Right ventricular outflow tract obstruction physical examination: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{Right ventricular outflow tract obstruction}} | {{Right ventricular outflow tract obstruction}} | ||
{{CMG}}; '''Associate Editor-In-Chief:''' {{CZ}} | {{CMG}}; '''Associate Editor-In-Chief:''' {{CZ}} | ||
==Overview== | ==Overview== | ||
Pulmonic stenosis is an acynotic condition which may present with [[cyanosis]] when associated with interatrial right-to-left shunt. Patients are normally healthy but on [[auscultation]] an ejection systolic murmur of grade II-VI to V-VI is best heard at the left upper sternal border. | |||
==Physical Examination== | ==Physical Examination== | ||
===Appearance of the patient=== | ===Appearance of the patient=== | ||
*A small percentage of patients have [[Noonan's syndrome]] | * Patients appear healthy | ||
:Small stature, retarded, triangle-faced shape, webbed neck, [[ptosis]], [[hypertelorism]], low set ears, and [[pectus]]. | * A small percentage of patients have [[Noonan's syndrome]]: | ||
:[[Noonan syndrome]] is familial. | :* Small stature, retarded, triangle-faced shape, webbed neck, [[ptosis]], [[hypertelorism]], low set ears, and [[pectus]]. | ||
:*[[Noonan syndrome]] is familial. | |||
===Neck=== | ===Neck=== | ||
*If the lesion is severe (>75 mm Hg pressure gradient) then there is a giant [[a wave]] secondary to the reduced compliance of the right ventricule. | *If the lesion is severe (>75 mm Hg pressure gradient) then there is a giant "[[a wave]]" secondary to the reduced compliance of the right ventricule, otherwise [[JVP]] is normal. | ||
===Heart=== | ===Heart=== | ||
* A | ====Palpation==== | ||
* Right ventricular heave or lift is present in moderate to severe pulmonary stenosis. | |||
* A precordial thrill is present in case of severe obstruction at the left suprasternal notch and the left upper sternal border. | |||
====Auscultation==== | |||
=====Heart Sounds===== | |||
* First heart sound ([[S1]]) is normal or loud. | |||
* Second heart sound ([[S2]]) is widely split. | |||
:* In mild forms, the pulmonic component of the second [[heart sound]] is loud. | |||
:* In severe forms, the pulmonic component of the second heart sound may be missing. | |||
* Fourth heart sound ([[S4]]) is heard at the left lower sternal border in presence of severe stenosis. | |||
* Ejection click is often present and best heard at the left sternal border. Loudness of the click decreases with inspiration. | |||
=====Murmurs===== | |||
* There is a loud systolic ejection [[murmur]] loudest in the second left intercostal space which peaks in late [[systole]]. | * There is a loud systolic ejection [[murmur]] loudest in the second left intercostal space which peaks in late [[systole]]. | ||
* | * It radiates into axillae and back. | ||
* Severe stenosis is clinical assessed by: | |||
:* long duration and late peaking of the ejection systolic murmur, | |||
:* short interval between the first heart sound (S1) and ejection click, | |||
:* increase in width between aortic (A2) and pulmonic component (P2) of the second heart sound (S2), and | |||
:* soft pulmonary component of second heart sound (P2) | |||
* Other murmurs: | |||
:* Severe pulmonary stenosis can lead to [[tricuspid regurgitation]] which results in an holosystolic murmur best heard at the left lower sternal border. | |||
:* An associated [[pulmonary regurgitation]] will result in an early diastolic decrescendo murmur. | |||
{{#ev:youtube|SWW1PTL9Jbw}} | |||
==References== | ==References== | ||
Latest revision as of 17:14, 7 November 2013
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Right ventricular outflow tract obstruction Microchapters |
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Differentiating Right ventricular outflow tract obstruction from other Diseases |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]
Overview
Pulmonic stenosis is an acynotic condition which may present with cyanosis when associated with interatrial right-to-left shunt. Patients are normally healthy but on auscultation an ejection systolic murmur of grade II-VI to V-VI is best heard at the left upper sternal border.
Physical Examination
Appearance of the patient
- Patients appear healthy
- A small percentage of patients have Noonan's syndrome:
- Small stature, retarded, triangle-faced shape, webbed neck, ptosis, hypertelorism, low set ears, and pectus.
- Noonan syndrome is familial.
Neck
- If the lesion is severe (>75 mm Hg pressure gradient) then there is a giant "a wave" secondary to the reduced compliance of the right ventricule, otherwise JVP is normal.
Heart
Palpation
- Right ventricular heave or lift is present in moderate to severe pulmonary stenosis.
- A precordial thrill is present in case of severe obstruction at the left suprasternal notch and the left upper sternal border.
Auscultation
Heart Sounds
- In mild forms, the pulmonic component of the second heart sound is loud.
- In severe forms, the pulmonic component of the second heart sound may be missing.
- Fourth heart sound (S4) is heard at the left lower sternal border in presence of severe stenosis.
- Ejection click is often present and best heard at the left sternal border. Loudness of the click decreases with inspiration.
Murmurs
- There is a loud systolic ejection murmur loudest in the second left intercostal space which peaks in late systole.
- It radiates into axillae and back.
- Severe stenosis is clinical assessed by:
- long duration and late peaking of the ejection systolic murmur,
- short interval between the first heart sound (S1) and ejection click,
- increase in width between aortic (A2) and pulmonic component (P2) of the second heart sound (S2), and
- soft pulmonary component of second heart sound (P2)
- Other murmurs:
- Severe pulmonary stenosis can lead to tricuspid regurgitation which results in an holosystolic murmur best heard at the left lower sternal border.
- An associated pulmonary regurgitation will result in an early diastolic decrescendo murmur.
{{#ev:youtube|SWW1PTL9Jbw}}