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==Overview==
==Overview==
Pulmonary hypertension (PH) can present with a myriad of physical signs that develop on a spectrum corresponding to the severity of the disease.  PH is often initially associated with a loud P2,  parasternal heave, and narrowed splitting of the second heart sound on physical examination. A third heart sound (S3) may also be heard on auscultation. As PH worsens, right ventricular failure can develop, which can be associated with  as increased [[jugular venous pressure]] (JVP), [[ascites]], [[peripheral edema]], [[Abdominojugular test|hepatojugular reflux]], and [[clubbing]].  
Pulmonary hypertension (PH) can present with a myriad of physical signs that develop on a spectrum corresponding to the severity of the disease.  PH is often initially associated with a loud P2,  parasternal heave, and narrowed splitting of the second heart sound on physical examination. A third heart sound (S3) may also be heard on auscultation. As PH worsens, right ventricular failure can develop, which can be associated with  as increased [[jugular venous pressure]] (JVP), [[ascites]], [[peripheral edema]], [[Abdominojugular test|hepatojugular reflux]], and [[clubbing]].  
A [[pansystolic murmur]] of [[tricuspid insufficiency]] can also be present on physical examination and is suggestive long-standing pulmonary hypertension.
A pansystolic murmur of [[tricuspid insufficiency]] can also be present on physical examination and is suggestive long-standing PH.
 


==Physical Examination==
==Physical Examination==
===General appearance===  
===General Appearance===  


The appearance of the patient may give clues as to the etiology of the condition. For example in [[Chronic obstructive pulmonary disease|COPD]], one of the most common causes of pulmonary hypertension, the patient may appear short of breath with pursed lips breathing and use of accessory muscles.  Later on in severe disease, the patient may appear [[cyanosis|cyanotic]] with extremities cold to the touch. <ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref>
The appearance of the patient may give clues as to the etiology of the condition. For example in [[Chronic obstructive pulmonary disease|COPD]], one of the most common causes of pulmonary hypertension, the patient may appear short of breath with pursed lips breathing and use of accessory muscles.  Later on in severe disease, the patient may appear [[cyanosis|cyanotic]] with extremities cold to the touch. <ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref>
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filling) and the height of the JVP column above the sternal angle. Physical findings may include:
filling) and the height of the JVP column above the sternal angle. Physical findings may include:


*'''Prominent 'a' wave''': due to forced atrial contraction  
* Prominent 'a' wave: due to forced atrial contraction  
*'''Prominent 'v' wave''': later if [[Tricuspid regurgitation|tricuspid regurgitation]] develops with right ventricular failure.  
* Prominent 'v' wave: later if [[Tricuspid regurgitation|tricuspid regurgitation]] develops with right ventricular failure.  
*'''Elevated JVP''': can be present if right ventricular failure develops
* Elevated JVP: can be present if right ventricular failure develops
*'''Postive [[Kussmaul's sign]]''': JVP elevation during inspiration (the opposite of what normally happens) because of right ventricular failure <ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref>
* Postive [[Kussmaul's sign]]: JVP elevation during inspiration (the opposite of what normally happens) because of right ventricular failure <ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref>
*'''Positive [[Hepatojugular reflux|Abdominojugular reflux]]''': JVP rises and remains elevated during a period of over 10 seconds whilst abdominal pressure is applied. This may be present if right ventricular failure develops <ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref>
* Positive [[Hepatojugular reflux|Abdominojugular reflux]]''': JVP rises and remains elevated during a period of over 10 seconds whilst abdominal pressure is applied. This may be present if right ventricular failure develops <ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref>


===Lungs===
===Lungs===
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====Palpation====
====Palpation====


*'''Left parasternal heave''': due to hyperdynamic right ventricle
* Left parasternal heave: due to hyperdynamic right ventricle
*'''Palpable P2''': correlates with severe disease <ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref>
* Palpable P2: correlates with severe disease <ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref>


====Ausculation====
====Ausculation====
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=====First and second heart sound (S1,S2) assessment=====
=====First and second heart sound (S1,S2) assessment=====


*'''Loud P2 component of S2''': this is due to forceful closure of the valve because of increased pulmonary pressure. It can be heard mostly in pulmonary area (upper right sternal border). If it is evident at the cardiac apex, this indicates more severe disease. It is best appreciated on inspiration. <ref name="isbn0-7817-7012-2">{{cite book |author=Thompson, Paul Richard; Topol, Eric J.; Califf, Robert M.; Prystowsky, Eric N.; Thomas, James Alan |title=Textbook of cardiovascular medicine |publisher=Lippincott Williams & Wilkins |location=Hagerstwon, MD |year=2007 |pages= |isbn=0-7817-7012-2 |oclc= |doi= |accessdate=}}</ref>
* Loud P2 component of S2: this is due to forceful closure of the valve because of increased pulmonary pressure. It can be heard mostly in pulmonary area (upper right sternal border). If it is evident at the cardiac apex, this indicates more severe disease. It is best appreciated on inspiration. <ref name="isbn0-7817-7012-2">{{cite book |author=Thompson, Paul Richard; Topol, Eric J.; Califf, Robert M.; Prystowsky, Eric N.; Thomas, James Alan |title=Textbook of cardiovascular medicine |publisher=Lippincott Williams & Wilkins |location=Hagerstwon, MD |year=2007 |pages= |isbn=0-7817-7012-2 |oclc= |doi= |accessdate=}}</ref>


=====Splitting of S2 assessment=====
=====Splitting of S2 assessment=====


*'''Narrowed splitting of S2''': in chronic pulmonary hypertension, pulmonary artery compliance decreases leading to earlier pulmonary valve closure and narrowed splitting. <ref name="isbn0-07-055417-X">{{cite book |author=Alexander, R. McNeill; Hurst, J. Willis; Schlant, Robert C. |title=The Heart, arteries and veins |publisher=McGraw-Hill, Health Professions Division |location=New York |year=1994 |pages= |isbn=0-07-055417-X |oclc= |doi= |accessdate=}}</ref>
* Narrowed splitting of S2: in chronic pulmonary hypertension, pulmonary artery compliance decreases leading to earlier pulmonary valve closure and narrowed splitting. <ref name="isbn0-07-055417-X">{{cite book |author=Alexander, R. McNeill; Hurst, J. Willis; Schlant, Robert C. |title=The Heart, arteries and veins |publisher=McGraw-Hill, Health Professions Division |location=New York |year=1994 |pages= |isbn=0-07-055417-X |oclc= |doi= |accessdate=}}</ref>
*'''Widened splitting of S2''': widened splitting may occur later if right ventricular failure or bundle branch block develops. <ref name="isbn0-7817-7012-2">{{cite book |author=Thompson, Paul Richard; Topol, Eric J.; Califf, Robert M.; Prystowsky, Eric N.; Thomas, James Alan |title=Textbook of cardiovascular medicine |publisher=Lippincott Williams & Wilkins |location=Hagerstwon, MD |year=2007 |pages= |isbn=0-7817-7012-2 |oclc= |doi= |accessdate=}}</ref>
* Widened splitting of S2: widened splitting may occur later if right ventricular failure or bundle branch block develops. <ref name="isbn0-7817-7012-2">{{cite book |author=Thompson, Paul Richard; Topol, Eric J.; Califf, Robert M.; Prystowsky, Eric N.; Thomas, James Alan |title=Textbook of cardiovascular medicine |publisher=Lippincott Williams & Wilkins |location=Hagerstwon, MD |year=2007 |pages= |isbn=0-7817-7012-2 |oclc= |doi= |accessdate=}}</ref>


=====Extra heart sounds assessment=====  
=====Extra heart sounds assessment=====  
*'''S4''': due to right ventricular hypertrophy and therefore reduced compliance secondary to pulmonary hypertension. It is increased with inspiration.
* S4: due to right ventricular hypertrophy and therefore reduced compliance secondary to pulmonary hypertension. It is increased with inspiration.
*'''S3''': if right ventricular failure develops. Increased with inspiration. <ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref>
* S3: if right ventricular failure develops. Increased with inspiration. <ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref>
 
=====Additional sounds assessment=====  
=====Additional sounds assessment=====  
*'''Systolic pulmonary ejection click''': increased with inspiration
* Systolic pulmonary ejection click: increased with inspiration


=====Murmurs assessment=====  
=====Murmurs assessment=====  
*'''Ejection midsystolic pulmonic murmur''': increased with inspiration
* Ejection midsystolic murmur: increased with inspiration
*'''Diastolic pulmonary regurgitation murmur (Graham-Steele murmur)''': indicates [[pulmonary insufficiency]]
* Diastolic murmur (Graham-Steele murmur): indicates [[pulmonary regurgitation]]
*'''Pansystolic murmur''': indicates [[tricuspid regurgitation]] and developing [[right ventricular failure]]<ref name="isbn0-7020-2993-9">{{cite book |author=Clark, Michael; Kumar, Parveen J. |title=Kumar and Clark's clinical medicine |publisher=Elsevier Saunders |location=St. Louis, Mo |year=2009 |pages= |isbn=0-7020-2993-9 |oclc= |doi= |accessdate=}}</ref>
* Pansystolic murmur: indicates [[tricuspid regurgitation]] and developing [[right ventricular failure]]<ref name="isbn0-7020-2993-9">{{cite book |author=Clark, Michael; Kumar, Parveen J. |title=Kumar and Clark's clinical medicine |publisher=Elsevier Saunders |location=St. Louis, Mo |year=2009 |pages= |isbn=0-7020-2993-9 |oclc= |doi= |accessdate=}}</ref>


===Abdomen===  
===Abdomen===  
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Findings in the abdomen include:
Findings in the abdomen include:


*'''[[Ascites]]''': indicates right ventricular failure
* [[Ascites]]: indicates right ventricular failure
*'''Painful [[hepatomegaly]]''': indicates right ventricular failure
* Painful [[hepatomegaly]]: indicates right ventricular failure
*'''Pulsatile liver''': due to tricuspid regurgitation <ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref>
* Pulsatile liver: due to tricuspid regurgitation <ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref>


===Legs===  
===Legs===  


*'''[[Edema]]''': indicates right ventricular failure <ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref>
* [[Edema]]: indicates right ventricular failure <ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref>
* [[Cool extremities]]: indicates severe disease
* [[Cool extremities]]: indicates severe disease


Revision as of 14:59, 29 August 2014

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Editor(s)-in-Chief: C. Michael Gibson, M.S., M.D. [1] Phone:617-632-7753; Assistant Editor(s)-in-Chief: Lisa Prior; Ralph Matar,

Overview

Pulmonary hypertension (PH) can present with a myriad of physical signs that develop on a spectrum corresponding to the severity of the disease. PH is often initially associated with a loud P2, parasternal heave, and narrowed splitting of the second heart sound on physical examination. A third heart sound (S3) may also be heard on auscultation. As PH worsens, right ventricular failure can develop, which can be associated with as increased jugular venous pressure (JVP), ascites, peripheral edema, hepatojugular reflux, and clubbing. A pansystolic murmur of tricuspid insufficiency can also be present on physical examination and is suggestive long-standing PH.

Physical Examination

General Appearance

The appearance of the patient may give clues as to the etiology of the condition. For example in COPD, one of the most common causes of pulmonary hypertension, the patient may appear short of breath with pursed lips breathing and use of accessory muscles. Later on in severe disease, the patient may appear cyanotic with extremities cold to the touch. [1]

Pulse

The pulse may be diminished. This usually occurs in more severe disease. [1]

Skin

JVP

Assessment of the JVP in pulmonary hypertension involves assessing the 'a' wave (coincides with atrial contraction), the 'v' wave (coincides with atrial filling) and the height of the JVP column above the sternal angle. Physical findings may include:

  • Prominent 'a' wave: due to forced atrial contraction
  • Prominent 'v' wave: later if tricuspid regurgitation develops with right ventricular failure.
  • Elevated JVP: can be present if right ventricular failure develops
  • Postive Kussmaul's sign: JVP elevation during inspiration (the opposite of what normally happens) because of right ventricular failure [1]
  • Positive Abdominojugular reflux: JVP rises and remains elevated during a period of over 10 seconds whilst abdominal pressure is applied. This may be present if right ventricular failure develops [1]

Lungs

Precordium

An holistic precordial assessment of pulmonary hypertension involves palpating the precordium for heaves and thrills and ausculatating to assess first and second heart sounds, splitting of the second heart sound and determining if there any added heart sounds or murmurs. Physical findings may include the following:

Palpation

  • Left parasternal heave: due to hyperdynamic right ventricle
  • Palpable P2: correlates with severe disease [1]

Ausculation

First and second heart sound (S1,S2) assessment
  • Loud P2 component of S2: this is due to forceful closure of the valve because of increased pulmonary pressure. It can be heard mostly in pulmonary area (upper right sternal border). If it is evident at the cardiac apex, this indicates more severe disease. It is best appreciated on inspiration. [3]
Splitting of S2 assessment
  • Narrowed splitting of S2: in chronic pulmonary hypertension, pulmonary artery compliance decreases leading to earlier pulmonary valve closure and narrowed splitting. [4]
  • Widened splitting of S2: widened splitting may occur later if right ventricular failure or bundle branch block develops. [3]
Extra heart sounds assessment
  • S4: due to right ventricular hypertrophy and therefore reduced compliance secondary to pulmonary hypertension. It is increased with inspiration.
  • S3: if right ventricular failure develops. Increased with inspiration. [1]
Additional sounds assessment
  • Systolic pulmonary ejection click: increased with inspiration
Murmurs assessment

Abdomen

Findings in the abdomen include:

  • Ascites: indicates right ventricular failure
  • Painful hepatomegaly: indicates right ventricular failure
  • Pulsatile liver: due to tricuspid regurgitation [1]

Legs

Shown below is an image depicting the physical examination findings of PH.

Physical exam findings in pulmonary hypertension and right ventricular failure

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP (2009). Clinical Examination: A Systematic Guide to Physical Diagnosis. Edinburgh: Churchill Livingstone. ISBN 0-7295-3905-9.
  2. ↑ Galiè N, Hoeper MM, Humbert M, Torbicki A, Vachiery JL, Barbera JA; et al. (2009). "Guidelines for the diagnosis and treatment of pulmonary hypertension: the Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS), endorsed by the International Society of Heart and Lung Transplantation (ISHLT)". Eur Heart J. 30 (20): 2493–537. doi:10.1093/eurheartj/ehp297. PMID 19713419.
  3. ↑ 3.0 3.1 Thompson, Paul Richard; Topol, Eric J.; Califf, Robert M.; Prystowsky, Eric N.; Thomas, James Alan (2007). Textbook of cardiovascular medicine. Hagerstwon, MD: Lippincott Williams & Wilkins. ISBN 0-7817-7012-2.
  4. ↑ Alexander, R. McNeill; Hurst, J. Willis; Schlant, Robert C. (1994). The Heart, arteries and veins. New York: McGraw-Hill, Health Professions Division. ISBN 0-07-055417-X.
  5. ↑ Clark, Michael; Kumar, Parveen J. (2009). Kumar and Clark's clinical medicine. St. Louis, Mo: Elsevier Saunders. ISBN 0-7020-2993-9.

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