Diagnosis: Heart murmurs: Tricuspid insufficiency

Physical Exam

Differential Diagnosis

Physical Exam

My approach

Best patient position

Location

- Best heard along the lower left sternal bornder

Quality of murmur

- high-pitched blowing

Sound in systole or diastole

- systolic murmur

Sound of S1 or S2 (A2,P2)

Pattern

- Intensity increases with inspiration

Radiation

- Radiates to he right sternal border

Other signs:

-

hospitalist handbook p. 52

HEART MURMURS*

1. Aortic stenosis: Crescendo-decrescendo systolic murmur heard best in the aortic area, radiating to the supraclavicular fossa and carotids. Rarely heard at the apex. A2 decreased; paradoxical S2 split (sign of critical AS in absence of LBBB); narrow pulse pressure. Pulsus parvus et tardus, S2 softens, murmur peaks later as aortic stenosis progresses. Gallavardin’s phenomenon is AS murmur heard in mitral area. Aortic sclerosis can mimic AS murmurs very closely.

2. Aortic insufficiency: High-pitched blowing diastolic murmur at left sternal border, 3rd or 4th interspace. Heard best with patient sitting, leaning forward, and holding breath at end-expiration. Wide pulse pressure, Quincke’s sign (capillary pulsation in nailbed with gentle pressure), Musset’s sign (head bobbing), Muller’s sign (pulsating uvula), Corrigan’s pulse (bounding, full carotid pulse with rapid downstroke), Hill’s sign (systolic BP in leg at least 30 mmHg higher than in arm). Austin-Flint: diastolic murmur in mitral area due aortic regurgitant flow impinging anterior mitral leaflet.

3. Pulmonic stenosis: Systolic murmur heard in pulmonic area, transmitted to the neck or left shoulder. A2 is decreased, P2 is delayed. RVH with parasternal lift.

4. Pulmonic insufficiency: High pitched decrescendo diastolic murmur heard in pulmonic area; often associated with pulmonary hypertension. Intensity may increase with inspiration.

5. Mitral stenosis: low-pitched rumbling diastolic murmur heard best at apex. Opening snap sometimes present.

6. Mitral insufficiency: loud, high-pitched holosystolic murmur heard best at apex, radiating to the left axilla (when ant leaflet incompetent) or to left sternal border (when pos leaflet incompetent). Soft S1.

7. Tricuspid insufficiency: high-pitched blowing systolic murmur best heard along the lower left sternal border, radiating to the right sternal border. Intensity increases with inspiration.

8. Pericardial friction rub: scratchy, leathery, scraping sound heard best along the left sternal border, 3rd interspace. 3 components: (1) atrial systole, (2) ventricular systole, (3) ventricular diastole. Usually the first two components are present. Heard best with patient leaning forward at end exhalation.

Etchells E, Bell C, Robb K. Does this patient have an abnormal systolic murmur? JAMA 1997; 277:564-71.

Choudhry NK, Etchells EE. The rational clinical examination. Does this patient have aortic regurgitation? JAMA 1999; 281:2231-8.

*mitral prolapse & IHSS are flow dependent murmurs

surgery.ucsf.edu/res

Multiple choice question

Questions 406-410

For each physical finding or group of findings, select the cardiovascuar disorder with which it is most likely to be associated.

a. Massive tricuspid regurgitation

b. Aortic regurgitation

c. Coarctation of the aorta

d. Thoracic aortic aneurysm

e. Myocarditis

#406: An elderly man with abnormal pupillary responses (Argyll Robertson pupil)

#407: A 24 year old drug addict with jugular venous distension and exophthalmos

#408: A patient with flushing and paling of the nail beds (Quincke pulse) and a bounding radial pulse

#409: A patient with conjunctivitis urethral discharge, and arthralgia

#410: A patient with short stature, webbed neck, low-set ears, and epicanthal folds

Th answers are: 406-d; 407-a; 408-b; 409-e; 410-c

(Greenfield, pp1468-1478)

The Argyll Robertson pupil (a pupil that constricts with accommodation but not in response to light) is characteristic of central nervous system syphilis and is associated with vascular system manifestations of that disease.

Treponema palidum invades the vasa vasorum and causes an obiterative endarteritis and necrosis.

The resulting aortitis gradually weakens the aortic wall and predisposes it to aneurysm formation.

Once an aneurysm has formed the prognosis is grave.

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Massive isolated tricuspid regurgitation produce a markedly elevated venous pressure, usually manifested by a severely engorged (often pulsatin) liver.

If the venous pressure is sufficiently elevated, exophthalmos may result.

Tricuspid regurgitation of rheumatic origin is almost never an isolated lesion and the major symptoms of patients who have rheumatic heart disease are usually attributable to concurrent left heart lesions.

Bacterial endocarditis from intravenous drug abuse is becoming an increasingly important cause of isolated tricuspid regurgitation.

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A Quincke pulse, which consists of alternate flushing and paling of the skin or nail beds is associated with aortic regurgitation.

Other charactesritic features of the peripheral pulse in aortic regurgitation include the waterhammer pulse (Corrigan pulse caused by a rapid systolic upstroke) and pulsus bisferiens, which describes a double systolic hump in the pulse contour

The finding of a wide pulse pressure provides an additional diagnostic clue to aortic regurgitation.

Myocarditis, aortitis and pericarditis have all been described in association with Rieter's syndrome; the original description included conjunctivitis, urethritis, and arthralgias.

Although itsw cause is unknown Reiter's sydrome is associated with HLA-B27 antigen, as are aortic regurgitation, pericarditis, and ankylosing spondylitis.

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Short stature, webbed neck, low-set ears, and epicanthal folds are the classic features of patients who have Turner's syndrome.

Persons affected by the syndrome, which is commonly linked with  aortic coarctation, are genotypically XO.

However, females and males have been described with normal sex chromosome constitutions (XX,XY) but with the phenotypic abnormalities of Turner's syndrome.

Additional cardiac lesions associated with Turner's syndrome include septal defects, valvular stenosis, and anomalies of the great vessesl.

pretest surgery p.279;291 queston 406-410