Book Reading-Heart Disease Braunwald

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

2. 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)

3. 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 edemaTV disease or constrictive pericarditis

4. Eyes • External ophthalmoplegia and ptosis Kearns-Sayre syndrome  complete AV block • Exophthalmos and starehyperthyroidism cause of high CO heart failure • Blue scleraosteogenesis imperfecta aortic dilatation, AR, dissection and MVP • Pulsation of eyeball or earlobe (Pulsatile exophthalmos) severe TR

5. Eye Fundi • HTN • Infective endocarditis Roth spots • Papilledema malignant HTN and cor pulmonale with severe hypoxia • Hypercholesterolemia beading of retinal artery • Embolic retinal occlusion  RHD, LA myxoma, atherosclerosis of aorta

6. Skin and Mucous membranes • Central cyanosis R to L shunt • Peripheral cyanosis CHF and PAOD • Bronze pigmentation of skin and loss of axillary and pubic hair hemochomatosis  cause of cardiomyopathy • Jaundice  Pulmonary infarction, congestive hepatomegaly, cardiac cirrhosis • Lentigines PS or HCM

7. 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

8. Extremities • ArachnodactylyMarfan syndrome • Systolic flushing of nail bedsQuincke sign AR(widened pulse pressure) • Clubbing of fingers and toescentral cyanosiscyanotic 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

9. 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

10. 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

11. 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

12. Jugular Venous Pulse(internal jugular vein)

13. Jugular Venous Pulse(internal jugular vein) • Kussmaul signparadoxical 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 cardiomyopathy, constrictive pericarditis, RV infarction

14. 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 waveTR • Equal a and v wave  ASD

15. Arterial Pulse • Carotid arterymost accurate representation of central aortic pulse • Brachial arterymost suitable for evaluating the rate of rise of pulse, contour, volume, and consistency

16. Normal Arterial Pulse

17. Abnormal Arterial Pulse • Bisferiens pulse: AR, AR + AS, HCOM • Dicrotic pulse: cardiac tamponade, severe HF, hypovolemia shock • Pulsus alternans(alternate > 20mmHg) LV failure • Pulsus bigeminusVPC related • Pulsus paradoxus cardiac tamponade, emphysema, asthma, hypovolemic shock, pulmonary embolism • Pulsus tardus slow upstroke • Pulsus parvuslow amplitude

18. Abnormal Arterial Pulse

19. 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

20. 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

21. The Cardiac ExaminationInspection • Respiration pattern • Collateral vein • Pectus excavatum (funnel chest): Marfan syn., homocystinuria, Ehlers-Danlos syn., Hunter-Hurler syn., MVP. • Cardiac pulsation thrusting apex >2cmLV enlarge lateral to midclavicular lineLV enlarge

22. The Cardiac ExaminationPalpation • In 30 degree, supine and lateral decubitus position • Left Ventricle Apical thrust (PMI) >10cm from the midsternal line or >3cm in diameter LV enlargement Double systolic outward thrust HCOM Systolic retraction of chest (Broadbent sign) constrictive pericarditis Presystolic expansion  reduced LV compliance (accompany with S4)

23. 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

24. 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

25. Cardiac AuscultationHeart Sound

26. 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

27. Cardiac AuscultationHeart Sound • Normal splitting of S2 in inspiration, S2 split into A2 and P2 • Abnormal splitting of S2 Wide physiological splittingdelay P2 or early A2 (RBBB or MR) Paradoxical splittingLBBB or RV pacemaker Narrow physiological splitting pulmonary hypertension Fixed splitting: ASD

28. Cardiac AuscultationHeart Sound • Early systolic soundsAortic or pulmonary ejection sounds (AS, bicuspid AV, PS) • Mid- to late systolic sounds (click) MVP • Early diastolic soundsMS (opening snap), pericardial knock (constrictive pericarditis), MR knock(with poor LV compliance), atrial myxoma(polp) • Mid- to late diastolic sounds S3 or S4

29. 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