cardiovascular disorders
Cardiovascular Examination
Abdominal and Extremity Examination
The abdomen and extremities are examined for signs of fluid overload, which may occur with heart failure as well as noncardiac disorders (eg, renal, hepatic, lymphatic). In the abdomen, significant fluid overload manifests as Ascites . Marked ascites causes visible abdominal distention, which is tense and nontender to palpation, with shifting dullness on abdominal percussion and a fluid wave. The liver may be distended and slightly tender, with a hepatojugular reflux present. In the extremities (primarily the legs), fluid overload is manifest as Edema , which is swelling of soft tissues due to increased interstitial fluid. Edema may be visible on inspection, but modest amounts of edema in very obese or muscular people may be difficult to recognize visually. Thus, extremities are palpated for presence and degree of pitting (visible and palpable depressions caused by pressure from the examiner’s fingers, which displaces the interstitial fluid). The area of edema is examined for extent, symmetry (ie, comparing both extremities), warmth, erythema, and tenderness. With significant fluid overload, edema may also be present over the sacrum, genitals, or both. Pitting edema is graded on a scale of 1 to 4, but there is no agreed-upon definition for these grades. Tenderness, erythema, or both, particularly when unilateral, suggests an inflammatory cause (eg, cellulitis or thrombophlebitis). Nonpitting edema is more suggestive of lymphatic or vascular obstruction than fluid overload. 