Pulmonic regurgitation physical examination: Difference between revisions

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{{Pulmonic regurgitation}}
{{Pulmonic regurgitation}}


{{CMG}}{{AE}}{{AKI}}; {{AA}}
{{CMG}}{{AE}}{{AKI}}; {{AA}}, {{JA}}


==Overview==
==Overview==
Physical examination findings of [[pulmonary regurgitation]] (PR) includes a well-appearing [[patient]]. On neck exam, increased [[JVP]], prominent [["a" wave]], [["v" wave]] in the neck may be observed. Precordial (cardiac) exam may reveal a palpable [[apical impulse]] (lift or heave) is usually present at the left lower sternal border because of [[right ventricular dilation]]. On [[auscultation]], it may be associated with wide splitting of [[S2]] with right sided [[S3]] accentuated with respiration. [[Murmur]] of [[pulmonic regurgitation]] may vary depending on the underlying cause. [[Pedal edema]] and [[hepatomegaly]] demonstrate [[right heart failure]].


==Physical Examination==
==Physical Examination==
===Appearance of the Patient===
*[[Patients]] are usually well-appearing.
*Certain causes of [[PR]] may manifest with typical [[Marfan's syndrome physical examination|Marfanoid habitus]].
===Vital Signs===
*[[Temperature]]: [[Fever]] (high-grade) may be demonstrated among [[patients]] with [[IE]]<ref name="pmid27582414">{{cite journal |vauthors=Holland TL, Baddour LM, Bayer AS, Hoen B, Miro JM, Fowler VG |title=Infective endocarditis |journal=Nat Rev Dis Primers |volume=2 |issue= |pages=16059 |date=September 2016 |pmid=27582414 |pmc=5240923 |doi=10.1038/nrdp.2016.59 |url=}}</ref>
*[[Blood pressure]]: Usually normal. [[Patients]] with [[carcinoid syndrome|carcinoid heart disease]] may demonstrate either pronounced [[hypotension]] or [[hypertension]] (due to relative quantities of [[vasoactive substances]] such as [[serotonin]])<ref name="pmid15367531">{{cite journal |vauthors=Fox DJ, Khattar RS |title=Carcinoid heart disease: presentation, diagnosis, and management |journal=Heart |volume=90 |issue=10 |pages=1224–8 |date=October 2004 |pmid=15367531 |pmc=1768473 |doi=10.1136/hrt.2004.040329 |url=}}</ref>
*[[Heart rate]]: [[Tachycardia]] is an important feature of [[PR]]. The [[pulse]] may be regular or uncommonly irregular in cases of [[atrial fibrillation]] which is a complications of [[PR]]. [[Tachycardia]] may also be demonstrated in [[carcinoid syndrome|carcinoid heart disease]]. 
*[[Respiratory rate]] is normal.
*[[Oxygen saturation]] (at room air): Normal (acyanotic heart disease).
===Skin===
*[[Cyanosis]] is not usually present. [[PR]] is not a [[cyanotic heart disease]]. Although rare, [[cyanosis]] in the immediate postoperative period [[congenital heart disease]] may demonstrate right-left shunt and require intervention.<ref name="pmid15227016">{{cite journal |vauthors=Morales CE, Eng-Cecena L, Angelini P, Dear WE, de Castro CM, Hall RJ |title=Cyanosis after surgical correction of pulmonary valve stenosis: an old problem revisited |journal=Tex Heart Inst J |volume=12 |issue=3 |pages=265–8 |date=September 1985 |pmid=15227016 |pmc=341868 |doi= |url=}}</ref>
*Among [[patients]] with [[carcinoid syndrome]], the [[physical examination]] may reveal [[pellagra]] with [[dermatitis]] of sun-exposed areas.<ref name="pmid15367531">{{cite journal |vauthors=Fox DJ, Khattar RS |title=Carcinoid heart disease: presentation, diagnosis, and management |journal=Heart |volume=90 |issue=10 |pages=1224–8 |date=October 2004 |pmid=15367531 |pmc=1768473 |doi=10.1136/hrt.2004.040329 |url=}}</ref>
===HEENT===
* Evidence of trauma: In [[PR]] due to [[trauma]]] a stabbing chest wound is visible and is a surgical emergency.
* [[Ocular]], [[visual]], [[ophthalmoscopy|ophthalmoscopic]], [[hearing]], [[nasal]], [[facial]] and [[throat]] exams are normal.


===Neck===
===Neck===
* Increased [[JVP]]
* Raised [[JVP]]/ [[Jugular venous distension]]<ref>{{cite book | last = Khavandi | first = Ali | title = Essential revision notes for the cardiology KBA | publisher = Oxford University Press | location = Oxford | year = 2014 | isbn = 978-0199654901 }} </ref><ref name="pmid24085809">{{cite journal |vauthors=Chua Chiaco JM, Parikh NI, Fergusson DJ |title=The jugular venous pressure revisited |journal=Cleve Clin J Med |volume=80 |issue=10 |pages=638–44 |date=October 2013 |pmid=24085809 |pmc=4865399 |doi=10.3949/ccjm.80a.13039 |url=}}</ref>
* Prominent "[[a wave]]" may be present
** Prominent "[[a wave]]" may be present.
* Prominent "[[v wave]]" may be present in presence of [[tricuspid regurgitation]]
** Prominent "[[v wave]]" may be present in presence of [[tricuspid regurgitation]].
*[[Hepatojugular reflux]] may be present in case of severe [[PR]] with right [[heart failure]].
===Lungs===
*Symmetric chest expansion
*Vesicular breath sounds


===Palpation===
===Abdomen===
* A palpable impulse (lift or heave) is usually present at the left lower sternal border because of right ventricular dilation.
*[[Abdominal tenderness]] in the right upper abdominal quadrant demonstrates [[hepatomegaly]] due to [[right heart failure]].<ref name="pmid22942628">{{cite journal |vauthors=Alvarez AM, Mukherjee D |title=Liver abnormalities in cardiac diseases and heart failure |journal=Int. J. Angiol. |volume=20 |issue=3 |pages=135–42 |date=September 2011 |pmid=22942628 |pmc=3331650 |doi=10.1055/s-0031-1284434 |url=}}</ref>
*[[Hepatosplenomegaly]] due to [[right heart failure]].<ref name="pmid22942628">{{cite journal |vauthors=Alvarez AM, Mukherjee D |title=Liver abnormalities in cardiac diseases and heart failure |journal=Int. J. Angiol. |volume=20 |issue=3 |pages=135–42 |date=September 2011 |pmid=22942628 |pmc=3331650 |doi=10.1055/s-0031-1284434 |url=}}</ref>
[[File:Clubbing TOF patient.pg.jpg|thumb|300px|right|Digital clubbing with cyanotic nail beds in an adult with tetralogy of Fallot - By Herbert L. Fred, MD and Hendrik A. van Dijk - http://cnx.org/content/m14916/latest/, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=11893501]]
===Back===
*Back exam is normal.
===Genitourinary===
*[[Genitourinary]] exam is normal.
===Extremities===
*[[Clubbing]] may be demonstrated in a patient with a history of [[TOF]].
*Pitting [[edema]] of the lower extremities demonstrates [[right heart failure]].<ref name="pmid22942628">{{cite journal |vauthors=Alvarez AM, Mukherjee D |title=Liver abnormalities in cardiac diseases and heart failure |journal=Int. J. Angiol. |volume=20 |issue=3 |pages=135–42 |date=September 2011 |pmid=22942628 |pmc=3331650 |doi=10.1055/s-0031-1284434 |url=}}</ref>


===Neuromuscular===
*Patient is oriented to persons, place, and time.
*The neuromuscular exam is normal.
==Cardiac exam==
===Position / Lighting / Draping===
*Position - The [[patient]] should be [[Supine position|supine]] and the bed or examination table should be at a 45-degree angle. The patient's hands should remain at her sides with her head resting on a pillow.
*Lighting - adjusted so that it is ideal.
*Draping - the chest should be fully exposed.
===Inspection===
The patient should be examined for a [[scar]] of previous [[surgery]] may be present and may indicate [[TOF]] repair ([[median sternotomy]] scar)
===Palpation of the precordium<ref>{{cite book | last = Khavandi | first = Ali | title = Essential revision notes for the cardiology KBA | publisher = Oxford University Press | location = Oxford | year = 2014 | isbn = 978-0199654901 }} </ref><ref name="pmid28228295">{{cite journal |vauthors=Malviya A, Jha PK, Kalita JP, Saikia MK, Mishra A |title=Idiopathic dilatation of pulmonary artery: A review |journal=Indian Heart J |volume=69 |issue=1 |pages=119–124 |date=2017 |pmid=28228295 |pmc=5319124 |doi=10.1016/j.ihj.2016.07.009 |url=}}</ref>===
* [[Apical impulse]] (lift or heave) is usually present at the left lower sternal border because of [[right ventricular dilation]].
*[[Right ventricle|Right ventricular]] [[heave]] may be present due to [[pulmonary hypertension]]. [[Heave]]s are best felt with the heel of the hand at the [[sternum|sternal]] border.
*The pulsations of dilated [[pulmonary artery|pulmonary arteries]] may be felt in second [[intercostal space]] on the [[Left sternal border|lateral sternal border]].
===Auscultation===
===Auscultation===
====Heart Sounds====
====Heart Sounds<ref>{{cite book | last = Khavandi | first = Ali | title = Essential revision notes for the cardiology KBA | publisher = Oxford University Press | location = Oxford | year = 2014 | isbn = 978-0199654901 }} </ref><ref name="pmid28228295">{{cite journal |vauthors=Malviya A, Jha PK, Kalita JP, Saikia MK, Mishra A |title=Idiopathic dilatation of pulmonary artery: A review |journal=Indian Heart J |volume=69 |issue=1 |pages=119–124 |date=2017 |pmid=28228295 |pmc=5319124 |doi=10.1016/j.ihj.2016.07.009 |url=}}</ref><ref>{{cite book | last = Khavandi | first = Ali | title = Essential revision notes for the cardiology KBA | publisher = Oxford University Press | location = Oxford | year = 2014 | isbn = 978-0199654901 }} </ref>====
* Pulmonic regurgitation is associated with wide splitting of S<sub>2</sub>.
* [[Pulmonic regurgitation]] is associated with wide splitting of [[Heart sounds#Second heart sound S2|S<sub>2</sub>]]. IDPA also demonstrate similar findings.
* [[P2]] is accentuated because of presence of pulmonary regurgitation. In case of, absence of pulmonic valves (congenital or secondary to surgical resection), P2 is inaudible.
* [[P2]] is accentuated due to [[pulmonary hypertension]]
* A right-sided S<sub>3</sub> may be audible and may also be accentuated with inspiration.
*[[P2]] is absent/inaudible in case of, absent [[pulmonic valves]] ([[congenital]] or secondary to surgical resection).
* Likewise, a right-sided [[S4]] may also be audible and accentuated with inspiration.
* A right-sided [[Heart sounds#Third heart sound S3|S<sub>3</sub>]] may be audible and may also be accentuated on [[inspiration]].
* Likewise, a right-sided [[Heart sounds#Fourth heart sound S4|S<sub>4</sub>]] may also be audible and accentuated on [[inspiration]].
*Extensive [[aneurysm]] of [[pulmonary artery]] may demonstrate a soft [[Heart sounds#Second heart sound S2|S<sub>2</sub>]]


====Murmur====
====Murmur====
* Murmur of residual pulmonic regurgitation after [[Tetralogy of Fallot]] repair:
*Classically a high-pitched early-[[diastole|diastolic]] murmur is heard at [[left sternal border|left upper sternal area]].
** It is a low-pitched and soft murmur.
* Murmur of residual [[PR]] after [[Tetralogy of Fallot]] repair<ref>{{cite book | last = Khavandi | first = Ali | title = Essential revision notes for the cardiology KBA | publisher = Oxford University Press | location = Oxford | year = 2014 | isbn = 978-0199654901 }} </ref>:
** Best heard along the second or third intercostal spaces adjacent to the left sternal border.
** It is a low-pitched and soft [[murmur]].
** It is accentuated by squatting and inspiration.
** Best heard along with the second or third [[intercostal space]] adjacent to the [[left sternal border]].
** It is made softer by Valsalva maneuvers or expiration.
** It is accentuated by [[squatting]] and on [[inspiration]].
** It is made softer by [[Valsalva maneuvers]] or [[expiration]].


* Murmur of pulmonic regurgitation associated with [[pulmonary hypertension|Pulmonic hypertension]]:
* [[Murmur]] of [[pulmonic regurgitation]] associated with [[pulmonary hypertension|Pulmonic hypertension]]:<ref name="BousvarosDeuchar19612">{{cite journal|last1=Bousvaros|first1=GeorgeA.|last2=Deuchar|first2=DennisC.|title=THE MURMUR OF PULMONARY REGURGITATION WHICH IS NOT ASSOCIATED WITH PULMONARY HYPERTENSION|journal=The Lancet|volume=278|issue=7209|year=1961|pages=962–964|issn=01406736|doi=10.1016/S0140-6736(61)90798-X}}</ref><ref name="pmid2662241">{{cite journal| author=Würtemberger G, Dinkel E, Joos A, Matthys H| title=[Pulmonary hypertension. Clinical picture and therapy]. | journal=Radiologe | year= 1989 | volume= 29 | issue= 6 | pages= 263-6 | pmid=2662241 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2662241  }} </ref>
** When the pulmonary artery systolic pressure exceeds 60 mm Hg, dilatation of the pulmonary artery ring may then result in Graham-Steell's murmur.
** When the [[pulmonary artery]] [[systolic pressure]] exceeds 60 mm Hg, dilatation of the [[pulmonary artery]] ring may then result in [[Graham-Steell's murmur]].
** It is a high-pitched, "blowing", early diastolic decrescendo murmur like that of [[aortic regurgitation]].
** It is a high-pitched, "blowing", early [[Diastolic heart murmur|diastolic decrescendo murmurs]] like that of [[aortic regurgitation]].
** Best heard along the left parasternal region.
** Best heard along the left parasternal region.
** It is accentuated by inspiration.
** It is accentuated on [[inspiration]].
 
*[[Murmur]] of [[PR]] associated with [[Idiopathic]] Dilatation of [[pulmonary artery|Pulmonary Artery]] (IDPA)<ref name="pmid28228295">{{cite journal |vauthors=Malviya A, Jha PK, Kalita JP, Saikia MK, Mishra A |title=Idiopathic dilatation of pulmonary artery: A review |journal=Indian Heart J |volume=69 |issue=1 |pages=119–124 |date=2017 |pmid=28228295 |pmc=5319124 |doi=10.1016/j.ihj.2016.07.009 |url=}}</ref><ref name="pmid13053026">{{cite journal |vauthors=KAPLAN BM, SCHLICHTER JG, GRAHAM G, MILLER G |title=Idiopathic congenital dilatation of the pulmonary artery |journal=J. Lab. Clin. Med. |volume=41 |issue=5 |pages=697–707 |date=May 1953 |pmid=13053026 |doi= |url=}}</ref>:
 
**[[PR]] of varying severities is observed.
==Sources==
** A pulmonic [[ejection systolic murmur]] of inconsistent nature is usually demonstrated (not transmitted to sub[[clavicle|clavicular]] or inter[[scapula|scapular]] area). On the contrary, the transmittance is observed in [[pulmonary stenosis]] with dilated [[pulmonary artery]].  
* Bouzbas, B., Kilner, P. J., & Gatzoulis, M. A. (2005). Pulmonary regurgitation: not a benign lesion. ''European Heart Journal'', 433-9. <ref name="pmid15640261">{{cite journal| author=Bouzas B, Kilner PJ, Gatzoulis MA| title=Pulmonary regurgitation: not a benign lesion. | journal=Eur Heart J | year= 2005 | volume= 26 | issue= 5 | pages= 433-9 | pmid=15640261 | doi=10.1093/eurheartj/ehi091 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15640261  }} </ref>
** A [[diastolic murmur]] is rare but may be demonstrated.
* Wessel, H. U., Cunningham, W. J., Paul, M. H., Bastanier, C. K., Muster, A. J., & Idriss, F. S. (1980). Exercise performance in tetralogy of Fallot after intracardiac repair. ''Journal of Thoracic and Cardiovascular Surgery'', 582-93. <ref name="pmid7421291">{{cite journal| author=Wessel HU, Cunningham WJ, Paul MH, Bastanier CK, Muster AJ, Idriss FS| title=Exercise performance in tetralogy of Fallot after intracardiac repair. | journal=J Thorac Cardiovasc Surg | year= 1980 | volume= 80 | issue= 4 | pages= 582-93 | pmid=7421291 | doi= | pmc= | url= }} </ref>
* Shimazaki, Y., Blackstone, E. H., & Kirklin, J. W. (1984). The natural history of isolated congenital pulmonary valve incompetence: surgical implications. ''Journal of Thoracic and Cardiovascular Surgery'', 257-9. <ref name="pmid6207619">{{cite journal| author=Shimazaki Y, Blackstone EH, Kirklin JW| title=The natural history of isolated congenital pulmonary valve incompetence: surgical implications. | journal=Thorac Cardiovasc Surg | year= 1984 | volume= 32 | issue= 4 | pages= 257-9 | pmid=6207619 | doi=10.1055/s-2007-1023399 | pmc= | url= }} </ref>
* Geva, T., Sandweiss, B. M., Gauvreau, K., Lock, J. E., & Powell, A. (2004). Factors associated with impaired clinical status in long-term survivors of tetralogy of Fallot repair evaluated by magnetic resonance imaging. ''Journal of the American College of Cardiology'', 1068-74. <ref name="pmid15028368">{{cite journal| author=Geva T, Sandweiss BM, Gauvreau K, Lock JE, Powell AJ| title=Factors associated with impaired clinical status in long-term survivors of tetralogy of Fallot repair evaluated by magnetic resonance imaging. | journal=J Am Coll Cardiol | year= 2004 | volume= 43 | issue= 6 | pages= 1068-74 | pmid=15028368 | doi=10.1016/j.jacc.2003.10.045 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15028368  }} </ref>


==References==
==References==

Latest revision as of 12:46, 8 August 2020

Pulmonic regurgitation Microchapters

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Overview

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Pathophysiology

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Epidemiology and Demographics

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Aravind Kuchkuntla, M.B.B.S[2]; Aysha Anwar, M.B.B.S[3], Javaria Anwer M.D.[4]

Overview

Physical examination findings of pulmonary regurgitation (PR) includes a well-appearing patient. On neck exam, increased JVP, prominent "a" wave, "v" wave in the neck may be observed. Precordial (cardiac) exam may reveal a palpable apical impulse (lift or heave) is usually present at the left lower sternal border because of right ventricular dilation. On auscultation, it may be associated with wide splitting of S2 with right sided S3 accentuated with respiration. Murmur of pulmonic regurgitation may vary depending on the underlying cause. Pedal edema and hepatomegaly demonstrate right heart failure.

Physical Examination

Appearance of the Patient

Vital Signs

Skin

HEENT

Neck

Lungs

  • Symmetric chest expansion
  • Vesicular breath sounds

Abdomen

Digital clubbing with cyanotic nail beds in an adult with tetralogy of Fallot - By Herbert L. Fred, MD and Hendrik A. van Dijk - http://cnx.org/content/m14916/latest/, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=11893501

Back

  • Back exam is normal.

Genitourinary

Extremities

Neuromuscular

  • Patient is oriented to persons, place, and time.
  • The neuromuscular exam is normal.

Cardiac exam

Position / Lighting / Draping

  • Position - The patient should be supine and the bed or examination table should be at a 45-degree angle. The patient's hands should remain at her sides with her head resting on a pillow.
  • Lighting - adjusted so that it is ideal.
  • Draping - the chest should be fully exposed.

Inspection

The patient should be examined for a scar of previous surgery may be present and may indicate TOF repair (median sternotomy scar)

Palpation of the precordium[7][8]

Auscultation

Heart Sounds[9][8][10]

Murmur

References

  1. ↑ Holland TL, Baddour LM, Bayer AS, Hoen B, Miro JM, Fowler VG (September 2016). "Infective endocarditis". Nat Rev Dis Primers. 2: 16059. doi:10.1038/nrdp.2016.59. PMC 5240923. PMID 27582414.
  2. ↑ 2.0 2.1 Fox DJ, Khattar RS (October 2004). "Carcinoid heart disease: presentation, diagnosis, and management". Heart. 90 (10): 1224–8. doi:10.1136/hrt.2004.040329. PMC 1768473. PMID 15367531.
  3. ↑ Morales CE, Eng-Cecena L, Angelini P, Dear WE, de Castro CM, Hall RJ (September 1985). "Cyanosis after surgical correction of pulmonary valve stenosis: an old problem revisited". Tex Heart Inst J. 12 (3): 265–8. PMC 341868. PMID 15227016.
  4. ↑ Khavandi, Ali (2014). Essential revision notes for the cardiology KBA. Oxford: Oxford University Press. ISBN 978-0199654901.
  5. ↑ Chua Chiaco JM, Parikh NI, Fergusson DJ (October 2013). "The jugular venous pressure revisited". Cleve Clin J Med. 80 (10): 638–44. doi:10.3949/ccjm.80a.13039. PMC 4865399. PMID 24085809.
  6. ↑ 6.0 6.1 6.2 Alvarez AM, Mukherjee D (September 2011). "Liver abnormalities in cardiac diseases and heart failure". Int. J. Angiol. 20 (3): 135–42. doi:10.1055/s-0031-1284434. PMC 3331650. PMID 22942628.
  7. ↑ Khavandi, Ali (2014). Essential revision notes for the cardiology KBA. Oxford: Oxford University Press. ISBN 978-0199654901.
  8. ↑ 8.0 8.1 8.2 Malviya A, Jha PK, Kalita JP, Saikia MK, Mishra A (2017). "Idiopathic dilatation of pulmonary artery: A review". Indian Heart J. 69 (1): 119–124. doi:10.1016/j.ihj.2016.07.009. PMC 5319124. PMID 28228295.
  9. ↑ Khavandi, Ali (2014). Essential revision notes for the cardiology KBA. Oxford: Oxford University Press. ISBN 978-0199654901.
  10. ↑ Khavandi, Ali (2014). Essential revision notes for the cardiology KBA. Oxford: Oxford University Press. ISBN 978-0199654901.
  11. ↑ Khavandi, Ali (2014). Essential revision notes for the cardiology KBA. Oxford: Oxford University Press. ISBN 978-0199654901.
  12. ↑ Bousvaros, GeorgeA.; Deuchar, DennisC. (1961). "THE MURMUR OF PULMONARY REGURGITATION WHICH IS NOT ASSOCIATED WITH PULMONARY HYPERTENSION". The Lancet. 278 (7209): 962–964. doi:10.1016/S0140-6736(61)90798-X. ISSN 0140-6736.
  13. ↑ Würtemberger G, Dinkel E, Joos A, Matthys H (1989). "[Pulmonary hypertension. Clinical picture and therapy]". Radiologe. 29 (6): 263–6. PMID 2662241.
  14. ↑ KAPLAN BM, SCHLICHTER JG, GRAHAM G, MILLER G (May 1953). "Idiopathic congenital dilatation of the pulmonary artery". J. Lab. Clin. Med. 41 (5): 697–707. PMID 13053026.

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