Pulmonic regurgitation physical examination: Difference between revisions
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==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 | |||
*[[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=== | ===Neck=== | ||
* Raised [[JVP]]<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> | * 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 | |||
*Fine/coarse [[crackles]] upon auscultation of the lung bases/apices unilaterally/bilaterally | |||
*Vesicular breath sounds | |||
*Expiratory/inspiratory wheezing with normal / delayed expiratory phase | |||
===Palpation=== | ===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]]. | |||
[[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]]. | |||
*[[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 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 | |||
* 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]]. | * [[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]].<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> | *[[Right ventricle|right ventricular]] [[heave]] may be present due to [[pulmonary hypertension]].<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> Heaves are best felt with the heel of the hand at the [[sternum|sternal]] border. | ||
===Auscultation=== | ===Auscultation=== | ||
====Heart Sounds==== | ====Heart Sounds==== | ||
| Line 23: | Line 81: | ||
* [[P2]] is accentuated due to [[pulmonary hypertension]]<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>. | * [[P2]] is accentuated due to [[pulmonary hypertension]]<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>. | ||
*[[P2]] is absent/inaudible in case of, absent [[pulmonic valves]] ([[congenital]] or secondary to surgical resection).<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> | *[[P2]] is absent/inaudible in case of, absent [[pulmonic valves]] ([[congenital]] or secondary to surgical resection).<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> | ||
* A right-sided S<sub>3</sub> may be audible and may also be accentuated | * 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 S<sub>4</sub> may also be audible and accentuated | * Likewise, a right-sided [[Heart sounds#Fourth heart sound S4|S<sub>4</sub>]] may also be audible and accentuated on [[inspiration]]. | ||
====Murmur==== | ====Murmur==== | ||
*Classically a high-pitched early-[[diastole|diastolic]] murmur is heard at [[left sternal border|left upper sternal area]].<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> | *Classically a high-pitched early-[[diastole|diastolic]] murmur is heard at [[left sternal border|left upper sternal area]].<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> | ||
Revision as of 18:30, 6 August 2020
|
Pulmonic regurgitation Microchapters |
|
Diagnosis |
|---|
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.[1][2]
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[3]
- 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
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[4][5]
- 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.
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.[6] 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[7].
- P2 is absent/inaudible in case of, absent pulmonic valves (congenital or secondary to surgical resection).[8]
- 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.[9]
- Murmur of residual pulmonic regurgitation after Tetralogy of Fallot repair:[1]
- 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:[2]
- 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.
References
- ↑ 1.0 1.1 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.
- ↑ 2.0 2.1 Würtemberger G, Dinkel E, Joos A, Matthys H (1989). "[Pulmonary hypertension. Clinical picture and therapy]". Radiologe. 29 (6): 263–6. PMID 2662241.
- ↑ 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.
- ↑ Khavandi, Ali (2014). Essential revision notes for the cardiology KBA. Oxford: Oxford University Press. ISBN 978-0199654901.
- ↑ 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.
- ↑ Khavandi, Ali (2014). Essential revision notes for the cardiology KBA. Oxford: Oxford University Press. ISBN 978-0199654901.
- ↑ Khavandi, Ali (2014). Essential revision notes for the cardiology KBA. Oxford: Oxford University Press. ISBN 978-0199654901.
- ↑ Khavandi, Ali (2014). Essential revision notes for the cardiology KBA. Oxford: Oxford University Press. ISBN 978-0199654901.
- ↑ Khavandi, Ali (2014). Essential revision notes for the cardiology KBA. Oxford: Oxford University Press. ISBN 978-0199654901.