MU PT 7780 – Differential Diagnosis
Teresa Briedwell PT, DPT
Cardiovascular System
Objectives:
1. The student will recognize and screen for signs and symptoms associated with cardiovascular disease.
2. The student will recognize situations requiring immediate medical attention and those that warrant
referral relative to the cardiovascular system.
3. The student can discuss the prevalence of cardiovascular disease and the relevance of that to the practice
of physical therapy.
4. The student will explain the rule of the three P’s related to likelihood of myocardial infarction.
5. The student will identify appropriate screening tools relative to the cardiovascular system.
6. The student will recognize normal and abnormal vital signs and utilize such information to screen and
monitor patients.
7. The student will utilize the Wells’ Clinical Decision Rule to determine the likelihood of a DVT.
Heart Disease –
• One of leading causes of death in industrialized countries
• CVD ~1 million deaths/year in United States
• >1 in 4 Americans has some form CVD
• ~ half of deaths from heart disease are sudden and unexpected
• 63% of women who died unexpectedly from heart disease had no prior symptoms
• Sudden death is first symptoms for half of all men who have heart attack
• Likelihood of heart attack in morning is 40% higher
• Presence of silent MI increases with age
What does this mean to us?
 This means many of your patients will have heart disease and could experience sudden distress, have
silent disease or subtle symptoms.
 This means as therapists we need to be aware and screening for these possibilities with every patient!
 Need to know CPR and how to use a defibrillator!
Signs and Symptoms of Heart Disease:
• Chest pain
• Neck and/or arm pain
• Palpitations
• Dyspnea (shortness of breath)
• Syncope (fainting)
• Cough
• Diaphoresis
• Cyanosis
• Pain with sweats
Signs and Symptoms of Vascular Disease:
• Edema
• Claudication (leg pain)
• Cold hands and feet
• Open wounds
• Skin discoloration
Cardiovascular disease can affect other systems:
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General: weakness, fatigue, weight change, poor exercise tolerance, peripheral edema
Integumentary: pressure ulcers, loss of body hair, cyanosis (lips and nail beds)
Central Nervous System: headaches, impaired vision, dizziness or syncope
Pulmonary: labored breathing, dyspnea, productive cough
Genitourinary: urinary frequency, nocturia, concentrated urine, decreased urine output
Musculoskeletal: chest, shoulder, back, neck jaw or arm pain, myalgias, muscular fatigue, muscle
atrophy, edema, claudication
Gastrointestinal: nausea, vomiting, ascites
Chest Pain
• May be cardiac or non-cardiac in origin
• Can radiate to neck, jaw, upper trapezius, upper back, shoulder or arms (most commonly left arm)
• Radiating pain follows ulnar nerve distribution
• Cardiac-related chest pain may be related to
• Angina
• MI
• Pericarditis
• Endocarditis
• Mitral valve prolapse
• Dissecting aortic aneurysm
• Often associated with other signs and symptoms – nausea, vomiting, diaphoresis, dyspnea,
fatigue, pallor,
or syncope
• Cervical disk disease and arthritic changes can mimic atypical chest pain of angina pectoris
(location and description of complaints vary with the underlying pathology)
Palpitations:
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Presence of an irregular heartbeat
Referred to as arrhythmias or dysrhythmias
May be considered physiologic (normal) if less than six beats per minute
Related to benign conditions such as mitral valve prolapse, ‘athlete’s heart”, caffeine, anxiety or
exercise
Related to severe conditions such as coronary artery disease, cardiomyopathy, complete heart
block, ventricular aneurysm, atrioventricular valve disease, mitral or aortic stenosis
Describes as racing, jump, bump, pound, flop, or flutter sensation of heart, sense of skipping
beats
Associated signs can include lightheadedness or syncope
Palpitations lasting for hours or occurring in conjunction with pain, SOB, fainting, or severe
lightheadedness or in individuals with family history of sudden death require medical referral
Patients can describe ‘palpitations’ related to overactive thyroid, caffeine use, medication side
effects or use of illegal drugs (cocaine)
Palpitations as a recurring symptom requires medical referral
Dyspnea: breathlessness or shortness of breath
• Can be cardiac or pulmonary in origin
• Can be related to activity, exertion or body position
• Orthopnea – difficulty breathing when recumbent
• Platypnea – difficulty breathing when sitting upright and ease of breathing when
recumbent
• Severity of dyspnea is related to extent of disease
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Dyspnea on exertion (DOE) – often result of left ventricle dysfunction, failure to clear all blood
from lungs resulting in pulmonary congestion and SOB
Extreme dyspnea includes Paroxysmal nocturnal dyspnea (PND) and orthopnea (breathlessness
relieved by sitting upright with pillows to support the trunk and head)
PND and sudden, unexplained episodes of SOB often accompany congestive heart failure upright position during day, fluid shunted away from lungs, increased perfusion; recumbent
position at night, increase fluid returned to lungs creating dyspnea
Dyspnea relieved by specific breathing (pursed-lip breathing) or by specific body position
(leaning forward on arms) generally related to pulmonary disease rather than cardiac
Patients with known cardiac involvement who develop progressively worse dyspnea needs
referral to physician
Patients who cannot climb a single flight of stairs without feeling moderately or severely winded
should have referral to physician
Patients who are awakened at night or experience shortness of breath when lying down need
referral to physician
Cardiac syncope (fainting):
• Sudden loss of consciousness accompanied by an inability to maintain postural tone
• Can be related to reduced oxygen delivery to brain
• Cardiac causes include – arrhythmias, orthostatic hypotension, poor ventricular function,
coronary artery disease, vertebral artery insufficiency
• Non-cardiac causes – anxiety, metabolic, emotional stress can cause hyperventilation and
subsequent lightheadedness (vasovagal syncope)
• Related to side effects of medications (vasodilators)
• Syncope without warning period of lightheadedness, dizziness, or nausea may be heart valve or
arrhythmia
• increased incidence with age, especially marked after age 70
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Medical referral recommended for unexplained syncope, especially in presence of heart or
circulatory problems or if risk factors for heart attack or stroke are present
Fatigue:
• Can be related to cardiac dysfunction, provoked by minimal exertion, possible causes include coronary
artery disease, aortic valve dysfunction, cardiomyopathy, myocarditis
• Fatigue of cardiac nature often accompanied by associated symptoms – dyspnea, chest pain, palpitations,
headache
• Beta-blockers prescribed for cardiac problems (hypertension, angina, anti-arrhythmias) can create
unusual fatigue
• Can be related to metabolic, neurologic, muscular or pulmonary pathology
• Is there an explanation? Sleep disturbances, etc.
• Fatigue beyond expectations during or after exercise is RED FLAG
Cough:
• •Generally associated with pulmonary disease, but can be pulmonary complication of cardiac disease
• Cough, especially at night, can be associated with heart failure, side effect of calcium channel blockers
• Left ventricular dysfunction, mitral valve dysfunction resulting in pulmonary edema or left ventricular
CHF
• Cough associated with exercise, metabolic stress, supine position, or PND
• Hacking cough, can produce large amount of frothy, blood-tinged sputum
• Congestive heart failure – large amount of fluid trapped in pulmonary tree, irritating lung mucosa
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Cyanosis:
• Bluish discoloration of lips, and nail beds of fingers and toes
• Suggests inadequate blood oxygen levels, reduced hemoglobin levels
• Most often associated with cardiac and pulmonary problems
• Can be related to hematologic or CNS disorder
• Central cyanosis – oxygen levels reduced in arterial blood (lung disease, congestive heart disease,
abnormal hemoglobin)
• Peripheral cyanosis – normal blood oxygenation but decreased or slow blood flow (congestive heart
failure, venous obstruction, anxiety, cold environment)
Edema:
• Accumulation of fluid, 3 lb. weight gain or greater or gradual, continuous gain over several days that
results in swelling of the ankles, abdomen, and hands combined with SOB, fatigue and dizziness
may be red-flag for CHF
• Other accompanying signs may be jugular vein distention, cyanosis (lips and appendages), right upper
quadrant pain-constant aching or sharp pain may occur secondary to enlarged liver
• Right heart failure can occur secondary to cardiac surgery, venous valve incompetence or obstruction,
cardiac valve stenosis, coronary artery disease, mitral valve dysfunction
• Noncardiac causes of edema include pulmonary hypertension, kidney dysfunction, cirrohosis, burns,
infection, lymphatic obstruction, use of nonsteroidal anti-inflammatory drugs or allergic reactions, deep
venous thrombosis
• Edema and accompanying symptoms persist despite rest, medical referral is required
• Edema of peripheral origin requires treatment of underlying etiology
Claudication:
• Leg pain associated with peripheral vascular disease, often simultaneously with coronary artery disease
• Often functional debilitating
• Can occur with other symptoms such as angina or dyspnea
• Pitting edema along with leg pain often seen with peripheral vascular disease
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Non-cardiac causes of leg pain should be ruled out – sciatica, pseudoclaudication, anterior compartment
syndrome, gout, peripheral neuropathy
Pseudoclaudication with low back disease often indicates spinal stenosis, discomfort frequently bilateral,
relieved by rest or flexion of lumbar spine
Vascular claudication may occur without physical findings, but usually accompanied by skin
discoloration and trophic changes (dry, thin, hairless skin) in presence of vascular disease
Assess core temperature, skin temperature and peripheral pulses, cool skin more indicative of vascular
obstruction, warm skin likely infection or inflammation
Abrupt onset of ischemic rest pain or sudden worsening of intermittent claudication may be due to
thromboembolism, need immediate physician
referral
Intermittent claudication with normal-appearing skin, exercise to point of claudication, marked pallor in
upper and lower extremities due to shunting of blood
Three P’s:
1. Pleuritic Pain (exacerbated by respiratory movements involving the diaphragm such as sighing,
deep breathing, coughing, sneezing, laughing or hiccups, can be cardiac in origin if pericariditis
or may be pulmonary)
2. Pain on palpation (musculoskeletal in origin)
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3. Pain with changes in position (musculoskeletal or pulmonary, pain that is worse when lying
down and improves with sitting up or leaning forward is often pleuritic in nature)
If two of three P’s are present, MI unlikely. MI or anginal pain occurs in approximately 5-7% of clients with
pain reproduced with palpation. Symptoms alter with positioning, % drops to 2%. If chest pain reproduced with
respiratory movements, likelihood of coronary event only 1%!
Wells’ Clinical Decision Rule for DVT
Clinical Presentation
Score
Active Cancer (within 6 months of diagnosis or receiving
palliative care)
Paralysis, paresis, or recent immobilization of lower
extremity
Bedridden for more than 3 days or major surgery in last 4
weeks
Localized tenderness in the center of the posterior calf, the
popliteal space, or along the femoral vein in the anterior
thigh/groin
Entire lower extremity swelling
1
Unilateral calf swelling (more than 3 mm larger than
uninvolved side)
Collateral superficial veins (nonvaricose)
1
An alternative diagnosis is as likely (or more likely) than
DVT (cellulitis, postoperative swelling, calf strain)
TOTAL POINTS
-2
KEY
-2 to 0
1 to 2
3 or more
Low probability of DVT
Moderate probability of DVT
High probability of DVT
1
1
1
1
1
(3%)
(17%)
(75%)
Medical consultation advised for low probability!
Medical referral is required for moderate or high probability!
MONITOR VITAL SIGNS!!!
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Longer pulse counts (one minute) more accurate, greater detection of arrhythmias
Look for abnormally high or low HR prior to activity, and in response to activity, monitor regularity of
heart rate
Increase in HR of 20bpm and that lasts > 3 minutes post rest or a change in position
• Wolthius (1977): healthy men (n = 700) exercising at 66% of maximal capacity (13/20 RPE)
showed the following increase in vital signs:
• HR ~50 bpm
• SBP ~30 mm
• DBP ~8 mm
• Wolthius RA (1977) The response of healthy men to treadmill exercise.
Circulation 55:153-157.
• DeTurk p.530: a rise in HR of > 50 bpm during exercise testing is a predictor of successful CHF
rehab.
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This is a little bit like apples and oranges however, because stress testing is a more medical,
controlled environment, especially maximal exertion testing. In the clinic, we have to be more
conservative.
• Resting SBP > 120 mmHg and/or DBP > 80 mmHg, especially with other risk factors
• Persistent rise or fall in BP over time (at least 3 consecutive readings over 2 weeks), especially if taking
NSAIDs or woman on birth control pills
• Watch for systolic BP that does not rise as work level increases
• Watch for systolic BP that falls with increasing work loads
• Lower standing SBP in adults over age 65 with history of falls
• A difference in resting pulse pressure greater than 40 mmHg
Healthy men exercising at 66% of maximal capacity (13/20 RPE) had a pulse pressure (SBP – DBP) of
~80 mm
HRWolthius RA (1977) The response of healthy men to treadmill exercise. Circulation
55:153-157.
• Watch for change in diastolic BP greater than 15-20 mmHg
• Remember some BP meds can keep HR lower (beta-blockers, digitalis, anti-dysrhythmias), use of rate
of perceived exertion is an acceptable gauge of exercise intensity
• Persons taking medications, such as beta-blockers or calcium channel blockers, may not achieve target
heart rate above 90bpm, safe rate of exercise, heart rate at two minutes post exercise should return to
resting level
• Patients being treated with NSAIDs and ACE inhibitors must be monitored closely during exercise for
elevated blood pressure
• Older adults (over 75) with decreasing BP over time may be early sign of Alzheimer’s, DBP <70mmHg
or decreases in SBP > 15 mmHg over 3 year period- increases risk of dementia
• Clients with stable angina usually has normal BP, BP may be elevated when anxiety accompanies chest
pain or during acute coronary insufficiency
• BP in lower extremities that is lower than in upper extremities
• BP changes in the presence of other warnings signs such as new or unstable angina, dizziness, nausea,
pallor, extreme diaphoresis
• Sudden fall in blood pressure (more than 10 to 15 mmHg of SBP) or more than 10 mmHg DBP with
concommitant rise in pulse (orthostatic hypotension), watch for postural hypotension in hypertensive
patients especially those on diuretics
Normal values:
Heart rate: Adult: 60-100 bpm
Child 5-12: 65-110 bpm
Child 1-7: 70-110 bpm
Infant, 6 months: 100-160 bpm
Newborn: 120-200 bpm
Normal Ranges for Blood Pressure by Patient Age
Systolic Systolic
Diastolic Diastolic
Age
(years)
Maximum Minimum Maximum Minimum
Newborn
Children
90
60
60
30
Less than 130
75
90
45
3
6-9
120
90
80
50
Key notes: heart rate and respiratory rate go down with age, BP goes up
Age
Systolic
Diastolic
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Young Adults
Adults
<120
<80
14-19
<120
<80
20-60
<120
<80
60+
<120
<80
Well-conditioned athletes tend to have lower BP values
Values combined from:
 The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure, 2004.
 Long T., Toscano K. Handbook of Pediatric Physical Therapy (2nd ed). Lippincott, Williams, and
Wilkins, 2002.
Guidelines for Immediate Medical Attention:
• Sudden worsening of intermittent claudication may be due to thromboembolism
• Symptoms of TIAs especially in individuals with history of heart disease, hypertension, or tobacco use
• Onset of angina requires immediate cessation of exercise, should subside within 3-5 minutes, use of
nitroglycerin (females can get results with antacids) as prescribed, anginal pain not relieved within 20
minutes or in presence of nausea, vomiting or profuse sweating – immediate attention
• Changes in presence of angina, such as increased intensity, decreased threshold of stimulus, or longer
duration of pain;
pain associated with MI is not relieved by rest, change of position, or
administration of nitroglycerin or antacids
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Have patient contact physician before leaving therapy, do not leave
nursing unit
unaccompanied; return to
Guidelines for Physician Referral:
• Client has combination of systemic signs or symptoms at presentation
• Women with chest or breast pain with positive family history or breast cancer
• Palpitations in any person with history of unexplained sudden death in the family; more than six
episodes of palpitations in 1 minute; palpitations lasting for hours or occurring in association with pain,
SOB, fainting, or severe lightheadedness
• Anyone who cannot climb a single flight of stairs without feeling moderately to severely winded or who
awakens at night or experiences shortness of breath when lying down
• Fainting (syncope) without warning period of lightheadedness, dizziness or nausea may be sign if valve
disease or arrhythmia; unexplained syncope in presence of heart or circulatory problems (or risk factors
for heart attack or stroke)
• Clients who are neurologically unstable often exhibit new arrhythmias, these new arrhythmias require
referral
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Known cardiac clients who
• Fail to relieve anginal pain with use of nitroglycerin
• Change in pattern of angina
• Abnormally severe chest pain with nausea and vomiting
• Anginal pain not relieved by rest
• Anginal pain radiates to jaw or left arm
• Upper back abnormally cool, sweaty, or moist to touch
• Client develops progressively worse dyspnea
• Individual with coronary artery stent experiencing chest pain
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Client demonstrates difference of more than 40 mmHg in resting pulse pressure; alternatively, if
pulse pressure is < 10 mm in resting or in response to exercise, that is not good either (DeTurk
p.530).
(SBP-DBP=pulse pressure)
Client has any doubt about his or her present condition
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Clues for Screening Cardiovascular Signs and Symptoms:
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Personal history of heart disease including hypertension
Age (postmenopausal women, anyone over 65)
Ethnicity (black women)
Other signs or symptoms – pallor, unexplained profuse perspiration, inability to talk, nausea, vomiting,
sense of impending doom or extreme anxiety
Three P’s
Chest pain may occur from intercostal muscle or periosteal trauma from vigorous coughing, palpation of
local chest wall produces tenderness, look for associated signs or symptoms
Angina is activated by physical exertion, emotional reactions, large meal or exposure to cold – lag time
of 5-10 minutes, immediate pain is likely to be musculoskeletal, TOS, or psychologic
Chest pain, shoulder pain or TMJ pain occurring in presence of coronary artery disease or previous
history of MI, especially if accompanied by associated signs or symptoms
Upper quadrant pain, that can be induced or reproduced by lower quadrant activity, such as biking, stair
climbing, or walking without use of arms – usually cardiac in origin
Recent history of pericarditis in presence of new chest, neck, or left shoulder pain, observe for additional
symptoms of dyspnea, increased pulse rate, elevated body temperature, malaise or myalgias
Individual with known risk factors for congestive heart disease, especially a history of angina, becomes
weak or short of breath while working with arms overhead, ischemia or infarction is likely cause of pain
and
associated symptoms
Insidious onset of joint or muscle pain in older client who has previously diagnosed heart murmur may
be caused by bacterial endocarditis, usually no morning stiffness to differentiate it from RA
Back pain associated with herniated lumbar disk but without neurologic deficits especially in presence
of heart murmur may be caused by bacterial endocarditis
Watch for arrhythmias in neurologically unstable clients (SCI, new CVA or new brain injury, check
pulse and ask/observe for dizziness
Anyone with chest pain must be evaluated for trigger points; if palpation of chest reproduces symptoms
(especially radiating pain), deactivation of trigger points must be carried out and followed by
reevaluation as part of screening for cardiac origin
Symptoms of vascular occlusive disease include exertional calf pain that is relieved by rest (intermittent
claudication), nocturnal aching of foot and forefoot (rest pain), and classic skin changes, especially hair
loss of foot and ankle; ischemic rest pain is relieved by placing limb in dependent position
Throbbing pain at base of neck and/or along the back into interscapular areas that increases with
exertion requires monitoring of vital signs and palpation of peripheral pulses to screen for aneurysm,
check for palpable abdominal heartbeat that increases in supine
References:
1.
2.
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4.
Goodman CC., Snyder TE. Differential Diagnosis for Physical Therapists: Screening for Referral (4th ed.). St. Louis: Saunders-Elsevier,
2007.
Boissonnault WG. Primary Care for the Physical Therapist: Examination and Triage. St. Louis: Saunders-Elsevier, 2005.
Long T., Toscano K. Handbook of Pediatric Physical Therapy (2nd ed). Lippincott, Williams, and Wilkins, 2002.
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, 2004.
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