Third degree AV block physical examination

The physical exam is usually remarkable for bradycardia. Most of the patients‘ will have cannon A-waves on the JVP exam due to the simultaneous contraction of atria and ventricles that lead to significant pushing of blood against the AV valve. Particularly with heart rates below 40/min, patients might also demonstrate findings consistent with decompensated heart failure and respiratory distress, such as diaphoresis, altered mental status, tachypnea, cold skin, and decreased capillary refill.

Physical examination of patients with third degree AV block is usually remarkable for bradycardia, hypotension and hypoperfusion plus/minus sign and symptoms of heart failure such as edema, pulmonary rales, and S3 gollop. In the presence of primary etiology and secondary heart block such as myocardial infarction or Lyme disease other sign and symptoms such as rash or chest pain might be present as well.

• The patient may present with altered mental status because of hypoperfusion.
• They might appear lethargic or anxious or present in severe unconscious state.
• Patient may be diaphoretic and pale and may experiencing severe chest pain if the cause of complete heart block is myocardial infarction.^[1][2]

• Bradycardia may be present.
• Tachypnea may be present.
• Patients might be febrile (Lyme disease, endocarditis)

• Skin rash may be present if the cause of complete heart block is endocarditis or rheumatic fever or Lyme disease.

• HEENT examination of patients with third degree AV block is usually normal.
• Cyanosis might be present.

• In the case of Lyme disease:
  • Headache
  • Pain on neck flexion
  • Some patients may have:
    • Pharyngitis
    • Conjunctivitis
    • Ptosis
    • Facial nerve palsy

• Cannon ‘a’ waves may be seen often.
• Elevated JVP may be seen in the presence of heart failure.

• Basilar rales may be heard.

• S₃ gallop may be heard in the presence of heart failure.

• Abdominal examination of patients with third degree AV block is usually normal.

• Nevertheless it depends to the basic etiology, for example in other rare etiologies of complete heart block such as infectious- rheumatologic / granolomatosis disease or amyloid disease the following findings might be present:
• Hepatomegaly
• Splenomegaly
• Hepatosplenomegaly

• Back examination of patients with third degree AV block is usually normal.

• Sacral edema ight be present in heart failure

• Genitourinary examination of patients with third degree AV block is usually normal.

• Neuromuscular examination of patients with third degree AV block is usually normal.

• In sever acute settings and in rare etiologies of complete heart block such as infectious, rheumatologic, granolomatosis disease or amyloid disease abnormal findings might be present such as:

• Altered mental status
• Coma
• Clonus may be present
• Hyperreflexia / hyporeflexia / areflexia
• Positive (abnormal) Babinski / plantar reflex unilaterally/bilaterally
• Bell spulsy suggestive of cranial nerve seven deficit in Lyme disease or sarcoidosis.

In acute or chronic decompensated heart failure the followings might be present:

• Pedal edema

• Clubbing
• Cyanosis

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