Mitral stenosis physical examination: Difference between revisions
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==Neck== | ==Neck== | ||
* [[Jugular venous distension]] | * [[Jugular venous distension]] is present. | ||
* Prominent [[A wave]] is present indicating increased right atrial pressure from pulmonary hypertension and right ventricular failure. | * Prominent [[A wave]] is present indicating increased right atrial pressure from pulmonary hypertension and right ventricular failure. | ||
* With the onset of [[atrial fibrillation]], A wave is lost and only a prominent [[V wave]] is visible. | * With the onset of [[atrial fibrillation]], A wave is lost and only a prominent [[V wave]] is visible. | ||
* Prominent | * Prominent C-V wave is present with [[tricuspid regurgitation]], indicating regurgitation of blood into the right atrium. | ||
==Heart== | ==Heart== | ||
Revision as of 14:41, 22 October 2012
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Mitral Stenosis Microchapters |
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Diagnosis |
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Treatment |
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Case Studies |
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Mitral stenosis physical examination On the Web |
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American Roentgen Ray Society Images of Mitral stenosis physical examination |
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Risk calculators and risk factors for Mitral stenosis physical examination |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]
Overview
Mitral stenosis is associated with a rumbling diastolic murmur and an opening snap. Later in the course of the disease there are signs of right heart failure such as pedal edema, ascites, and congestive hepatopathy.
Vitals
- Tachycardia may be present if there is a reduction in cardiac output
- The pulse may be irregularly irregular with the onset of atrial fibrillation
- Due to the decreased stroke volume, arterial pulses are reduced in volume
Head
- There is sometimes presence of mitral facies with patches of pink and purple on the cheeks due to reduced cardiac output and peripheral vasoconstriction.
- There may be a malar flush.
Neck
- Jugular venous distension is present.
- Prominent A wave is present indicating increased right atrial pressure from pulmonary hypertension and right ventricular failure.
- With the onset of atrial fibrillation, A wave is lost and only a prominent V wave is visible.
- Prominent C-V wave is present with tricuspid regurgitation, indicating regurgitation of blood into the right atrium.
Heart
Palpation
- Left parasternal heave is palpable if right ventricular hypertrophy is present due to pulmonary hypertension
- Due to the underfilling of the left ventricle, the PMI may not be palpable or displaced
- A diastolic thrill may be palpated rarely
- A P2 may be palpable in the 2cd left intercostal space
- A right ventricular lift may be present
The Opening Snap of Mitral Stenosis
The closing of the mitral valve and the tricuspid valve constitutes the first heart sound (S1). It is not actually the valve closure which produces a sound but rather the sudden cessation of blood flow caused by the closure of the mitral and tricuspid valves. The mitral valve opening is normally not heard except in mitral stenosis as the opening snap. As the severity of the mitral stenosis increases, the pressure in the left atrium increases, and the mitral valve opens earlier and more abruptly in ventricular diastole. An opening snap which is a high pitched additional sound may be heard after the A2 (aortic) component of the second heart sound (S2), which correlates to the forceful opening of the mitral valve. Initially, an opening snap is heard because there is an increased gradient between the left atrium and the left ventricle and S1 is loud. As the valve calcifies and left atrial pressure increases, S1 becomes softer and the opening snap moves closer to S2.
Mid-diastolic rumbling murmur heard after the opening snap
The murmur is best heard at the apical region and is not radiated. Since it is low-pitched it should be picked up by the bell of the stethoscope. Rolling the patient towards left, as well as isometric exercise will accentuate the murmur. If the patient is in normal sinus rhythm, there will be a “presystolic accentuation” of the murmur due to increased flow across the valve with normal atrial contraction. The duration of the murmur and not the intensity of the murmur correlates with the severity of mitral stenosis.
{{#ev:youtube|E0fDFsmVQfY}} An opening snap
- S1:The first heart sound is unusually loud and may be palpable due to the increased force of the closing of the mitral valve.
- S2:If pulmonary hypertension secondary to mitral stenosis is severe, the P2 (pulmonic component of the second heart sound (S2) will become loud. When pulmonary hypertension develops, murmurs of pulmonary insufficiency (Graham Steel murmur), tricuspid regurgitation and a right sided S3 can be heard.
- S3: Flow of blood into the heart during rapid filling is not normally heard except in certain pathological states where it constitutes the third heart sound (S3).
Periphery
- Ankle/sacral edema when there is right heart failure
References