Patent ductus arteriosus physical examination: Difference between revisions
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{{CMG}}; '''Associate Editor-In-Chief:''' [[Priyamvada Singh|Priyamvada Singh, M.B.B.S.]] [mailto:psingh13579@gmail.com], {{CZ}}, '''Assistant Editor-In-Chief:''' [[Kristin Feeney|Kristin Feeney, B.S.]] [mailto:kfeeney@elon.edu] {{RG}} | {{CMG}}; '''Associate Editor-In-Chief:''' [[Priyamvada Singh|Priyamvada Singh, M.B.B.S.]] [mailto:psingh13579@gmail.com], {{CZ}}, '''Assistant Editor-In-Chief:''' [[Kristin Feeney|Kristin Feeney, B.S.]] [mailto:kfeeney@elon.edu] {{RG}} | ||
==Overview== | ==Overview== | ||
Golden standard of [[Patent ductus arteriosus|PDA]] diagnosis is continuous machine-like in usually preterm infant. It is more over an acyanotic heart disease which may be [[cyanotic]] due to accompanied situations. | Golden standard of [[Patent ductus arteriosus|PDA]] diagnosis is [[Continuous heart murmur|continuous]] machine-like in usually [[preterm]] infant. It is more over an acyanotic heart disease which may be [[cyanotic]] due to accompanied situations. | ||
==Physical Examination== | ==Physical Examination== | ||
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* [[Murmur]] may be present. Its nature may be different for [[neonate]]s and older patient. This is so because of the relative difference in [[pulmonary vascular resistance|pulmonary]] and [[systemic vascular resistance]] in them. | * [[Murmur]] may be present. Its nature may be different for [[neonate]]s and older patient. This is so because of the relative difference in [[pulmonary vascular resistance|pulmonary]] and [[systemic vascular resistance]] in them. | ||
** In the [[newborn]], the pressure during [[systole]] is greater in [[aorta]] compared to [[pulmonary circulation]]. However, this gradient between [[aortic]] and [[pulmonary]] circulation is not so prominent in [[diastole]]. Due to this, the murmur may only be audible during the [[systole]]. | ** In the [[newborn]], the pressure during [[systole]] is greater in [[aorta]] compared to [[pulmonary circulation]]. However, this gradient between [[aortic]] and [[pulmonary]] circulation is not so prominent in [[diastole]]. Due to this, the murmur may only be audible during the [[systole]]. | ||
** The pulmonary artery pressure falls after the [[newborn]] period. Due to this, the pressure in [[aorta]] is higher than the pulmonary artery both in [[systole]] and in [[diastole]]. This in turn leads to the characteristic [[continuous murmur|continuous]], [[continuous murmur|machinery murmur]] or [[Gibson's murmur]] (both during [[systole]] and [[diastole]]). | ** The [[pulmonary artery]] pressure falls after the [[newborn]] period. Due to this, the pressure in [[aorta]] is higher than the pulmonary artery both in [[systole]] and in [[diastole]]. This in turn leads to the characteristic [[continuous murmur|continuous]], [[continuous murmur|machinery murmur]] or [[Gibson's murmur]] (both during [[systole]] and [[diastole]]). | ||
* Features of machinery murmur are:<ref name="pmid22574086">{{cite journal| author=Ginghină C, Năstase OA, Ghiorghiu I, Egher L| title=Continuous murmur--the auscultatory expression of a variety of pathological conditions. | journal=J Med Life | year= 2012 | volume= 5 | issue= 1 | pages= 39-46 | pmid=22574086 | doi= | pmc=3307079 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22574086 }}</ref><ref name="SchneiderMoore2006">{{cite journal|last1=Schneider|first1=Douglas J.|last2=Moore|first2=John W.|title=Patent Ductus Arteriosus|journal=Circulation|volume=114|issue=17|year=2006|pages=1873–1882|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.105.592063}}</ref><ref name="pmid18711613">{{cite journal| author=Wiyono SA, Witsenburg M, de Jaegere PP, Roos-Hesselink JW| title=Patent ductus arteriosus in adults: Case report and review illustrating the spectrum of the disease. | journal=Neth Heart J | year= 2008 | volume= 16 | issue= 7-8 | pages= 255-9 | pmid=18711613 | doi=10.1007/bf03086157 | pmc=2516289 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18711613 }}</ref> | * Features of machinery [[Murmurs|murmur]] are:<ref name="pmid22574086">{{cite journal| author=Ginghină C, Năstase OA, Ghiorghiu I, Egher L| title=Continuous murmur--the auscultatory expression of a variety of pathological conditions. | journal=J Med Life | year= 2012 | volume= 5 | issue= 1 | pages= 39-46 | pmid=22574086 | doi= | pmc=3307079 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22574086 }}</ref><ref name="SchneiderMoore2006">{{cite journal|last1=Schneider|first1=Douglas J.|last2=Moore|first2=John W.|title=Patent Ductus Arteriosus|journal=Circulation|volume=114|issue=17|year=2006|pages=1873–1882|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.105.592063}}</ref><ref name="pmid18711613">{{cite journal| author=Wiyono SA, Witsenburg M, de Jaegere PP, Roos-Hesselink JW| title=Patent ductus arteriosus in adults: Case report and review illustrating the spectrum of the disease. | journal=Neth Heart J | year= 2008 | volume= 16 | issue= 7-8 | pages= 255-9 | pmid=18711613 | doi=10.1007/bf03086157 | pmc=2516289 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18711613 }}</ref> | ||
** Best heard in the left infraclavicular region. | ** Best heard in the left infraclavicular region. | ||
** The [[murmur]] maybe 3/6 or less. | ** The [[murmur]] maybe 3/6 or less. | ||
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* Displaced [[apex]] (indicating left ventricular overload) | * Displaced [[apex]] (indicating left ventricular overload) | ||
* [[Continuous murmur]] (maybe grade 2,3 and occasionally 4) | * [[Continuous murmur]] (maybe grade 2,3 and occasionally 4) | ||
* The features of [[murmur]] are very similar to that seen with small ducts, however, they are louder than that associated with small PDA. | * The features of [[murmur]] are very similar to that seen with small ducts, however, they are louder than that associated with small [[Patent ductus arteriosus|PDA]]. | ||
====Large PDA==== | ====Large PDA==== | ||
*[[Pulmonary]] to systemic flow ratio >2.2 to 1 | *[[Pulmonary]] to systemic flow ratio >2.2 to 1 | ||
* Dynamic left ventricular impulse | * Dynamic left [[ventricular]] impulse | ||
* Left ventricular [[thrill]] | * Left ventricular [[thrill]] | ||
*[[S1]] is normal, [[S2]] may be split with an accentuated [[pulmonary]] component. The continuous [[machinery murmur]]s with similar features as seen in moderate and small sized ducts but with louder intensity (4/6 grade) could be heard. | *[[S1]] is normal, [[S2]] may be split with an accentuated [[pulmonary]] component. The continuous [[machinery murmur]]s with similar features as seen in moderate and small sized ducts but with louder intensity (4/6 grade) could be heard. | ||
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** The [[JVP]] may be elevated due to RV failure. Prominent "[[a wave]]" due to diminished RV compliance and [[RVH]]. | ** The [[JVP]] may be elevated due to RV failure. Prominent "[[a wave]]" due to diminished RV compliance and [[RVH]]. | ||
** Signs of [[pulmonary hypertension]] associated with [[right-to-left shunt]] start appearing. | ** Signs of [[pulmonary hypertension]] associated with [[right-to-left shunt]] start appearing. | ||
** As the [[pulmonary hypertension]] increases, left to right flow across the duct decreases and there is no audible [[murmur]]. A murmur of pulmonic insufficiency may be noted ([[Graham-Steell murmur]]) due to the dilation of the [[pulmonic valve]] ring resulting from [[pulmonary hypertension]]. Flow into a dilated [[pulmonary]] trunk causes a pulmonic ejection sound and pulmonic ejection murmur. The second pulmonic heart sound is closely split or not split. | ** As the [[pulmonary hypertension]] increases, left to right flow across the duct decreases and there is no audible [[murmur]]. | ||
**A murmur of pulmonic insufficiency may be noted ([[Graham-Steell murmur]]) due to the dilation of the [[pulmonic valve]] ring resulting from [[pulmonary hypertension]]. | |||
**Flow into a dilated [[pulmonary]] trunk causes a pulmonic ejection sound and pulmonic ejection murmur. | |||
**The second pulmonic heart sound is closely split or not split. | |||
===Abdomen=== | ===Abdomen=== | ||
* Abdominal examination of patients with [[patent ductus arteriosus]] is usually normal. | *[[Abdominal]] examination of patients with [[patent ductus arteriosus]] is usually normal. | ||
===Back=== | ===Back=== | ||
* Back examination of patients with [[patent ductus arteriosus]] is usually normal. | * Back examination of patients with [[patent ductus arteriosus]] is usually normal. | ||
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* [[Differential cyanosis]] | * [[Differential cyanosis]] | ||
**[[Cyanosis]] is more pronounced in lower extremities compared to upper, this is so because the ductus originates distal to the [[left subclavian artery]]. | **[[Cyanosis]] is more pronounced in lower extremities compared to upper, this is so because the ductus originates distal to the [[left subclavian artery]]. | ||
**The left subclavian artery mainly supplies the upper extremities which escape the [[shunting]] of [[blood]]. | **The left [[subclavian artery]] mainly supplies the upper [[extremities]] which escape the [[shunting]] of [[blood]]. | ||
==References== | ==References== | ||
Revision as of 12:46, 12 March 2020
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Patent Ductus Arteriosus Microchapters |
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Differentiating Patent Ductus Arteriosus from other Diseases |
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Diagnosis |
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Treatment |
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Medical Therapy |
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Case Studies |
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Patent ductus arteriosus physical examination On the Web |
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American Roentgen Ray Society Images of Patent ductus arteriosus physical examination |
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Risk calculators and risk factors for Patent ductus arteriosus physical examination |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Priyamvada Singh, M.B.B.S. [2], Cafer Zorkun, M.D., Ph.D. [3], Assistant Editor-In-Chief: Kristin Feeney, B.S. [4] Ramyar Ghandriz MD[5]
Overview
Golden standard of PDA diagnosis is continuous machine-like in usually preterm infant. It is more over an acyanotic heart disease which may be cyanotic due to accompanied situations.
Physical Examination
Appearance of the Patient
- PDA is an acyanotic cardiac congenital disease. Some certain comorbidities can cause the infant to get cyanotic.
Vital Signs
Pulse
- Brisk upstroke pulse: Bounding arterial pulses are present due to the continuous runoff of blood from the aorta into the pulmonary artery during diastole.
Blood Pressure
Skin
- Skin examination of patients with patent ductus arteriosus is usually normal.
HEENT
- HEENT examination of patients with patent ductus arteriosus is usually normal.
Neck
- Neck examination of patients with patent ductus arteriosus is usually normal.
Lungs
- Pulmonary examination of patients with patent ductus arteriosus is usually normal.
- At late course of disease elevated pulmonary blood pressure may cause related symptoms.
Heart
Small PDA
- Pulmonary to systemic flow ratio <1.5 to 1.[1]
- Normal precordial activity.
- Murmur may be present. Its nature may be different for neonates and older patient. This is so because of the relative difference in pulmonary and systemic vascular resistance in them.
- In the newborn, the pressure during systole is greater in aorta compared to pulmonary circulation. However, this gradient between aortic and pulmonary circulation is not so prominent in diastole. Due to this, the murmur may only be audible during the systole.
- The pulmonary artery pressure falls after the newborn period. Due to this, the pressure in aorta is higher than the pulmonary artery both in systole and in diastole. This in turn leads to the characteristic continuous, machinery murmur or Gibson's murmur (both during systole and diastole).
- Features of machinery murmur are:[2][3][4]
- Best heard in the left infraclavicular region.
- The murmur maybe 3/6 or less.
- The intensity is maximal immediately before and after the second heart sound (S2).
- Not vary with changing postures.
Moderate PDA
- Pulmonary to systemic flow ratio between 1.5 and 2.2 to 1
- As a result of the runoff from the aorta, there are bounding pulses, and the pulse pressure widens.
- A continuous thrill may be present in the first or second left intercostal space.
- Displaced apex (indicating left ventricular overload)
- Continuous murmur (maybe grade 2,3 and occasionally 4)
- The features of murmur are very similar to that seen with small ducts, however, they are louder than that associated with small PDA.
Large PDA
- Pulmonary to systemic flow ratio >2.2 to 1
- Dynamic left ventricular impulse
- Left ventricular thrill
- S1 is normal, S2 may be split with an accentuated pulmonary component. The continuous machinery murmurs with similar features as seen in moderate and small sized ducts but with louder intensity (4/6 grade) could be heard.
- An apical diastolic rumble due to increased flow across the mitral valve may be present.
- A third heart sound may be present.
- If there is no reduction in the size of the ductus, after age 2, the progressive obstructive disease develops in these patients:
- Signs of heart failure develop
- The JVP may be elevated due to RV failure. Prominent "a wave" due to diminished RV compliance and RVH.
- Signs of pulmonary hypertension associated with right-to-left shunt start appearing.
- As the pulmonary hypertension increases, left to right flow across the duct decreases and there is no audible murmur.
- A murmur of pulmonic insufficiency may be noted (Graham-Steell murmur) due to the dilation of the pulmonic valve ring resulting from pulmonary hypertension.
- Flow into a dilated pulmonary trunk causes a pulmonic ejection sound and pulmonic ejection murmur.
- The second pulmonic heart sound is closely split or not split.
Abdomen
- Abdominal examination of patients with patent ductus arteriosus is usually normal.
Back
- Back examination of patients with patent ductus arteriosus is usually normal.
Genitourinary
- Genitourinary examination of patients with patent ductus arteriosus is usually normal.
Neuromuscular
- Neuromuscular examination of patients with patent ductus arteriosus is usually normal.
Extremities
- Differential cyanosis
- Cyanosis is more pronounced in lower extremities compared to upper, this is so because the ductus originates distal to the left subclavian artery.
- The left subclavian artery mainly supplies the upper extremities which escape the shunting of blood.
References
- ↑ Maganti K, Rigolin VH, Sarano ME, Bonow RO (2010). "Valvular heart disease: diagnosis and management". Mayo Clin Proc. 85 (5): 483–500. doi:10.4065/mcp.2009.0706. PMC 2861980. PMID 20435842.
- ↑ Ginghină C, Năstase OA, Ghiorghiu I, Egher L (2012). "Continuous murmur--the auscultatory expression of a variety of pathological conditions". J Med Life. 5 (1): 39–46. PMC 3307079. PMID 22574086.
- ↑ Schneider, Douglas J.; Moore, John W. (2006). "Patent Ductus Arteriosus". Circulation. 114 (17): 1873–1882. doi:10.1161/CIRCULATIONAHA.105.592063. ISSN 0009-7322.
- ↑ Wiyono SA, Witsenburg M, de Jaegere PP, Roos-Hesselink JW (2008). "Patent ductus arteriosus in adults: Case report and review illustrating the spectrum of the disease". Neth Heart J. 16 (7–8): 255–9. doi:10.1007/bf03086157. PMC 2516289. PMID 18711613.
- ↑ Schneider, Douglas J.; Moore, John W. (2006). "Patent Ductus Arteriosus". Circulation. 114 (17): 1873–1882. doi:10.1161/CIRCULATIONAHA.105.592063. ISSN 0009-7322.