Pulmonary hypertension physical examination: Difference between revisions
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{{Pulmonary hypertension}} | {{Pulmonary hypertension}} | ||
'''Editor(s)-in-Chief:''' [[User:C Michael Gibson |C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com] | '''Editor(s)-in-Chief:''' [[User:C Michael Gibson |C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com] ; '''Assistant Editor(s)-in-Chief:''' [[User:Lisa Prior|Lisa Prior]]; [[User:Ralph Matar|Ralph Matar]] | ||
==Overview== | ==Overview== | ||
Pulmonary hypertension (PH) can present with a myriad of physical signs that develop on a spectrum corresponding to the severity of the disease. | Pulmonary hypertension (PH) can present with a myriad of physical signs that develop on a spectrum corresponding to the severity of the disease. PH is often initially associated with a loud P2, parasternal heave, and narrowed splitting of the second heart sound on physical examination. A third heart sound (S3) may also be heard on auscultation. As PH worsens, [[right ventricular failure]] can develop, which can be associated with as increased [[jugular venous pressure]] (JVP), [[ascites]], [[peripheral edema]], [[Abdominojugular test|hepatojugular reflux]], and [[clubbing]]. A pansystolic murmur of [[tricuspid insufficiency]] can also be present on physical examination and is suggestive long-standing PH. | ||
A pansystolic murmur of [[tricuspid insufficiency]] can also be present on physical examination and is suggestive long-standing PH. | |||
==Physical Examination== | ==Physical Examination== | ||
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* [[Spider nevi]]: suggestive of liver disease | * [[Spider nevi]]: suggestive of liver disease | ||
* [[Palmar erythema]]: suggestive of liver disease | * [[Palmar erythema]]: suggestive of liver disease | ||
* [[Clubbing]]: may be indicative of [[congenital heart disease]] or pulmonary veno-occlusive disease<ref name="pmid19713419">{{cite journal| author=Galiè N, Hoeper MM, Humbert M, Torbicki A, Vachiery JL, Barbera JA et al.| title=Guidelines for the diagnosis and treatment of pulmonary hypertension: the Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS), endorsed by the International Society of Heart and Lung Transplantation (ISHLT). | journal=Eur Heart J | year= 2009 | volume= 30 | issue= 20 | pages= 2493-537 | pmid=19713419 | doi=10.1093/eurheartj/ehp297 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19713419 }} </ref> | * [[Clubbing]]: may be indicative of [[congenital heart disease]] or [[pulmonary veno-occlusive disease]]<ref name="pmid19713419">{{cite journal| author=Galiè N, Hoeper MM, Humbert M, Torbicki A, Vachiery JL, Barbera JA et al.| title=Guidelines for the diagnosis and treatment of pulmonary hypertension: the Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS), endorsed by the International Society of Heart and Lung Transplantation (ISHLT). | journal=Eur Heart J | year= 2009 | volume= 30 | issue= 20 | pages= 2493-537 | pmid=19713419 | doi=10.1093/eurheartj/ehp297 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19713419 }} </ref> | ||
===JVP=== | ===JVP=== | ||
Assessment of the [[Jugular venous pressure|JVP]] in pulmonary hypertension involves assessing the 'a' wave (coincides with atrial contraction), the 'v' wave (coincides with atrial | Assessment of the [[Jugular venous pressure|JVP]] in pulmonary hypertension involves assessing the 'a' wave (coincides with atrial contraction), the 'v' wave (coincides with atrial filling) and the height of the JVP column above the sternal angle. Physical findings may include: | ||
filling) and the height of the JVP column above the sternal angle. Physical findings may include: | |||
* Prominent 'a' wave: due to forced atrial contraction | * Prominent 'a' wave: due to forced atrial contraction | ||
* Prominent 'v' wave: later if [[Tricuspid regurgitation|tricuspid regurgitation]] develops with right ventricular failure | * Prominent 'v' wave: later if [[Tricuspid regurgitation|tricuspid regurgitation]] develops with [[right ventricular failure]] | ||
* Elevated JVP: can be present if right ventricular failure develops | * Elevated [[JVP]]: can be present if [[right ventricular failure]] develops | ||
* Postive [[Kussmaul's sign]]: JVP elevation during inspiration (the opposite of what normally happens) because of right ventricular failure<ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref> | * Postive [[Kussmaul's sign]]: [[JVP]] elevation during inspiration (the opposite of what normally happens) because of [[right ventricular failure]]<ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref> | ||
* Positive [[Hepatojugular reflux|abdominojugular reflux]]: JVP rises and remains elevated during a period of over 10 seconds whilst abdominal pressure is applied. This may be present if right ventricular failure develops.<ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref> | * Positive [[Hepatojugular reflux|abdominojugular reflux]]: [[JVP]] rises and remains elevated during a period of over 10 seconds whilst abdominal pressure is applied. This may be present if [[right ventricular failure]] develops.<ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref> | ||
===Lungs=== | ===Lungs=== | ||
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* [[Crackles]] upon inspirations are indicative of [[interstitial lung disease]]. | * [[Crackles]] upon inspirations are indicative of [[interstitial lung disease]]. | ||
=== | ===Cardiovascular=== | ||
An holistic [[precordium|precordial]] assessment of pulmonary hypertension involves [[Palpation of the precordium|palpating the precordium]] for [[Heave|heaves]] and thrills and ausculatating to assess first | An holistic [[precordium|precordial]] assessment of pulmonary hypertension involves [[Palpation of the precordium|palpating the precordium]] for [[Heave|heaves]] and thrills and ausculatating to assess first and second heart sounds, splitting of the second heart sound and determining if there any added [[Heart sounds|heart sounds]] or murmurs. Physical findings may include the following: | ||
and second heart sounds, splitting of the second heart sound and determining if there any added [[Heart sounds|heart sounds]] or murmurs. Physical findings may include the | |||
following: | |||
====Palpation==== | ====Palpation==== | ||
* Left parasternal heave: due to hyperdynamic right ventricle | * Left parasternal heave: due to hyperdynamic [[right ventricle]] | ||
* Palpable P2: correlates with severe disease <ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref> | * Palpable P2: correlates with severe disease <ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref> | ||
| Line 58: | Line 54: | ||
=====Splitting of S2===== | =====Splitting of S2===== | ||
* Narrowed splitting of S2: in chronic pulmonary hypertension, pulmonary artery compliance decreases leading to earlier pulmonary valve closure and narrowed splitting. <ref name="isbn0-07-055417-X">{{cite book |author=Alexander, R. McNeill; Hurst, J. Willis; Schlant, Robert C. |title=The Heart, arteries and veins |publisher=McGraw-Hill, Health Professions Division |location=New York |year=1994 |pages= |isbn=0-07-055417-X |oclc= |doi= |accessdate=}}</ref> | * Narrowed splitting of S2: in chronic pulmonary hypertension, pulmonary artery compliance decreases leading to earlier pulmonary valve closure and narrowed splitting.<ref name="isbn0-07-055417-X">{{cite book |author=Alexander, R. McNeill; Hurst, J. Willis; Schlant, Robert C. |title=The Heart, arteries and veins |publisher=McGraw-Hill, Health Professions Division |location=New York |year=1994 |pages= |isbn=0-07-055417-X |oclc= |doi= |accessdate=}}</ref> | ||
* Widened splitting of S2: widened splitting may occur later if right ventricular failure or bundle branch block develops. <ref name="isbn0-7817-7012-2">{{cite book |author=Thompson, Paul Richard; Topol, Eric J.; Califf, Robert M.; Prystowsky, Eric N.; Thomas, James Alan |title=Textbook of cardiovascular medicine |publisher=Lippincott Williams & Wilkins |location=Hagerstwon, MD |year=2007 |pages= |isbn=0-7817-7012-2 |oclc= |doi= |accessdate=}}</ref> | * Widened splitting of S2: widened splitting may occur later if right ventricular failure or bundle branch block develops.<ref name="isbn0-7817-7012-2">{{cite book |author=Thompson, Paul Richard; Topol, Eric J.; Califf, Robert M.; Prystowsky, Eric N.; Thomas, James Alan |title=Textbook of cardiovascular medicine |publisher=Lippincott Williams & Wilkins |location=Hagerstwon, MD |year=2007 |pages= |isbn=0-7817-7012-2 |oclc= |doi= |accessdate=}}</ref> | ||
=====Extra Heart Sounds===== | =====Extra Heart Sounds===== | ||
* S4: due to right ventricular hypertrophy and therefore reduced compliance secondary to pulmonary hypertension. It is increased with inspiration. | * S4: due to right ventricular hypertrophy and therefore reduced compliance secondary to pulmonary hypertension. It is increased with inspiration. | ||
* S3: if right ventricular failure develops. Increased with inspiration. <ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref> | * S3: if right ventricular failure develops. Increased with inspiration.<ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref> | ||
=====Additional Sounds===== | =====Additional Sounds===== | ||
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* Pulsatile liver: due to tricuspid regurgitation <ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref> | * Pulsatile liver: due to tricuspid regurgitation <ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref> | ||
=== | ===Extremities=== | ||
* [[Edema]]: indicates right ventricular failure <ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref> | * [[Edema]]: indicates [[right ventricular failure]]<ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref> | ||
* [[Cool extremities]]: indicates severe disease | * [[Cool extremities]]: indicates severe disease | ||
Shown below is an image depicting the physical examination findings of PH. | Shown below is an image depicting the physical examination findings of PH. | ||
<figure-inline>[[Image:Pulmonary_hypertension_physical_exam.png|1095x1095px]]</figure-inline> | <figure-inline><figure-inline>[[Image:Pulmonary_hypertension_physical_exam.png|1095x1095px]]</figure-inline></figure-inline> | ||
==References== | ==References== | ||
Revision as of 15:56, 26 March 2018
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Editor(s)-in-Chief: C. Michael Gibson, M.S., M.D. [1] ; Assistant Editor(s)-in-Chief: Lisa Prior; Ralph Matar
Overview
Pulmonary hypertension (PH) can present with a myriad of physical signs that develop on a spectrum corresponding to the severity of the disease. PH is often initially associated with a loud P2, parasternal heave, and narrowed splitting of the second heart sound on physical examination. A third heart sound (S3) may also be heard on auscultation. As PH worsens, right ventricular failure can develop, which can be associated with as increased jugular venous pressure (JVP), ascites, peripheral edema, hepatojugular reflux, and clubbing. A pansystolic murmur of tricuspid insufficiency can also be present on physical examination and is suggestive long-standing PH.
Physical Examination
General Appearance
The appearance of the patient may give clues as to the etiology of the condition. For example in COPD, one of the most common causes of pulmonary hypertension, the patient may appear short of breath with pursed lips breathing and use of accessory muscles. Later on in severe disease, the patient may appear cyanotic with extremities cold to the touch.[1]
Pulse
The pulse may be diminished. This usually occurs in more severe disease.[1]
Skin
- Telangiectasia: suggestive of scleroderma
- Digital ulceration: suggestive of scleroderma
- Sclerodactyly: suggestive of scleroderma
- Spider nevi: suggestive of liver disease
- Palmar erythema: suggestive of liver disease
- Clubbing: may be indicative of congenital heart disease or pulmonary veno-occlusive disease[2]
JVP
Assessment of the JVP in pulmonary hypertension involves assessing the 'a' wave (coincides with atrial contraction), the 'v' wave (coincides with atrial filling) and the height of the JVP column above the sternal angle. Physical findings may include:
- Prominent 'a' wave: due to forced atrial contraction
- Prominent 'v' wave: later if tricuspid regurgitation develops with right ventricular failure
- Elevated JVP: can be present if right ventricular failure develops
- Postive Kussmaul's sign: JVP elevation during inspiration (the opposite of what normally happens) because of right ventricular failure[1]
- Positive abdominojugular reflux: JVP rises and remains elevated during a period of over 10 seconds whilst abdominal pressure is applied. This may be present if right ventricular failure develops.[1]
Lungs
- Lung exam is generally normal.
- Crackles upon inspirations are indicative of interstitial lung disease.
Cardiovascular
An holistic precordial assessment of pulmonary hypertension involves palpating the precordium for heaves and thrills and ausculatating to assess first and second heart sounds, splitting of the second heart sound and determining if there any added heart sounds or murmurs. Physical findings may include the following:
Palpation
- Left parasternal heave: due to hyperdynamic right ventricle
- Palpable P2: correlates with severe disease [1]
Ausculation
First and second heart sound (S1,S2)
- Loud P2 component of S2: this is due to the forceful closure of the valve because of increased pulmonary pressure. It can be heard mostly in the pulmonary area (upper right sternal border). If it is evident at the cardiac apex, this indicates more severe disease. It is best appreciated on inspiration.[3]
Splitting of S2
- Narrowed splitting of S2: in chronic pulmonary hypertension, pulmonary artery compliance decreases leading to earlier pulmonary valve closure and narrowed splitting.[4]
- Widened splitting of S2: widened splitting may occur later if right ventricular failure or bundle branch block develops.[3]
Extra Heart Sounds
- S4: due to right ventricular hypertrophy and therefore reduced compliance secondary to pulmonary hypertension. It is increased with inspiration.
- S3: if right ventricular failure develops. Increased with inspiration.[1]
Additional Sounds
- Systolic pulmonary ejection click: increased with inspiration
Murmurs
- Ejection midsystolic murmur: increased with inspiration
- Diastolic murmur (Graham-Steele murmur): indicates pulmonary regurgitation
- Pansystolic murmur: indicates tricuspid regurgitation and developing right ventricular failure[5]
Abdomen
Findings in the abdomen include:
- Ascites: indicates right ventricular failure
- Painful hepatomegaly: indicates right ventricular failure
- Pulsatile liver: due to tricuspid regurgitation [1]
Extremities
- Edema: indicates right ventricular failure[1]
- Cool extremities: indicates severe disease
Shown below is an image depicting the physical examination findings of PH.
<figure-inline><figure-inline>
</figure-inline></figure-inline>
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP (2009). Clinical Examination: A Systematic Guide to Physical Diagnosis. Edinburgh: Churchill Livingstone. ISBN 0-7295-3905-9.
- ↑ Galiè N, Hoeper MM, Humbert M, Torbicki A, Vachiery JL, Barbera JA; et al. (2009). "Guidelines for the diagnosis and treatment of pulmonary hypertension: the Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS), endorsed by the International Society of Heart and Lung Transplantation (ISHLT)". Eur Heart J. 30 (20): 2493–537. doi:10.1093/eurheartj/ehp297. PMID 19713419.
- ↑ 3.0 3.1 Thompson, Paul Richard; Topol, Eric J.; Califf, Robert M.; Prystowsky, Eric N.; Thomas, James Alan (2007). Textbook of cardiovascular medicine. Hagerstwon, MD: Lippincott Williams & Wilkins. ISBN 0-7817-7012-2.
- ↑ Alexander, R. McNeill; Hurst, J. Willis; Schlant, Robert C. (1994). The Heart, arteries and veins. New York: McGraw-Hill, Health Professions Division. ISBN 0-07-055417-X.
- ↑ Clark, Michael; Kumar, Parveen J. (2009). Kumar and Clark's clinical medicine. St. Louis, Mo: Elsevier Saunders. ISBN 0-7020-2993-9.