PE and History

7/28/2019 PE and History

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Book Reading-Heart DiseaseBraunwald

Chapter 4 Physical Examination of

the Heart and Circulation (I)

Presenter R4

Superviser P


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The General PE

General appearanceskin color, truncal

obesity, long extremities

Respirationorthopnea, Cheyne-Stokes

(periodic), JVE

Position sit quietly(angina), sitting upright

(CHF), moving about(AMI), leaning

forwards (pericarditis)


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Head and Face

Expressionless face, periorbital puffiness,loss of lateral eyebrows, large tongue and

dry sparse hairMyxedema Ear lobe crease frequent in CAD

De Musset sign (bobbing of head with each

heart beat) severe AR Facial edemaTV disease or constrictive

pericarditis


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Eyes

External ophthalmoplegia and ptosis Kearns-

Sayre syndrome complete AV block

Exophthalmos and starehyperthyroidismcause of high CO heart failure

Blue scleraosteogenesis imperfecta aortic

dilatation, AR, dissection and MVP Pulsation of eyeball or earlobe (Pulsatile

exophthalmos) severe TR


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Eye Fundi

HTN

Infective endocarditis Roth spots

Papilledemamalignant HTN and corpulmonale with severe hypoxia

Hypercholesterolemia beading of retinal

artery Embolic retinal occlusion RHD, LA

myxoma, atherosclerosis of aorta


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Skin and Mucous membranes

Central cyanosis R to L shunt

Peripheral cyanosis CHF and PAOD

Bronze pigmentation of skin and loss of axillaryand pubic hair hemochomatosis cause ofcardiomyopathy

Jaundice Pulmonary infarction, congestive

hepatomegaly, cardiac cirrhosis LentiginesPS or HCM


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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


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Extremities

ArachnodactylyMarfan syndrome

Systolic flushing of nail bedsQuincke signAR(widened pulse pressure)

Clubbing of fingers and toescentralcyanosiscyanotic heart or hypoxic pulmonarydisease

Unilateral clubbing aortic aneurysm

Differential cyanosis PDA with reverse shunt

Osler nodes, Janeway lesions, splinterhemorrhage IE

Edema, bilateral or unilateral


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Chest

Barrel-shaped chest suspect emphysema,

chronic bronchitis and cor pulmonale

Bulging of right upper sternum aortic aneurysm

Pectus excavatum (Funnel chest) or pectus

carinatum (Pigeon chest)Marfan syn.

Kyphoscoliosis induce cor pulmonale Rales and wheezing BS pulmonary edema


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Abdomen

Painful hepatomegaly due to right heartfailure hepatojugular reflex

Pulsation over liver severe TR or constrictivepericarditis

Palpable kidney suspect polycystic kidneydisease cause of HTN

Systolic bruit over umbilicus or flankrenovascular HTN

Aortic aneurysm palpable below umbilicus


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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


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Kussmaul signparadoxical rise in JVP duringinspiration constrictive pericarditis andsometimes in CHF and TS

Prominent a wave RVH, pulmonaryhypertention and TS

Cannon a wave AV dissociaton

Absent a wave atrial fribrillation

A steeply rising H wave restrictivecardiomyopathy, constrictive pericarditis, RVinfarction


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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


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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


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Normal Arterial Pulse


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Abnormal Arterial Pulse

Bisferiens pulse: AR, AR + AS, HCOM

Dicrotic pulse: cardiac tamponade, severe HF,hypovolemia shock

Pulsus alternans(alternate > 20mmHg) LVfailure

Pulsus bigeminusVPC related

Pulsus paradoxus cardiac tamponade,emphysema, asthma, hypovolemic shock,

pulmonary embolism

Pulsus tardusslow upstroke

Pulsus parvuslow amplitude


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Abnormal Arterial Pulse


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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


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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


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The Cardiac Examination

Inspection

Respiration pattern

Collateral vein

Pectus excavatum (funnel chest): Marfansyn., homocystinuria, Ehlers-Danlos syn.,Hunter-Hurler syn., MVP.

Cardiac pulsation

thrusting apex >2cmLV enlarge

lateral to midclavicular lineLV enlarge


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Palpation

In 30 degree, supine and lateral decubitus position

Left Ventricle

Apical thrust (PMI)>10cm from the midsternal line or >3cm indiameter LV enlargement

Double systolic outward thrustHCOM

Systolic retraction of chest (Broadbent sign)constrictive pericarditis

Presystolic expansion reduced LV compliance(accompany with S4)


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Palpation

Right ventricle

palpable systolic movement in left

parasternal area RVH or enlargement

Thrills accompany with load harsh low

to median frequency murmur


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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


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Heart Sound


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Heart sound

S1: closure of MVApex

closure of TVleft lower SB

Widely split of S1: RBBB

Single S1: LBBB

Load S1: Rapid heart rate, short PR, MS


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Heart Sound

Normal splitting of S2 in inspiration, S2 splitinto A2 and P2

Abnormal splitting of S2

Wide physiological splittingdelay P2 or earlyA2 (RBBB or MR)

Paradoxical splittingLBBB or RV pacemaker

Narrow physiological splitting pulmonaryhypertension

Fixed splitting: ASD


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Heart Sound

Early systolic soundsAortic or pulmonaryejection 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), atrialmyxoma(polp)

Mid- to late diastolic sounds S3 or S4


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Heart sound

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

LV dysfunction, AR, increase rate orvolume of ventricle filling

S4 is generated during atrial contribution to

ventricle filling (may be normal in elderly?) HTN,AS, HCM, ischemic heart, acute

MR

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PE and History