Book Reading-Heart Disease Braunwald Chapter 4 Physical Examination of the Heart and Circulation (I) Presenter R4 吳明昇 Superviser P 蔡良敏.

Book Reading-Heart DiseaseBraunwald

Chapter 4 Physical Examination of the Heart and Circulation (I)

Presenter R4 吳明昇Superviser P 蔡良敏

The General PE

• General appearance—skin color, truncal obesity, long extremities

• Respiration—orthopnea, Cheyne-Stokes (periodic), JVE

• Position– sit quietly(angina), sitting upright (CHF), moving about(AMI), leaning forwards (pericarditis)

Head and Face

• Expressionless face, periorbital puffiness, loss of lateral eyebrows, large tongue and dry sparse hair Myxedema

• Ear lobe crease frequent in CAD • De Musset sign (bobbing of head with each

heart beat) severe AR• Facial edemaTV disease or constrictive p

ericarditis

Eyes

• External ophthalmoplegia and ptosis Kearns-Sayre syndrome complete AV block

• Exophthalmos and starehyperthyroidism cause of high CO heart failure

• Blue scleraosteogenesis imperfecta aortic dilatation, AR, dissection and MVP

• Pulsation of eyeball or earlobe (Pulsatile exophthalmos) severe TR

Eye Fundi

• HTN• Infective endocarditis Roth spots• Papilledema malignant HTN and cor pul

monale with severe hypoxia• Hypercholesterolemia beading of retinal

artery• Embolic retinal occlusion RHD, LA myx

oma, atherosclerosis of aorta

Skin and Mucous membranes

• Central cyanosis R to L shunt• Peripheral cyanosis CHF and PAOD• Bronze pigmentation of skin and loss of axillary a

nd pubic hair hemochomatosis cause of cardiomyopathy

• Jaundice Pulmonary infarction, congestive hepatomegaly, cardiac cirrhosis

• Lentigines PS or HCM

Skin and Mucous membranes

• Xanthoma over sc or tendon suspect hyperlipoproteinemia cause of premature atherosclerosis

• Hereditary telangiectases (skin, mucosa, GI tract and airway) of lung cause of R to L shunt

Extremities

• ArachnodactylyMarfan syndrome• Systolic flushing of nail bedsQuincke sign A

R(widened pulse pressure)• Clubbing of fingers and toescentral cyanosisc

yanotic heart or hypoxic pulmonary disease• Unilateral clubbing aortic aneurysm• Differential cyanosis PDA with reverse shunt• Osler nodes, Janeway lesions, splinter hemorrhage

IE• Edema, bilateral or unilateral

Chest

• Barrel-shaped chest suspect emphysema, chronic bronchitis and cor pulmonale

• Bulging of right upper sternum aortic aneurysm• Pectus excavatum (Funnel chest) or pectus carinat

um (Pigeon chest) Marfan syn.• Kyphoscoliosis induce cor pulmonale• Rales and wheezing BS pulmonary edema

Abdomen

• Painful hepatomegaly due to right heart failure hepatojugular reflex

• Pulsation over liver severe TR or constrictive pericarditis

• Palpable kidney suspect polycystic kidney disease cause of HTN

• Systolic bruit over umbilicus or flank renovascular HTN

• Aortic aneurysm palpable below umbilicus

Jugular Venous Pulse(internal jugular vein)

• It was evaluated in 45 degree position• Upper normal limit 4cm above sternal angle (9

cm CVP)• Abdominal-jugular reflex press periumbilical area for 10-30 s normal < 3cm elevation and only transiently Abnormal right heart failure or TR, if not elevated PAWP or CVP

Jugular Venous Pulse(internal jugular vein)

Jugular Venous Pulse(internal jugular vein)

• Kussmaul signparadoxical rise in JVP during inspiration constrictive pericarditis and sometimes in CHF and TS

• Prominent a wave RVH, pulmonary hypertention and TS

• Cannon a wave AV dissociaton• Absent a wave atrial fribrillation• A steeply rising H wave restrictive cardiomyop

athy, constrictive pericarditis, RV infarction

Jugular Venous Pulse(internal jugular vein)

• Rapid and deep y with rapid rise to H wave ( W-shaped) constrictive pericarditis

• Prominent X descent cardiac tamponade

• Prominent c-v waveTR

• Equal a and v wave ASD

Arterial Pulse

• Carotid arterymost accurate representation of central aortic pulse

• Brachial arterymost suitable for evaluating the rate of rise of pulse, contour, volume, and consistency

Normal Arterial Pulse

Abnormal Arterial Pulse

• Bisferiens pulse: AR, AR + AS, HCOM• Dicrotic pulse: cardiac tamponade, severe HF, hyp

ovolemia shock• Pulsus alternans(alternate > 20mmHg) LV failu

re • Pulsus bigeminusVPC related • Pulsus paradoxus cardiac tamponade, emphyse

ma, asthma, hypovolemic shock, pulmonary embolism

• Pulsus tardus slow upstroke• Pulsus parvuslow amplitude

Abnormal Arterial Pulse

AR-widen pulse pressure

• Corrigan or Water-hammer pulse• Pistol shot sound (Traube sign): systolic murmur• Duroziez sign: diastolic murmur• Quincke sign• Hill sign: SBP in low ex- arm > 20mmHg• Becker sign: visible pulsation in retina• Mueller sign: pulsating uvula

Arterial Pulse in Vascular disease

• Normal aorta is palpable above umbilicus

• A palpable aorta below umbilicus suspect aortic aneurysm

• Absent dorsalis pedis and posterior tibial artery 2% normal aberrant course

• 50% stenosis artery bruits

The Cardiac ExaminationInspection

• Respiration pattern• Collateral vein• Pectus excavatum (funnel chest): Marfan sy

n., homocystinuria, Ehlers-Danlos syn., Hunter-Hurler syn., MVP.

• Cardiac pulsation thrusting apex >2cmLV enlarge lateral to midclavicular lineLV enlarge

The Cardiac ExaminationPalpation

• In 30 degree, supine and lateral decubitus position• Left Ventricle Apical thrust (PMI) >10cm from the midsternal line or >3cm in diamet

er LV enlargement Double systolic outward thrust HCOM Systolic retraction of chest (Broadbent sign) co

nstrictive pericarditis Presystolic expansion reduced LV compliance

(accompany with S4)

The Cardiac ExaminationPalpation

• Right ventricle

palpable systolic movement in left parasternal area RVH or enlargement

Thrills accompany with load harsh low to median frequency murmur

Cardiac Auscultation

• Aortic area R 2nd ICS

• Pulmonary area L 2nd ICS

• Tricuspid area L 4th ICS

• Mitral area Apex

• Bell lower pitch sound, slightly to firmly

• Diaphragm high pitch sound, firmly

Cardiac AuscultationHeart Sound

Heart sound

• S1: closure of MV—Apex

closure of TV—left lower SB Widely split of S1: RBBB Single S1: LBBB Load S1: Rapid heart rate, short PR, MS

Cardiac AuscultationHeart Sound

• Normal splitting of S2 in inspiration, S2 split into A2 and P2

• Abnormal splitting of S2 Wide physiological splittingdelay P2 or early

A2 (RBBB or MR) Paradoxical splittingLBBB or RV pacemaker Narrow physiological splitting pulmonary

hypertension Fixed splitting: ASD

Cardiac AuscultationHeart Sound

• Early systolic soundsAortic or pulmonary ejection sounds (AS, bicuspid AV, PS)

• Mid- to late systolic sounds (click) MVP• Early diastolic soundsMS (opening snap),

pericardial knock (constrictive pericarditis), MR knock(with poor LV compliance), atrial myxoma(polp)

• Mid- to late diastolic sounds S3 or S4

Heart sound

• S3 is generated during ventricle rapid filling (normal < 40Y)

LV dysfunction, AR, increase rate or volume of ventricle filling

• S4 is generated during atrial contribution to ventricle filling (may be normal in elderly?)

HTN,AS, HCM, ischemic heart, acute MR