate HF
Removal of such medications may represent a
therapeutic opportunity.
Diet
Awareness and restriction of sodium and fluid
intake should be assessed.
Adherence to medical regimen
Access to medications; family support; access to
follow-up; cultural sensitivity.
Physical Examination
Comments
BMI and evidence of weight loss
Obesity may be a contributing cause of HF;
cachexia may correspond with poor prognosis.
Blood pressure (supine and upright)
Assess for hypertension or hypotension. Width
of pulse pressure may reflect adequacy of cardiac
output. Response of blood pressure to Valsalva
maneuver may reflect LV filling pressures.
Pulse
Manual palpation will reveal strength and
regularity of pulse rate.
Examination for orthostatic changes
in blood pressure and heart rate
Consistent with volume depletion or excess
vasodilation from medications.
Jugular venous pressure at rest and
following abdominal compression
(http://wn.com/Jugular_Venous_
Distension_Example)
Most useful finding on physical examination to
identify congestion.
Presence of extra heart sounds and
murmurs
S3 is associated with adverse prognosis in HFrEF.
Murmurs may be suggestive of valvular heart
disease.
Size and location of point of maximal Enlarged and displaced point of maximal
impulse
impulse suggests ventricular enlargement.
Presence of RV heave
Suggests significant RV dysfunction and/or
pulmonary hypertension.
Pulmonary status: respiratory rate,
rales, pleural effusion
In advanced chronic HF, rales are often absent
despite major pulmonary congestion.
Hepatomegaly and/or ascites
Usually markers of volume overload.
Peripheral edema
Many patients, particularly those who are young,
may not be edematous despite intravascular
volume overload. In obese patients and elderly
patients, edema may reflect peripheral rather
than cardiac causes.
Temperature of lower extremities
Cool lower extremities may reflect inadequate
cardiac output.
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