Cardiovascular Physical exam review

Dr. Pattarapong Makarawate, MD

AORTIC STENOSIS

AORTIC REGURGITATION

AORTIC REGURGITATION

CONGESTIVE HEART FAILURE

CARDIAC TAMPONADE

ABNORMALITIES OF THE ARTERIAL PULSE

JVP Inspection

Normal JVP Waveform

l Consists
la,c

of 3 positive waves

&v

l And
lx,

3 descents

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 JAMA 1996;275:630-634 VALVE

Normal JVP Waveform

l l l

a wave - atrial systole x descent onset of atrial relaxation c wave - small positive notch in the 'x' descent due to bulging of the AV ring into the atria in ventricular contraction.

x' (prime) descent !!!

l

occurs during systole due to RV contraction pulling down the TV valve ring descent of the base a measure of RV contractility

v wave - after the x' descent - slow positive wave due to right atrial filling from venous return y descent - rapid emptying of the RA into RV due to TV opening

JVP- HJR & Kussmaul s sign

l

Hepato-jugular reflux (various definitions)

sustained rise 1 cm for 30 sec. l venous tone & SVR l RV compliance
l

JVP normally falls with inspiration l Kussmaul s sign

l

Positive HJR correlates with LVEDP > 15

inspiratory in JVP l constriction l rarely tamponade l RV infarction

l

Specific JVP patterns

Condition
Normal waveform Post CABG Atrial fibrillation Tricuspid regurgitation Complete heart block Tamponade Constriction RV infarction

Pattern
X' deeper than Y X' shallower, now = Y CV wave CV wave Irregular cannon A waves JVP brisk X' > Y JVP brisk X' & Y descents X' less exaggerated than Y 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

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

THE 3RD HEART SOUND

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
l

THE 4TH HEART SOUND

AHA EXAMINATION OF THE HEART PART 4

Diastolic extra sounds

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
l

MURMURS - INTENSITY
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
l
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 l LLSB l APEX

- AS

TR, VSD, HCM - MR

Diastolic Murmurs by Position

l LUSB l LLSB l APEX l 3RD

- PR - TS - MS

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)

STANDING

SQUATTING

PHYSICAL FINDINGS MURMUR MAY BE HARSH LLSB MANEUVERS

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

Mitral stenosis : Auscultation

MVA OS

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
Tetralogy of fallot l Eisenmenger syndrome l Pulmonary atresia with VSD l Pulmonic stenosis with right to left shunt
l

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, l l

RV heave(pressure overload ) no thrill, palpable P2 early diastolic rumble of PR.

PDA
Continuous murmur grade 12, peaking in late systole, and best heard in the 1st 2nd ICS-LPSB

Diastolic murmur disappear + loud P2 in moderate PHT

Wide pulse pressure

LV volume overload (apical displacement + S3)

Continuous murmur
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.
l

COARCTATION OF AORTA

CLINICAL MANIFESTATION

Crescendo-decrescendo systolic murmur throughout chest wall from collateral a.

Interscapular systolic murmur from the coarctation site LVH

Differential SBP > 10 mm Hg (brachial >popliteal a.)

Radial-femoral pulse delay unless significant AR

RIGHT VENTRICULAR OUTFLOW TRACT OBSTRUCTION

CLINICAL MANIFESTATION

Prominent JVP, RV lift, a thrill in the 2nd LICS

Systolic ejection click (decreases on inspiration) Unusual in dysplastic PS or subvalvar or supravalvar RVOTO

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

An ejection sound from aortic dilation Soft and delayed P2 High-pitched DBM - AR, HSM - VSD patch leak.

Low-pitched DBM from PR at LPSB. RVH SEM from RVOTO

EBSTEIN ANOMALY

ANATOMY
l

l l

Apical displacement of the septal, posterior, or (rarely) anterior leaflet of the TV Atrialization (functioning as an atrial chamber) of the inflow tract of RV and small functional RV TR (or in exceptional TS) Associated anomalies include
l l l

PFO or ASD (50%) Accessory pathways (25%) RVOTO, VSD, coarctation of the aorta, PDA, or mitral valve disease

CLINICAL MANIFESTATION

Unimpressive JVP (large and compliant RA and atrialized RV)

Cyanosis R-L shunt

SEM from TR Right side S3

Widely split S1 with a loud tricuspid component (the sail sound ) Widely split S2 from RBBB

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 Dilated infundibulum

l l l

Leftward convexity
l

Cardiomegaly, highly variable in degree The pulmonary vasculature is usually normal to reduced