Aortic coarctation physical examination: Difference between revisions
Jump to navigation
Jump to search
No edit summary |
|||
| Line 9: | Line 9: | ||
* In human anatomy, the [[subclavian arteries]] are two major arteries of the upper thorax. They receive blood from the arch of the aorta. The left [[subclavian artery]] supplies blood to the left arm and the right subclavian artery supplies blood to the right arm, with some branches supplying the head and thorax. | * In human anatomy, the [[subclavian arteries]] are two major arteries of the upper thorax. They receive blood from the arch of the aorta. The left [[subclavian artery]] supplies blood to the left arm and the right subclavian artery supplies blood to the right arm, with some branches supplying the head and thorax. | ||
* Abnormalities in blood pressure and pulses are hallmark of diagnosis in [[coarctation of aorta]].The physical finding depends on the severity and location of constriction relative to the the origin of subclavian artery: | * Abnormalities in blood pressure and pulses are hallmark of diagnosis in [[coarctation of aorta]].The physical finding depends on the severity and location of constriction relative to the the origin of subclavian artery: | ||
** Tachypnea | |||
** Labored breathing (prominent accessory muscles) | |||
** Tachycardia | |||
** Left subclavian proximal to coarctation - [[Hypertension]] and normal pulses in both arms and [[hypotension]] and diminished pulses in lower extremities (differential hypertension). Synchronous radial pulses, but radial-femoral delay will be present under palpation in either arm. This may be appreciated best by simultaneous arm and leg pulse palpation. | ** Left subclavian proximal to coarctation - [[Hypertension]] and normal pulses in both arms and [[hypotension]] and diminished pulses in lower extremities (differential hypertension). Synchronous radial pulses, but radial-femoral delay will be present under palpation in either arm. This may be appreciated best by simultaneous arm and leg pulse palpation. | ||
** Left subclavian distal to coarctation - Hypotension and diminished pulses in left arm and lower extremities. Asynchronous radial pulses will be detected in the right and left arms. A [[radial-femoral delay]] between the right arm and the femoral artery may be apparent, while no such delay may be observed with left arm radial-femoral palpation. | ** Left subclavian distal to coarctation - Hypotension and diminished pulses in left arm and lower extremities. Asynchronous radial pulses will be detected in the right and left arms. A [[radial-femoral delay]] between the right arm and the femoral artery may be apparent, while no such delay may be observed with left arm radial-femoral palpation. | ||
| Line 14: | Line 17: | ||
** In mild cases though the pulses are palpable in all for extremities a brachio femoral delay can be appreciated. | ** In mild cases though the pulses are palpable in all for extremities a brachio femoral delay can be appreciated. | ||
** Femoral pulses are often diminished in strength. Exercise exacerbates this gradient. | ** Femoral pulses are often diminished in strength. Exercise exacerbates this gradient. | ||
====General physical examination==== | ====General physical examination==== | ||
=====Neck===== | =====Neck===== | ||
There may be "webbing" of the neck in patients with [[Turner syndrome]], 10% of whom have aortic coarctation. | There may be "webbing" of the neck in patients with [[Turner syndrome]], 10% of whom have aortic coarctation. | ||
=====Extremities===== | =====Extremities===== | ||
* Differential cyanosis (pink upper extremities with cyanotic lower extremities) may occur when right-to-left shunt across a patent ductus arteriosus provides flow to the lower body. | |||
* Reversed differential cyanosis (upper body cyanosis with normal lower-body oxygen) may occur with associated lesions like transposition of the great arteries, patent ductus arteriosus, and pulmonary hypertension (right-to-left shunt) | |||
Occasionally adults may have narrow hips and thin legs or have an undeveloped left arm (in those patients in which the coarctation compromises the origin of the [[subclavian artery]]). | Occasionally adults may have narrow hips and thin legs or have an undeveloped left arm (in those patients in which the coarctation compromises the origin of the [[subclavian artery]]). | ||
| Line 29: | Line 32: | ||
* There are 3 potential sources of a murmur: arterial collateral, an associated [[bicuspid aortic valve]] (systolic ejection click), and the coarctation itself which can be heard over the left infraclavicular area and under scapula. Murmurs due to associated cardiac abnormalities such as VSD or aortic valve stenosis, may also be detected. | * There are 3 potential sources of a murmur: arterial collateral, an associated [[bicuspid aortic valve]] (systolic ejection click), and the coarctation itself which can be heard over the left infraclavicular area and under scapula. Murmurs due to associated cardiac abnormalities such as VSD or aortic valve stenosis, may also be detected. | ||
* A prominent P2 may be present if there is associated [[pulmonary hypertension]]. | * A prominent P2 may be present if there is associated [[pulmonary hypertension]]. | ||
=====Other presentations===== | |||
== | |||
== | |||
* Congestive heart failure (may present as [[tachycardia]], [[tachypnea]], ankle edema, [[anasarca]], [[jugular vein distention]], [[pleural effusion]] with dullness to percussion at the bases, [[rales]], [[hepatomegaly]], [[ascites]], [[S3]][[gallop rhythm]], displaced [[point of maximum impulse]] ([[PMI]]) consistent with an enlarged left ventricle) | * Congestive heart failure (may present as [[tachycardia]], [[tachypnea]], ankle edema, [[anasarca]], [[jugular vein distention]], [[pleural effusion]] with dullness to percussion at the bases, [[rales]], [[hepatomegaly]], [[ascites]], [[S3]][[gallop rhythm]], displaced [[point of maximum impulse]] ([[PMI]]) consistent with an enlarged left ventricle) | ||
* Shock | * Shock | ||
==Presentation based on age== | |||
===Neonates (Early presentation)=== | |||
===Children, Adults (Late presentation) | |||
==References== | ==References== | ||
Revision as of 14:54, 12 April 2012
|
Aortic coarctation Microchapters |
|
Diagnosis |
|---|
|
Treatment |
|
Case Studies |
|
Aortic coarctation physical examination On the Web |
|
American Roentgen Ray Society Images of Aortic coarctation physical examination |
|
Risk calculators and risk factors for Aortic coarctation physical examination |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Priyamvada Singh, M.B.B.S.[2], Cafer Zorkun, M.D., Ph.D. [3]; Assistant Editor(s)-In-Chief: Kristin Feeney, B.S.[4]
Overview
Physical examination acts as an important tool in the diagnosis of coarctation of aorta. In majority of patients with coarctation, the constriction is located just distal to the subclavian artery. Due to the presence of constriction at isthmus (proximal to the descencing aorta) the pressure of blood proximal to constriction is high whereas the pressure distal to constriction is low. This leads to hypertension in the upper extremities (supplied by subclavian) and hypotension in lower extremities. The difference is usually in systolic blood pressure whereas the diastolic blood pressures are typically similar. Similarly, the pulses in upper extremities are bounding whereas the femoral pulses are often diminished (brachial-femoral delay)
Physical Examination
Vital Signs
Pulses & Blood Pressure
- In human anatomy, the subclavian arteries are two major arteries of the upper thorax. They receive blood from the arch of the aorta. The left subclavian artery supplies blood to the left arm and the right subclavian artery supplies blood to the right arm, with some branches supplying the head and thorax.
- Abnormalities in blood pressure and pulses are hallmark of diagnosis in coarctation of aorta.The physical finding depends on the severity and location of constriction relative to the the origin of subclavian artery:
- Tachypnea
- Labored breathing (prominent accessory muscles)
- Tachycardia
- Left subclavian proximal to coarctation - Hypertension and normal pulses in both arms and hypotension and diminished pulses in lower extremities (differential hypertension). Synchronous radial pulses, but radial-femoral delay will be present under palpation in either arm. This may be appreciated best by simultaneous arm and leg pulse palpation.
- Left subclavian distal to coarctation - Hypotension and diminished pulses in left arm and lower extremities. Asynchronous radial pulses will be detected in the right and left arms. A radial-femoral delay between the right arm and the femoral artery may be apparent, while no such delay may be observed with left arm radial-femoral palpation.
- Both right and left subclavian artery originate below coarctation - Blood pressure and pulses decreased in all four extremities.
- In mild cases though the pulses are palpable in all for extremities a brachio femoral delay can be appreciated.
- Femoral pulses are often diminished in strength. Exercise exacerbates this gradient.
General physical examination
Neck
There may be "webbing" of the neck in patients with Turner syndrome, 10% of whom have aortic coarctation.
Extremities
- Differential cyanosis (pink upper extremities with cyanotic lower extremities) may occur when right-to-left shunt across a patent ductus arteriosus provides flow to the lower body.
- Reversed differential cyanosis (upper body cyanosis with normal lower-body oxygen) may occur with associated lesions like transposition of the great arteries, patent ductus arteriosus, and pulmonary hypertension (right-to-left shunt)
Occasionally adults may have narrow hips and thin legs or have an undeveloped left arm (in those patients in which the coarctation compromises the origin of the subclavian artery).
Cardiovascular
Heart sounds
- The S2 is loud secondary to hypertension
- An S4 may be present secondary to LVH
Additional sounds (murmurs)
- There are 3 potential sources of a murmur: arterial collateral, an associated bicuspid aortic valve (systolic ejection click), and the coarctation itself which can be heard over the left infraclavicular area and under scapula. Murmurs due to associated cardiac abnormalities such as VSD or aortic valve stenosis, may also be detected.
- A prominent P2 may be present if there is associated pulmonary hypertension.
Other presentations
- Congestive heart failure (may present as tachycardia, tachypnea, ankle edema, anasarca, jugular vein distention, pleural effusion with dullness to percussion at the bases, rales, hepatomegaly, ascites, S3gallop rhythm, displaced point of maximum impulse (PMI) consistent with an enlarged left ventricle)
- Shock
Presentation based on age
Neonates (Early presentation)
===Children, Adults (Late presentation)