Pulmonic regurgitation physical examination

Pulmonic regurgitation Microchapters
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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]

Overview

Physical examination findings of pulmonary regurgitation includes increased JVP, prominent "a" wave, "v" wave in the neck. 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.

Physical Examination

Appearance of the Patient

• Patients are usually well-appearing.
• Certain causes of PR may manifest with typical Marfanoid habitus.

Vital Signs

• Temperature: Fever (high-grade) may be demonstrated among patients with IE
• Blood pressure: Usually normal
• Heart rate: Tachycardia with regular pulse or (ir)regularly irregular pulse is an important feature of PR.
• Weak/bounding pulse / pulsus alternans / paradoxical pulse / asymmetric pulse
• Respiratory rate.*Tachypnea / bradypnea
• Oxygen saturation (at room air):
• Hypothermia / hyperthermia may be present
• High/low blood pressure with normal pulse pressure / wide pulse pressure / narrow pulse pressure

Skin

• Cyanosis
• Jaundice
• Pallor
• Bruises

HEENT

• Evidence of trauma: In PR due to trauma] a stabbing chest wound is visible and is a surgical emergency.
• Icteric sclera
• Ocular, visual, ophthalmoscopic, hearing, nasal, facial and throat exams are normal.
• Erythematous throat with/without tonsillar swelling, exudates, and/or petechiae.

Neck

• Raised JVP/ Jugular venous distension
  • Prominent "a wave" may be present.
  • 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
• Fine/coarse crackles upon auscultation of the lung bases/apices unilaterally/bilaterally
• Vesicular breath sounds
• Expiratory/inspiratory wheezing with normal / delayed expiratory phase

Abdomen

• Abdominal tenderness in the right upper abdominal quadrant demonstrates hepatomegaly due to right heart failure.
• A palpable abdominal mass in the right/left upper/lower abdominal quadrant
• Hepatomegaly / splenomegaly / hepatosplenomegaly due to right heart failure.

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.
• Cyanosis
• Pitting/non-pitting edema of the upper/lower extremities
• Muscle atrophy

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

• Lesions
• Precordial bulge
• Visible apex beat
• A scar of previous surgery may be present and may indicate TOF repair (median sternotomy scar)

Palpation of the precordium

• Apical impulse (lift or heave) is usually present at the left lower sternal border because of right ventricular dilation.
• right ventricular heave may be present due to pulmonary hypertension. Heaves are best felt with the heel of the hand at the sternal border.

Auscultation

Heart Sounds

• Pulmonic regurgitation is associated with wide splitting of S₂.
• P2 is accentuated due to pulmonary hypertension.
• P2 is absent/inaudible in case of, absent pulmonic valves (congenital or secondary to surgical resection).
• A right-sided S₃ may be audible and may also be accentuated on inspiration.
• Likewise, a right-sided S₄ may also be audible and accentuated on inspiration.

Murmur

• Classically a high-pitched early-diastolic murmur is heard at left upper sternal area.
• Murmur of residual pulmonic regurgitation after Tetralogy of Fallot repair:
  • It is a low-pitched and soft murmur.
  • Best heard along with the second or third intercostal spaces adjacent to the left sternal border.
  • It is accentuated by squatting and inspiration.
  • It is made softer by Valsalva maneuvers or expiration.

• Murmur of pulmonic regurgitation associated with Pulmonic hypertension:
  • 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 murmurs like that of aortic regurgitation.
  • Best heard along the left parasternal region.
  • It is accentuated by inspiration.