Ventricular septal defect physical examination: Difference between revisions

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{{Ventricular septal defect}}
{{Ventricular septal defect}}


{{CMG}}  '''Associate Editor-In-Chief:''' [[Priyamvada Singh]], [[MBBS]]; [[User:KeriShafer|Keri Shafer, M.D.]] [mailto:kshafer@bidmc.harvard.edu]; Leida Perez, M.D.


{{CMG}}and Leida Perez, M.D.
==Children==
 
===Small VSD===
'''Associate Editor-In-Chief:''' [[User:KeriShafer|Keri Shafer, M.D.]] [mailto:kshafer@bidmc.harvard.edu], [[Priyamvada Singh]], [[MBBS]]
 
__NOTOC__
 
 
==Physical Examination <ref> Braunwald Zipes Libby.  Heart disease: A textbook of cardiovascular medicine, 6th Edition chapter 43:W.B. Saunders ;.pp 1533</ref> ==
 
'''Children'''
 
 
'''Small VSD''':
 
* Asymptomatic  
* Asymptomatic  
* A systolic thrill may be palpable along the left sternal border
* A systolic thrill may be palpable along the left sternal border
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* In patients with small muscular defects, the murmur may end in mid systole because of systolic contraction of the septal musculature.
* In patients with small muscular defects, the murmur may end in mid systole because of systolic contraction of the septal musculature.


 
===Medium-Sized VSD===
'''Medium-Sized VSD''':
 
* Forceful left ventricular impulse
* Forceful left ventricular impulse
* Systolic thrill along left sternal border
* Systolic thrill along left sternal border
* Heart sound- split with accentuated pulmonic component , third heart sound (S3)(suggest increased flow across mitral valve)
* Heart sound- split with accentuated pulmonic component , third heart sound (S3)(suggest increased flow across mitral valve)
*[[Murmur]]
*[[Murmur]]
** Harsh holosystolic murmur at 3rd to 4th  intercostal space to left side of sternum (characteristic VSD murmur)
** Harsh holosystolic murmur at 3rd to 4th  intercostal space to left side of sternum (characteristic VSD murmur)
** Rumbling mid-diastolic murmur at cardiac apex suggesting increase flow across the mitral valve.
** Rumbling mid-diastolic murmur at cardiac apex suggesting increase flow across the mitral valve.
** Midsystolic ejection murmur due to increased flow across pulmonary valve.  
** Midsystolic ejection murmur due to increased flow across pulmonary valve.  


 
===Large-Sized VSD with Pulmonary Obstructive Disease===
 
'''Large-Sized VSD with Pulmonary Obstructive Disease''':
 
* Features similar to seen in medium sized VSD.
* Features similar to seen in medium sized VSD.
* In the first 2 years of age the patients have signs of left sided volume overload. After age 2 old, the patients have signs and symptoms of progressive pulmonary vascular obstructive disease. As a consequence, poor growth and left anterior thorax may bulge outward early.  
* In the first 2 years of age the patients have signs of left sided volume overload. After age 2 old, the patients have signs and symptoms of progressive pulmonary vascular obstructive disease. As a consequence, poor growth and left anterior thorax may bulge outward early.  
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* In the first two years there is a prominent LV impulse, but with the development of pulmonary hypertension, this LV prominence is diminished and cyanosis is present, worsens with effort and with time.
* In the first two years there is a prominent LV impulse, but with the development of pulmonary hypertension, this LV prominence is diminished and cyanosis is present, worsens with effort and with time.


==Adults==
===Small VSD===
*May be asymptomatic with no signs or symptoms
*[[Holosystolic murmur]] heard best at left sternal border in the 3rd and 4th intercostal space


'''Adults'''
===Moderate VSD===
 
Small VSD -
 
*asymptomatic
*Holosystolic murmur heard best at left sternal border in the 3rd and 4th intercostal space
 
 
'''Moderate VSD'''
 
* Displaced cardiac apex
* Displaced cardiac apex
* Harsh holosystolic murmur at 3rd to 4th  intercostal space to left side of sternum  
* Harsh holosystolic murmur at 3rd to 4th  intercostal space to left side of sternum  
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* Midsystolic ejection murmur due to increased flow across pulmonary valve.  
* Midsystolic ejection murmur due to increased flow across pulmonary valve.  


 
===Large VSD===
'''Large VSD'''
Large VSD may progress to [[Eisenmenger syndrome]]. Physical examination may reveal-
 
 
Large VSD may change to [[Eisenmenger syndrome]]. Physical examination may reveal-


* [[Central cyanosis]], [[Clubbing]] (suggesting hypoxemia)
* [[Central cyanosis]], [[Clubbing]] (suggesting hypoxemia)
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* Rhythm disturbances - [[Atrial fibrillation]], [[atrial flutter]], [[ventricular tachycardia]]
* Rhythm disturbances - [[Atrial fibrillation]], [[atrial flutter]], [[ventricular tachycardia]]
* Peripheral edema in case of right sided heart failure.
* Peripheral edema in case of right sided heart failure.
* [[Pulmonary hypertension]]-
* [[Pulmonary hypertension]]-
**right ventricular heave
**right ventricular heave
**palpable, loud P2
**palpable, loud P2
** right sided S4
** right sided S4
* [[Pulmonary regurgitation]]- high pitched decresendo diastolic murmur ([[Graham Steelle murmur]])
* [[Pulmonary regurgitation]]- high pitched decresendo diastolic murmur ([[Graham Steelle murmur]])


 
==Video Examples of Physical Examination Findings==
 
In first video one can appreciate '''the normal heart sound'''. On careful listening one can appreciate the '''S1 and S2 (lub-dub)'''
 
<youtube v=xS3jX1FYG-M/>
<youtube v=xS3jX1FYG-M/>


 
In the second video one can appreciate that the '''first and second heart sounds are not audible and a murmur that covers the whole systole is there'''. This is characteristic '''holosystolic murmur''' of '''ventricular septal defect'''
 
In first video one can appreciate '''the normal heart sound'''. On careful listening one can appreciate the '''S1 and S2 (lub-dub)'''
 
<youtube v=7oKz6J0Ay_I/>
<youtube v=7oKz6J0Ay_I/>
In the second video one can appreciate that the '''first and second heart sounds are not audible and a murmur that covers the whole systole is there'''. This is characteristic '''holosystolic murmur''' of '''ventricular septal defect'''


==References==
==References==
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[[Category: Cardiology]]
[[Category: Cardiology]]
[[Category:Pediatrics]]
[[Category:Mature chapter]]


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{{WH}}
{{WS}}
{{WS}}

Revision as of 14:13, 23 July 2011

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor-In-Chief: Priyamvada Singh, MBBS; Keri Shafer, M.D. [2]; Leida Perez, M.D.

Children

Small VSD

  • Asymptomatic
  • A systolic thrill may be palpable along the left sternal border
  • Loud holosystolic murmur (harsher quality than that of MR)localized to the left lower sternal border.
  • In patients with small muscular defects, the murmur may end in mid systole because of systolic contraction of the septal musculature.

Medium-Sized VSD

  • Forceful left ventricular impulse
  • Systolic thrill along left sternal border
  • Heart sound- split with accentuated pulmonic component , third heart sound (S3)(suggest increased flow across mitral valve)
  • Murmur
    • Harsh holosystolic murmur at 3rd to 4th intercostal space to left side of sternum (characteristic VSD murmur)
    • Rumbling mid-diastolic murmur at cardiac apex suggesting increase flow across the mitral valve.
    • Midsystolic ejection murmur due to increased flow across pulmonary valve.

Large-Sized VSD with Pulmonary Obstructive Disease

  • Features similar to seen in medium sized VSD.
  • In the first 2 years of age the patients have signs of left sided volume overload. After age 2 old, the patients have signs and symptoms of progressive pulmonary vascular obstructive disease. As a consequence, poor growth and left anterior thorax may bulge outward early.
  • JVD may be elevated due to RV failure.
  • In the first two years there is a prominent LV impulse, but with the development of pulmonary hypertension, this LV prominence is diminished and cyanosis is present, worsens with effort and with time.

Adults

Small VSD

  • May be asymptomatic with no signs or symptoms
  • Holosystolic murmur heard best at left sternal border in the 3rd and 4th intercostal space

Moderate VSD

  • Displaced cardiac apex
  • Harsh holosystolic murmur at 3rd to 4th intercostal space to left side of sternum
  • Rumbling mid-diastolic murmur at cardiac apex suggesting increase flow across the mitral valve.
  • Midsystolic ejection murmur due to increased flow across pulmonary valve.

Large VSD

Large VSD may progress to Eisenmenger syndrome. Physical examination may reveal-

Video Examples of Physical Examination Findings

In first video one can appreciate the normal heart sound. On careful listening one can appreciate the S1 and S2 (lub-dub) <youtube v=xS3jX1FYG-M/>

In the second video one can appreciate that the first and second heart sounds are not audible and a murmur that covers the whole systole is there. This is characteristic holosystolic murmur of ventricular septal defect <youtube v=7oKz6J0Ay_I/>

References

Template:WH Template:WS

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