Pulmonic regurgitation physical examination
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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
- 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[1]
- Blood pressure: Usually normal. Patients with carcinoid heart disease may demonstrate either pronounced hypotension or hypertension (due to relative quantities of vasoactive substances such as serotonin)[2]
- 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 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.[3]
- Among patients with carcinoid syndrome, the physical examination may reveal pellagra with dermatitis of sun-exposed areas.[2]
HEENT
- Evidence of trauma: In PR due to trauma] a stabbing chest wound is visible and is a surgical emergency.
- Ocular, visual, ophthalmoscopic, hearing, nasal, facial and throat exams are normal.
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
- Vesicular breath sounds
Abdomen
- Abdominal tenderness in the right upper abdominal quadrant demonstrates hepatomegaly due to right heart failure.[6]
- Hepatosplenomegaly due to right heart failure.[6]
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.[6]
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]
- 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.
- The pulsations of dilated pulmonary arteries may be felt in second intercostal space on the lateral sternal border.
Auscultation
Heart Sounds[9][8][10]
- Pulmonic regurgitation is associated with wide splitting of S2. IDPA also demonstrate similar findings.
- 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.
- Extensive aneurysm of pulmonary artery may demonstrate a soft S2
Murmur
- Classically a high-pitched early-diastolic murmur is heard at left upper sternal area.
- Murmur of residual PR after Tetralogy of Fallot repair[11]:
- It is a low-pitched and soft murmur.
- Best heard along with the second or third intercostal space adjacent to the left sternal border.
- It is accentuated by squatting and on inspiration.
- It is made softer by Valsalva maneuvers or expiration.
- Murmur of pulmonic regurgitation associated with Pulmonic hypertension:[12][13]
- 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 on inspiration.
- Murmur of PR associated with Idiopathic Dilatation of Pulmonary Artery (IDPA)[8][14]:
- PR of varying severities is observed.
- A pulmonic ejection systolic murmur of inconsistent nature is usually demonstrated (not transmitted to subclavicular or interscapular area). On the contrary, the transmittance is observed in pulmonary stenosis with dilated pulmonary artery.
- A diastolic murmur is rare but may be demonstrated.
References
- ↑ 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.
- ↑ 2.0 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Khavandi, Ali (2014). Essential revision notes for the cardiology KBA. Oxford: Oxford University Press. ISBN 978-0199654901.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Würtemberger G, Dinkel E, Joos A, Matthys H (1989). "[Pulmonary hypertension. Clinical picture and therapy]". Radiologe. 29 (6): 263–6. PMID 2662241.
- ↑ 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.