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Cases | Cardiothoracic | Bell

Caroline Bell: Physical Examination

Vital signs

Temp 97 degrees; pulse 112 and irregular; BP 162/98, height 62 inches, weight 120 pounds.

HEENT

Normal.

Neck

No lymphadenopathy or jugular venous distension; thyroid palpable, minimally enlarged, and somewhat nodular.

Chest

Resonant, breath sounds clear.

Heart

PMI palpable in the 5th ICS, MCL; S1 and S2 irregularly irregular with variable intensity of S1, no gallops or murmurs.

Abdomen

Soft and non-tender; no organomegaly or mass.

Extremities

Normal.

Skin

Normal.

Neurological exam

Reflexes 3 plus at the elbows and knees.

Self-assessment question:

Which of the following rhythms is/are incompatible with Dr. Grey's findings on physical examination?

a. Sinus rhythm with premature atrial beats
b. Atrial flutter with variable conduction
c. Ventricular bigeminy
d. Atrial fibrillation

The correct answer is c, ventricular bigeminy.

In ventricular begiminy each sinus beat is followed by a PVC giving rise to a short interval followed by a long interval. The result is a syncopated rhythm that repeats itself, as in da dum...da dum...da dum... All the rest are consistent with Dr. Grey's finding of an irregularly irregular pulse. The distinction is important since regularly irregular rhythms usually denote premature contractions with fixed coupling. Atrial fibrillation is a common cause of an irregularly irregular rhythm, especially in individuals over age 65.

Next: Test results

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Last modified: Thursday, 01-Aug-2002 16:42:08 EDT. (PL)

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