Cardiovascular Physical exam review
Dr. Pattarapong Makarawate, MD
CARDIAC TAMPONADE
CONGESTIVE HEART FAILURE
AORTIC REGURGITATION
AORTIC REGURGITATION
AORTIC STENOSIS
ABNORMALITIES OF THE ARTERIAL PULSE
JVP Inspection
Normal JVP Waveform
l Consists of 3 positive waves l a,c & v
l And 3 descents l x, x'(x prime)
and y
THE CENTRAL VENOUS PRESSURE
A WAVE- ATRIAL CONTRACTON C WAVE- BULGING OF TRICUSPID VALVE X DESCENT- ATRIAL RELAXATION V WAVE-CLOSURE OF TRICUSPID VALVE WITH ATRIAL DISTENSION Y DESCENT- OPENING OF THE TRICUSPID VALVE
JAMA 1996;275:630-634
l a wave - atrial systole l x descent – onset of
atrial relaxation l c wave - small positive
notch in the 'x' descent due to bulging of the AV ring into the atria in ventricular contraction.
l x' (prime) descent !!! l occurs during systole due
to RV contraction pulling down the TV valve ring “descent of the base”
l a measure of RV contractility
l v wave - after the x' descent - slow positive wave due to right atrial filling from venous return
l y descent - rapid emptying of the RA into RV due to TV opening
Normal JVP Waveform
JVP- HJR & Kussmaul’s sign
l Hepato-jugular reflux (various definitions) l sustained rise 1 cm
for 30 sec. l ↑ venous tone &
SVR l ↓ RV compliance
l Positive HJR correlates with LVEDP > 15
l JVP normally falls with inspiration
l Kussmaul’s sign l inspiratory ↑ in JVP l constriction l rarely tamponade l RV infarction
Specific JVP patterns Condition Pattern
Normal waveform X' deeper than Y
Post CABG X' shallower, now = Y
Atrial fibrillation CV wave
Tricuspid regurgitation CV wave
Complete heart block Irregular cannon A waves
Tamponade ↑ JVP brisk X' > Y
Constriction ↑ JVP brisk X' & Y descents X' less exaggerated than Y
RV infarction ↑ JVP –low amplitude
CANNON A WAVE AHA EXAMINATION OF THE HEART PART 2
CLASS NOTES
THE BASIC HEART SOUNDS
BRAUNWALD E.HEART DISEASE 1994 ;29
AHA EXAMINATION OF THE HEART PART 4
NORMAL AND ABNORMAL 2ND HEART SOUNDS
AHA EXAMINATION OF THE HEART PART 4
THE 3RD HEART SOUND
l VENTRICULAR ORIGIN - FROM RAPID DIASTOLIC FILLING
l EARLY DIASTOLE l BELL l > 40 YO ABNORMAL l < 40 YO MAY BE NORMAL l CONGESTIVE HEART FAILURE OR
VALVULAR DISEASE
l ATRIAL ORIGIN - RAPID DIASTOLIC FILLING
l LATE DIASTOLE l HYPERTROPHY OR FIBROTIC VENTRICLE l BEL l REQUIRES ATRIAL KICK DISAPPEARS IN
PATIENTS WITH A FIB l AORTIC STENOSIS, HYPERTROPHIC
CARDIOMYOPATHY, HYPERTENSION
THE 4TH HEART SOUND
AHA EXAMINATION OF THE HEART PART 4
Diastolic extra sounds
l 1. Opening snap ( OS ) l 2. Pericardial knocks l 3. Tumor plop l 4. Third heart sound ( S3 ) l 5. Fourth heart sound ( S 4 ) l - decrease LV compliance : LVH
( HT,AS,HOCM ),ischemia l - RV S4 gallop: increase with inspiration: PHT,
PS , Ebstein anomaly
MURMURS - INTENSITY
l GRADE I - HEARD, TUNE IN l GRADE II – FAINT l GRADE III – BETWEEN 3 AND 4 l GRADE IV – ASSOCIATED WITH A THRILL l GRADE V – HEARD IF JUST THE RIM OF
THE STETHOSCOPE TOUCHES THE CHEST
l GRADE VI – HEARD WITHOUT TOUCHING THE CHEST
FREEMAN AND LEVINE ANN INT MED 6:1371;1993
SYSTOLIC MURMURS JAMA 1997;277:564-571
LOCATION OF SYSTOLIC MURMURS
JAMA 1997;277:564-571
Systolic Murmurs by Position
l RUSB - AS
l LLSB – TR, VSD, HCM
l APEX - MR
Diastolic Murmurs by Position
l LUSB - PR
l LLSB - TS l APEX - MS
l 3RD ICS, LSB - AR
Aortic Valve stenosis
PE in severe AS
l S 4 ( especially in < 40 years ) l SEM : long and peak in midsystole + at
least grade > 4/6 ( except in poor LV ) l A2 : decrease absent l Paradoxical split S 2 ( prolong LV
ejection time ).
HOCM
l Bisferiens pulse l double apical impulse ( palpable
presystolic wave at apex and double systolic lift )
l Prominent S4, paradoxical split of S2
HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY (HOCM)
PHYSICAL FINDINGS
MURMUR MAY BE HARSH
LLSB
MANEUVERS
SQUATTING
STANDING
DM 1994;52-112
DDx HOCM vs AS
l HOCM ; location at LLSB > AVA l Carotid pulse : bisferiens > pulsus
parvus et tardus l LV impulse : double apical impulse l Valsava ( strain phase ) increase
murmur. l Squatting decrease murmur.
Aortic Insufficiency
Mitral stenosis : Investigation
• EKG • CXR • Echo
OS
Mitral stenosis : Auscultation
MVA
Mitral Valve Prolapse
Effect of special maeuvers
l Suspected MVP: standing make the click and systolic murmur earlier.
l Suspected HOCM: hand grip and squating make intensity of murmur decrease. : valsava and standing make intensity of murmur increase.
Short cases
Most common case l Mitral stenosis + TR l Mitral regurgitation + MVP l Aortic stenosis l Aortic regurgitation l Pulmonic stenosis l Continuous murmur l PDA + PHT l Coronary AV fistula l Rupture sinus of valsava to RV or RA
Short cases
Most common case l ASD with PHT l VSD l Atrial fibrillation l Bradycardia Complete AV block l Hyperthyroidism l Marfan syndrome with AR+MR l Dextrocardia with ?
Short cases
l Uncommon cases l Tetralogy of fallot l Congenital heart disease with reverse
shunt l Hypertrophic cardiomyopathty
HOCM l Constrictive pericarditis l Prosthetic heart valve dysfunction l Pulmonic regurgitation in PHT l Pericarditis with pericardial rub
Technique
l Use time efficiency l Don’t miss some clues l Repeated cases? l Neck vein clues. l Peripheral pulse deficit. l Wide pulse pressure. l Good describe and complete answer.
Long cases
Common cases l Multiple valves problem l Hyperthyroidism l Tetralogy of fallot l Hypertrophic cardiomyopathty HOCM l Dilated cardiomyopathy caused? l Restrictive cardiomyopahy in
amyloidosis, unknown caused
Long cases
Common cases l Constrictive pericarditis from TB l Secondary hypertension, renal artery
stenosis l Infective endocarditis (subacute IE) and
complication l Reverse shunt congenital heart disease l Prosthetic heart valve malfunction l Primary pulmonary hypertension and
secondary l Coarctation of aorta
Long cases
Common cases l Takayasu disease l Marfan syndrome l Acute coronary syndrome with
complication VSD, MR l Sudden cardiac arrest and arrhythmia l Congestive heart failure l Dextrocardia
Long cases
Uncommon cases l Chronic Aortic dissection l Chronic pulmonary embolism l Coarctation of aorta l Aortic aneurysm l Ebstein’s anomaly with WPW l Vitamin B1 deficiency: cardiac beriberi l Transposition of great vessel l Pericarditis and pericardial effusion
Cyanotic heart disease
Common l Tetralogy of fallot l Eisenmenger’ syndrome l Pulmonary atresia with VSD l Pulmonic stenosis with right to left
shunt
Tips
l Graham steel murmur = Pulmonic regur. due to PHT.
l Austin Flint murmur = MS murmur caused by AR jet.
l Pulsus paradoxus in cardiac temponade
Tips
PE in ASD
l Pulse normal, sometimes small l Normal JVP ( v wave in severe TR ) l RV heave, normal apex beat l Wide fixed split S2, increase P 2 if PHT l SEM at PVA l TR if PHT
Tips VSD
Harsh HSM grade 3-4/6. Maximal at the 3rd -4th ICS LPSB.
Apical diastolic rumble (increase flow through MV) S3 at apex
PE in VSD
l 1. Small VSD l - normal pulse and JVP. l - thrill at LLSB, no LV/RV heave. l - normal or wide split S2. l - PSM at LLSB ( radiate to right of
sternum/apex but not to axilla ).
PE in VAS
l 2. large shunt , normal PA pressure l murmur/thrill same l LV heave ( volume overload pattern ) l S3 and apical mid diastolic murmur
( from increase flow ). l if moderate PHT: RV heave+palpable
P2,wide split S2
VSD with Eisenmenger
l Cyanosis, RV heave(pressure overload ) l no thrill, palpable P2 l early diastolic rumble of PR.
PDA
Diastolic murmur disappear + loud P2 in moderate PHT
Continuous murmur grade 1–2, peaking in late systole, and best heard in the 1st – 2nd ICS-LPSB
LV volume overload (apical displacement + S3)
Wide pulse pressure
Continuous murmur
l 1. R/O to-and-fro murmur l 2. PDA : left infraclavicular / PVA , in PHT
decrease diastolic murmur , in severe PHT = PR murmur.
l 3. Ruptured sinus of valsava ( Rt/non cusp to RA/RV ) : lower sternal boarder.
l 4. Coronary AV fistula : coronary artery to RA/RV : lower sternal boarder.
COARCTATION OF AORTA
CLINICAL MANIFESTATION
Crescendo-decrescendo systolic murmur throughout chest wall from collateral a.
Radial-femoral pulse delay unless significant AR
LVH
Interscapular systolic murmur from the coarctation site
Differential SBP > 10 mm Hg (brachial >popliteal a.)
RIGHT VENTRICULAR OUTFLOW TRACT OBSTRUCTION
CLINICAL MANIFESTATION
Systolic ejection click (decreases on inspiration)
Unusual in dysplastic PS or subvalvar or supravalvar RVOTO
Prominent JVP, RV lift, a thrill in the 2nd LICS
SEM • Valvular stenosis in 2nd LICS • Subvalvular stenosis at 3rd -5th LICS • Supravalvular stenosis: wide distribution
Normal S1, a split S2 with a diminished P2 (except supravalvular)
TETRALOGY OF FALLOT
Most common form of cyanotic CHD after 1 year (10%) of CHD
CLINICAL MANIFESTATION
Continuous murmurs: to assess shunt patency
Low-pitched DBM from PR at LPSB. RVH SEM from RVOTO
Soft and delayed P2 High-pitched DBM - AR, HSM - VSD patch leak.
An ejection sound from aortic dilation
EBSTEIN ANOMALY
ANATOMY
l Apical displacement of the septal, posterior, or (rarely) anterior leaflet of the TV
l Atrialization (functioning as an atrial chamber) of the inflow tract of RV and small functional RV
l TR (or in exceptional TS) l Associated anomalies include
l PFO or ASD (50%) l Accessory pathways
(25%) l RVOTO, VSD,
coarctation of the aorta, PDA, or mitral valve disease
CLINICAL MANIFESTATION
Unimpressive JVP (large and compliant RA and atrialized RV)
SEM from TR Right side S3
Widely split S1 with a loud tricuspid component (the “sail sound”) Widely split S2 from RBBB
Cyanosis R-L shunt
DIAGNOSTIC TESTING
Electrocardiogram. l Low voltage: typical l Peaked P waves in lead
II and V1 l Prolonged PR interval l Short PR interval and a
delta wave (WPW type B )
l An rsr´ pattern = RV conduction delay is typically seen in lead V1
l AF/AFL are common l ECG may be normal
DIAGNOSTIC TESTING CHEST RADIOGRAPHY
“water bottle” appearance l A rightward convexity
l Enlarged RA and atrialized RV
l Leftward convexity l Dilated infundibulum
l Cardiomegaly, highly variable in degree
l The pulmonary vasculature is usually normal to reduced