how to differentiate between cardiac and respiratory dyspnea

1977;238(19):20662067. The life expectancy of somebody with cardiac asthma depends on how far their heart failure has progressed, the underlying cause, and their overall health. During exercise, oxygenation is measured by using either a pulse oximeter or an arterial line, and interpretation of the complete test requires analysis of oxygen consumption, carbon dioxide production, anaerobic threshold, heart rate and rhythm, blood pressure, minute ventilation, continuous monitoring of gas exchange, severity of perceived exertion, dyspnea, chest pain and leg discomfort. You should go to the ER if youre having trouble breathing and nothing you try makes it better. It can help to ask yourself the following questions while youre waiting to see a doctor to help determine whether its cardiac asthma: Cardiac asthma is caused by heart failure. Its caused by a buildup of fluid in the lungs due to the inability of the heart to effectively clear fluid from the lungs. WALTER C. MORGAN, M.D., AND HEIDI L. HODGE, M.D. Chronic Dyspnea: Diagnosis and Evaluation | AAFP Trauma or inflammation in these regions results in pain localized in the cutaneous distribution of those nerves. All Rights Reserved. Fluid in your lungs makes it hard to breathe, especially when youre lying down. Treat other conditions that make heart failure worse. and transmitted securely. A number of disorders cause dyspnea, including acute heart failure syndrome (AHFS), chronic obstructive pulmonary disease (COPD), asthma, pulmonary embolism, pneumonia, metabolic acidosis, neuromuscular weakness, and others. A family history of similar symptoms increases the likelihood of rare diagnoses such as familial Mediterranean fever. Patients with unexplained pleuritic chest pain should have chest radiography to evaluate for abnormalities, including pneumonia, that may be the cause of their pain. BRIAN V. REAMY, MD, PAMELA M. WILLIAMS, MD, AND MICHAEL RYAN ODOM, MD. 2. How to differentiate heart blocks - EMS1 The emergency clinician must provide appropriate initial treatment for a potentially life-threatening illness while working through a wide differential diagnosis. This can cause shortness of breath, coughing and wheezing similar to the signs and symptoms of asthma. Pleuritic Chest Pain: Sorting Through the Differential Diagnosis Since heart failure causes cardiac asthma, lowering your risk of heart failure cuts your risk of cardiac asthma, too. All Rights Reserved. This increased cardiac workload can result in such symptoms as tachycardia, palpitations, dyspnea, dizziness, orthopnea, and exertional dyspnea. Although a class effect is assumed, studies on the treatment of pleuritic chest pain in humans have focused on the use of indomethacin at dosages of 50 to 100 mg orally up to three times per day. Know the difference. Arterial blood gas measurement can provide information about altered pH, hypercapnia, hypocapnia or hypoxemia. Exercise treadmill testing is relatively safe and has few risks: only one in 10,000 patients dies of malignant arrhythmia or acute myocardial infarction, and only two in 10,000 have serious but nonfatal arrhythmia or another complication.11, The normal physiologic response to exercise testing is an increase in blood pressure and heart rate. In contrast . Heart failure. Prognostic importance of elevated jugular venous pressure and a third heart sound in patients with heart failure. Thyroid abnormalities rarely present with dyspnea and can be assessed by measurement of the serum thyroid-stimulating hormone level.4,8. This disruption in blood flow leads to increased blood pressure in the blood vessels of the lungs, which causes leakage and accumulation of fluid. One study showed that of 236 adults presenting to their primary care physician with community-acquired pneumonia, 10 were found to have an underlying lung cancer.42 The percentage of those with lung cancer rose to 17% in smokers older than 60 years.42 Studies have shown resolution of radiographic abnormalities in 60% to 73% of patients by six weeks after diagnosis.42 Further evaluation should be considered in patients with persisting symptoms or radiographic abnormalities. All Rights Reserved. In patients with cardiac dyspnea, the major cause of dyspnea also is increased lung stiffness, leading to a type of restrictive lung disease. In patients diagnosed with pneumonia who smoke tobacco, have persistent symptoms, or are older than 50 years, it is important to document resolution of the abnormality with repeat chest radiography performed six weeks after initial treatment.42 These patients are at increased risk of developing pneumonia secondary to an obstructing lesion such as lung cancer. When pleuritic inflammation occurs near the diaphragm, pain can be referred to the neck or shoulder. We aimed to assess the utility of easily applicable diagnostic tools in the differential diagnosis of cardiac and pulmonary causes of dyspnea in patients presenting with shortness of breath. spcificity of BNP is only 75% [4]. It is exacerbated by deep breathing, coughing, sneezing, or laughing. You can learn more about how we ensure our content is accurate and current by reading our. Congest Heart Fail 2004;10:146. Wells PS, Anderson DR, Rodger M, et al. In 1933 he coined the very 2006 Jun-Aug;22(3-4):435-41. doi: 10.1007/s10554-005-9055-6. Provided by the Springer Nature SharedIt content-sharing initiative, Over 10 million scientific documents at your fingertips, Not logged in al [10]. Keep reading as we break down everything you need to know about cardiac asthma, including what causes it, what symptoms occur, and how its treated. Careers. 2023 Springer Nature Switzerland AG. Heart Problems That Affect Breathing: Heart Failure, Tachycardia, and More 1-ranked heart program in the United States. Breathlessness: Cardiac or Pulmonary? | The BMJ Your healthcare provider can make a diagnosis from: Your healthcare provider can use a number of tests to diagnose cardiac asthma, including: Cardiac asthma treatments are different from treatments for bronchial asthma. The most common organic causes of dyspnea are cardiac and pulmonary disorders.6. has gained little recognition in the English medical literature, although Cardiac asthma lasts as long as you have the condition thats causing it. Overview Heart failure occurs when the heart muscle doesn't pump blood as well as it should. Normal arterial blood gas measurements do not exclude cardiac or pulmonary disease as a cause of dyspnea.2, Complete pulmonary function testing can be obtained if screening office spirometry is inconclusive. However, these treatments arent necessary if youre able to breathe well enough to get adequate oxygen. Difference between cardiac asthma and bronchial asthma pdf Bronchial asthma vs. Dyspnea is the sensation of shortness of breath. In contrast, pneumothorax could lead to hyperresonance on lung examination. Gallavardin L. Y a-t-il un quivalent non douloureux de langine de Federal government websites often end in .gov or .mil. Copyright 1998 by the American Academy of Family Physicians. Cardiac or pulmonary dyspnea in patients admitted to the emergency The test may be repeated until the results are consistent. See permissionsforcopyrightquestions and/or permission requests. The site is secure. Copyright 2023 American Academy of Family Physicians. Those with sleep apnea may present with PND , causing disrupted sleep and nighttime awakenings. Ware LB, Matthay MA. There are limitations to the sensitivity and specificity of treadmill testing, however, and interpretation of the results may vary. Le Gal G, Righini M, Roy PM, et al. Am J Cardiol 1989;64:834. An exercise ECG is important in identifying the presence of ischemic heart disease and the amount of myocardium at risk. 2023 American Medical Association. BMJ 2005;331:4435. Cardiac asthma: Not your typical asthma. McCullough PA, Hollander JE, Nowak RM, et al. Computed tomography coronary angiography in patients without known coronary artery disease can demonstrate possible non-cardiovascular causes of non-acute retrosternal chest pain. 9.Type 1 and 2 respiratory failure - Arterial blood gas will differentiate the cause. This measurement is more commonly used for the evaluation of acute dyspnea but it can also be used in the evaluation of patients who have gradually become dyspneic or who are chronically dyspneic. 10. According to Schwinger (2021), heart failure is characterized by symptoms like the ones experienced by the 72-year-old male patient in this case study, such as dyspnea, elevated jugular venous pressure, edema of the ankles, pulmonary crackles and more. Treatment is guided by the underlying diagnosis. A validated clinical decision rule for pulmonary embolism should be employed to guide the use of additional tests such as d-dimer assays, ventilation-perfusion scans, or computed tomography angiography.3033 Table 3 integrates red flag symptoms of serious causes of pleuritic chest pain, physical examination, and diagnostic findings to aid in the evaluation of pleuritic chest pain.9,10,34,35, After excluding the six serious causes of pleuritic chest pain that require emergent evaluation, there are two primary management considerations: controlling the pain and treating the etiology of the underlying condition. Cough, fever, and sputum production should prompt evaluation for community-acquired pneumonia. Before In: Mebazaa, A., Gheorghiade, M., Zannad, F.M., Parrillo, J.E. JAMA 1997;277:17129. Heart failure doesn't mean your heart isn't working. Cardiol, in press. Voltage abnormality suggests left or right ventricular hypertrophy if the voltage is excessive, or pericardial effusion or obstructive lung disease with increased chest diameter if the voltage is diminished. Validated clinical decision rules are available to help exclude coronary artery disease. descriptive, though somewhat awkward combination of Latin and Greek, FOIA [Acute dyspnea in the emergency room: the utility of troponin, natriuretic, procalcitonin and D-dimers]. Rales or wheezing can indicate congestive heart failure, and expiratory wheezing alone may indicate obstructive lung disease. In SVT . The final treatment option when all other treatments have failed is a heart transplant. Weakness. Cardiac vs pulmonary origin. It often has multiple etiologies. Myocardial infarction, pericarditis, aortic dissection, pneumonia, and pneumothorax are other serious causes that should be ruled out using history and physical examination, electrocardiography, troponin assays, and chest radiography before another diagnosis is made. Patients may demonstrate shallower breaths as they attempt to avoid deep breathing that triggers pain.23 Likewise, hypotension and a markedly widened pulse pressure should raise concerns for aortic dissection or severe myocardial infarction. A finger-stick hemoglobin determination or a complete blood count can quantify the severity of suspected anemia. The main difference between respiratory arrest and cardiac arrest is that respiratory arrest occurs when a person stops breathing while cardiac arrest occurs when a person's heart stops beating (or only quivers ineffectively). Acute pulmonary edema. Week 2 Discussion-NR 507.doc - Jane Carissa Ali Dr. sciencedirect.com/science/article/abs/pii/S0889856112001397, heart.org/en/health-topics/heart-failure/causes-and-risks-for-heart-failure/causes-of-heart-failure, nhs.uk/conditions/heart-failure/diagnosis/, uspharmacist.com/article/cardiac-asthma-not-your-typical-asthma. Privacy Policy| PubMed Mortality rates at 1 year and 5 years after heart failure diagnosis are about 22 and 43 percent, respectively. Patients may present with an initial normal examination even when serious conditions are present. Whats the outlook for people with cardiac asthma? Echocardiography can detect a valvular abnormality and may be diagnostically helpful in patients with questionable murmurs in the context of dyspnea. It is a common finding in many different conditions. Chest pain: how to distinguish between cardiac and noncardiac causes Atypical chest pain must be differentiated from other types of chest pain, including chest wall pain, pleurisy, gallbladder pain, hiatal hernia, and chest pain associated with anxiety disorders. Professor of Medicine Tachycardia or tachypnea may be present with any of the serious causes of pleuritic chest pain but should raise suspicion for pulmonary embolism, pneumothorax, or myocardial infarction. Pleuritic chest pain has many etiologies. Further testing is individualized. No breathing. MeSH Cassin M, Badano LP, Solinas L, Macor F, Burelli C, Antonini-Canterin F, Cappelletti P, Rubin D, Tropeano P, Deganuto L, Nicolosi GL. Whats the Difference Between a Heart Attack and Heart Failure? Chest 1992;101:12932. Heart failure doesnt mean your heart isnt working. Cardiac asthma is a sign of a larger condition: heart failure. (2008). The pattern of shortness of breath can help doctors determine which condition you have. Arterial blood gas measurement can be normal, however, in patients with clinically significant pulmonary disease. This is called advanced heart failure. Malik A, et al. Certain heart conditions gradually leave the heart too weak or stiff to fill and pump blood properly. As a result, patients with dyspnea purely related to obstructive lung disease seldom pose a problem in the separation of cardiac and pulmonary dyspnea. - 208.113.161.207. Is my breathing trouble keeping me awake. Acute dyspnea is mostly due to potentially life-threatening cardiac or respiratory conditions, and treating it promptly requires understanding of the underlying mechanisms. In COPD, the air sacs in the lungs lose their elasticity, and the airways become inflamed and narrowed, making it difficult to breathe. Accessed 3/4/2022. Unauthorized use of these marks is strictly prohibited. The hemoglobin desaturation curve can be shifted to the left or right depending on the pH, temperature (e.g., oximeter used on a cool extremity) or arterial carbon monoxide or carbon dioxide level. Ailani RK, Ravakhah K, DiGiovine B, et al. Pleuritic chest pain is caused by inflammation of the parietal pleura and can be triggered by a variety of causes. 1 A consensus statement from the American Thoracic Society defines dyspnea as a "subjective experience. Circulatory system mainly includes the heart, blood vessels, blood, lymph and lymph vessels. Cardiac asthma is a condition caused by heart failure that leads to asthma-like symptoms, such as wheezing, coughing, and trouble breathing. The patient exhales fully, then takes a maximum inhalation and blows out as hard and as fast as possible, continuing the exhalation as long as possible to ensure that maximal volumes are measured. Neck bruits are indicative of macrovascular disease and suggest concomitant disease of the coronary arteries, especially if the patient has a history of diabetes, hypertension or smoking. Am J Med 2004;116:363-368. Abidov A, Rozanski A, Hachamovitch R, et al: Prognostic significance A consultation with a pulmonologist or cardiologist may be helpful to guide the selection and interpretation of second-line testing, Dyspnea is defined as abnormal or uncomfortable breathing in the context of what is normal for a person according to his or her level of fitness and exertional threshold for breathlessness.14 Dyspnea is a common symptom and can be caused by many different conditions. What kinds of exercise would you recommend? Dyspnea: How to Differentiate Between Acute Heart Failure Syndrome and Other Diseases. This is more likely to occur when the effusion is due to malignancy, renal failure, or rheumatoid pleurisy.41. Peripheral perfusion of the extremities should be evaluated by assessing pulses, capillary refill time, edema and hair growth pattern. Do I have any risk factors for heart failure, such as high blood pressure or coronary artery disease? The DLCO is used to indirectly measure the gas exchange of oxygen and carbon dioxide across the alveolar surface. electrocardiography) that help to recognize congestive heart failure (CHF) 3. N Engl J Med 2002;347:1617. The Whole Idea Is to Identify What'S Going on And We Will People with cardiac asthma typically experience symptoms such as coughing, trouble breathing, and shortness of breath due to pulmonary congestion. Cheng TO: Shortness of breath: COPD or CHF? A thorough history and physical examination should be performed to diagnose or exclude life-threatening causes of pleuritic chest pain. National Heart, Lung, and Blood Institute. In patients with persistent symptoms, persons who smoke, and those older than 50 years with pneumonia, it is important to document radiographic resolution with repeat chest radiography six weeks after initial treatment. These initial modalities are inexpensive, safe and easily accomplished. The absence of a clear diagnosis warrants additional diagnostic testing. Mixed cardiac and pulmonary disorders are also common sources of dyspnea6,7 and include COPD with pulmonary hypertension and cor pulmonale, deconditioning, pulmonary emboli and trauma. Does this dyspneic patient in the emergency department have congestive heart failure? equivalent [5,6]. As an adjective cardiac is pertaining to the heart. Am Heart J 1967;73:579-581. ACE inhibitors help widen blood vessels and unload the heart, while beta-blockers slow your heart rate and lower your blood pressure. Most potentially lethal causes of pleuritic chest pain (i.e., pulmonary embolism, myocardial infarction, aortic dissection, and pneumothorax) typically have an acute onset over minutes. Predictors of elevated B-type natriuretic peptide concentrations in dyspneic patients without heart failure: an analysis from the breathing not properly multinational study. Clipboard, Search History, and several other advanced features are temporarily unavailable. From the Stanford University School of Medicine and Medical Center, Stanford, Calif. To register for email alerts, access free PDF, and more, Get unlimited access and a printable PDF ($40.00), 2023 American Medical Association. Unlike bronchial asthma, cardiac asthma is difficulty breathing because of pulmonary edema or fluid in your lungs. This may sound similar to cardiac asthma symptoms. A total of 243 citations were identified using the key words pleurisy and pleuritic chest pain, and the search was limited to human studies. However, as Coats 9500 Euclid Avenue, Cleveland, Ohio 44195 |, Important Updates + Notice of Vendor Data Event, (https://pubmed.ncbi.nlm.nih.gov/23337063/), (https://www.nhlbi.nih.gov/health-topics/heart-failure), Heart, Vascular & Thoracic Institute (Miller Family). Maisel AS, Krishnaswamy P, Nowak RM, et al. When evaluating a patient with a possible psychiatric component of dyspnea, it is helpful to know if the feelings of dyspnea and anxiety are concurrent, if associated paresthesias of the mouth and fingers exist, and if the anxiety precedes or follows dyspnea. Springfield CL, Sebat F, Johnson D, et al. It is a symptom of many conditions that affect the respiratory system. A number of systemic diseases, such as rheumatoid arthritis, systemic lupus erythematosus and sarcoidosis, can cause interstitial lung disease, which leads to a restrictive pattern on spirometry. PubMedGoogle Scholar, Department of Anesthesiology and Critical Care Medicine, Lariboisire University Hospital, Assistance Publique-Hpitaux de Paris, Universit Paris Diderot, Paris, France, Alexandre Mebazaa MD, PhD (Professor of Medicine) (Professor of Medicine), Feinberg School of Medicine, Northwestern University, Chicago, IL, USA, Mihai Gheorghiade MD, FACC (Professor of Medicine and Surgery, Associate Chief, Division of Cardiology and Chief, Cardiology Clinical Service) (Professor of Medicine and Surgery, Associate Chief, Division of Cardiology and Chief, Cardiology Clinical Service), Department of Cardiology Centre dInvestigation Clinique (CIC), INSERM U-684, Centre Hospitalier Universitaire, University Henri Poincar, Nancy, France, Faiez M. Zannad MD, PhD, FESC (Professor of Medicine) (Professor of Medicine), Robert Wood Johnson Medical School, University of Medicine and Dentistry of New Jersey, Camden, NJ, USA, Joseph E. Parrillo MD (Professor of Medicine, Chief, Department of Medicine Edward D. Viner MD Chair, Department of Medicine and Director) (Professor of Medicine, Chief, Department of Medicine Edward D. Viner MD Chair, Department of Medicine and Director), Cooper Heart Institute, Cooper University Hospital, Camden, NJ, USA, Picard, C.R., Tazi, A. Although other causes may contribute, the cardiac and pulmonary organ systems are most frequently involved in the etiology of dyspnea.5. Living an overall healthy lifestyle may help improve your heart failure symptoms or prevent heart failure in the first place. Cardiac or pulmonary dyspnea in patients admitted to the emergency department. Customize your JAMA Network experience by selecting one or more topics from the list below. COVID-19 primarily posed a threat to the respiratory system and violated many different organs, including the heart, kidney, liver, and blood vessels with the development of the disease. Does the clinical examination predict airflow limitation? It's caused by a buildup of fluid in the lungs due to . Tests that may be performed to help diagnose heart failure include: If you think you may be experiencing cardiac asthma, its critical to seek medical attention immediately. Metabolism. Part of Springer Nature. Difference Between Cardiovascular and Circulatory System In cases of persistent or recurrent pain, or when significant pathology is discovered, patient care should continue as required based on the etiology. Piccone U, Potenza S, Pala M, Bongarzoni A, Regalia F. Minerva Cardioangiol. The broad differential diagnosis of dyspnea contains four general categories: cardiac, pulmonary, mixed cardiac or pulmonary, and noncardiac or nonpulmonary (Table 1). These studies have shown improvements in pain and mechanical lung function.36 Corticosteroids should be reserved for patients who are intolerant of nonsteroidal anti-inflammatory drugs. To treat cardiac asthma, your healthcare provider may give you medicines or recommend treatments for heart failure, which is most often to blame for cardiac asthma. The physiology of normal respiration and gas exchange is complex, and that of dyspnea is even more so. In new-onset heart failure due to large myocardial infarction, cardiac examination may show an extra heart sound (third or fourth heart sound). Blaivas M. Incidence of pericardial effusion in patients presenting to the emergency department with unexplained dyspnea. 7. Lancet 2004;364:61320. Sometimes other symptoms occur before sudden cardiac arrest. Chest 1999;116:11004. To make your symptoms better and improve your quality of life, follow your healthcare providers advice: Contact your healthcare provider if you start to get new symptoms or your symptoms get worse. Heart failure can cause fluid to build up in the lungs (pulmonary edema) and in and around the airways. Competing interests: A medication history that includes the use of drugs with a high risk of adverse pulmonary effects should raise concerns for a pharmacologic reaction. Thus, a borderline-normal oxygen saturation percentage may actually reflect an abnormally low PaO2 in some cases.10 Pulse oximetry is, however, valuable as a rapid, widely available and noninvasive means of assessment and is accurate in most clinical situations. Lahn M, Bijur P, Gallagher EJ. Dyspnea Differentiation Index - Chest These might include: Chest discomfort. Clinical and radiologic evaluation, peak expiratory . As I indicated in my recent paper [2], weight gain usually indicates Light RW, George RB. poitrine deffort? To differentiate between the two, a doctor will likely start by looking at your medical history and risk factors to determine whether heart failure is the cause. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Pneumonia and pneumothorax can be evaluated with chest radiography.1 Aortic dissection can be excluded with chest radiography in very low-risk patients; otherwise, computed tomography angiography should be performed.19, Viruses are common causative agents of pleuritic chest pain. This fluid makes it hard for you to breathe (cardiac asthma). Cardiac asthma is often misdiagnosed as asthma, but a proper diagnosis is critical for receiving proper treatment maximizing your outlook. (2013). It may arise as a result of numerous mechanisms.1,2 However, in both cardiac and pulmonary disease, the most common cause is disordered lung mechanics. -350. Learn about the many differences between heart, Healthline has strict sourcing guidelines and relies on peer-reviewed studies, academic research institutions, and medical associations. This article updates a previous article on this topic by Kass, et al.3. Copyright 2017 by the American Academy of Family Physicians. Factors such as the duration of the dyspnea, precipitating circumstances such as exertion, daytime or nighttime occurrence, the presence of chest pain or palpitations, the number of pillows the patient uses during sleep, how well the patient sleeps, concomitant coughing, exercise tolerance, and the ability to keep up with peers can all help narrow the differential diagnosis.8,9, Other factors to be considered include past and current use of tobacco, exercise tolerance, environmental allergies, occupational history and the presence of asthma, coronary artery disease, congestive heart failure or valvular heart problems. Bookshelf If your body isnt receiving enough oxygen, youll likely be given oxygen or put on a noninvasive ventilator. Acad Emerg Med 2001;8:11436. Before you get to this point, its good to let your family and healthcare provider know what kind of care you want. Understanding The Differences Between Asthma And COPD: A Comprehensive You may not have given much thought to your sleeping position, but the way you spend your night can have an impact on your overall health, including. What is Circulatory System? In most patients, the cause or causes of dyspnea can be determined in a straightforward fashion by using the history and physical examination to identify common cardiac or pulmonary etiologies. Further testing is individualized. Noncardiac or nonpulmonary disease must be considered in patients with minimal risk factors for pulmonary disease and no clinical evidence of cardiac or pulmonary disease. Tachycardia is a fast heart rate -- usually more than 100 beats per minute in an adult. Symptoms of cardiac asthma may be the initial symptoms of heart failure, or they may be present along with other signs of heart failure, such as: Cardiac asthma can be difficult to diagnose due to its similarity to asthma. Loss of consciousness. PubMed Covid-19 symptoms usually manifest between 2 to 14 days following exposure, with an average incubation time of 5-6 days. 2000 Feb;1(2):186-201. Although the clinical diagnosis of typical acute pulmonary edema or acute severe asthma is readily made, the presentation is less typical in a number of cases, for which consultation among ED physicians and respiratory and cardiology consultants is needed. No pulse. A patient's ability to perform a treadmill test can be limited by poor aerobic conditioning, by lower extremity pathology such as arthritis, claudication or edema, or by coincidental pulmonary disease. I read with interest the article by Rutten et al [1] in which they In an attempt to compensate for the low cardiac output, heart rate and arte- rIovenous oxygen difference increase. Can the clinical examination diagnose left-sided heart failure in adults? Tsung O. Cheng, M.D. While contemporary . A restrictive pattern can be caused by extrapulmonary factors, such as obesity; by skeletal abnormalities, such as kyphosis or scoliosis; by compressing pleural effusion, and by neuromuscular disorders, such as multiple sclerosis or muscular dystrophy. Chamber size, hypertrophy and left ventricular ejection fraction can also be assessed. CAS Pleuritic chest pain is characterized by sudden and intense sharp, stabbing, or burning pain in the chest when inhaling and exhaling. Ultrasonography of the internal jugular vein in patients with dyspnea without jugular venous distention on physical examination. Congestive heart failure. This process is experimental and the keywords may be updated as the learning algorithm improves. These citations were reviewed independently by the authors and then collaboratively at a series of conference calls to identify the key references to be included in the article.

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