Valvular Heart Disease: Examination

A comprehensive clinical examination is the basis for selecting further diagnostic steps:

• General physical examination – including blood pressure, pulse, body weight, height; further:
  • Inspection (viewing).
    • Skin, mucous membranes, and sclerae (white part of the eye) [cyanosis (bluish discoloration of the skin and/or central mucous membranes caused by a lack of oxygen)]
    • Neck vein congestion? [heart failure (cardiac insufficiency)]
    • Edema/water retention? [heart failure (cardiac insufficiency)]
      • Lower leg: pretibial/pre-shin, ankle.
      • In the recumbent patient: presacral/pretibial, sacrum.
    • Peripheral cyanosis, generalized? – In valvular vitiation (heart defects)]
    • Central cyanosis (cyanosis of the skin and central mucous membranes)? [in vitias (heart defects) with right-to-left shunt (in this disorder, deoxygenated venous blood enters the systemic circulation directly, bypassing the pulmonary circulation); heart failure (cardiac insufficiency)]
• Auscultation (listening) of the heart.
  • Aortic valve (auscultation point: 2nd intercostal space, abbreviated ICR, right parsternal).
    • Aortic stenosis – spindle-shaped rough systolic p.m. 2nd ICR (intercostal space/intercostal rib space) right parasternal (next to sternum), continued into carotids (carotid arteries)
    • Aortic insufficiency – diastolic decrengeal murmur after the 2nd heart sound p.m. over the aorta or Erb (auscultation point corresponding approximately to the center of the heart figure; it is located in the 3 ICR left, about two QF (transverse fingers) parasternal (next to the sternum)); spindle-shaped systolic (in relative aortic stenosis).
  • Pulmonary valve (auscultation point: 2nd ICR left parasternal).
  • Tricuspid valve (auscultation point: 5th ICR right parasternal).
  • Mitral valve (auscultation point: 5th ICR left medioclavicular line).
    • Mitral stenosis – throbbing first heart sound, mitral opening sound, diastolic decrescendo murmur (a murmur continuously decreasing in intensity), transitioning to a presystolic crescendo murmur (a murmur continuously increasing in intensity)
    • Mitral regurgitation – high-frequency, banded systolic (systolic murmur) p.m. (punctum maximum) above the apex of the heart, carried away into the left axilla (axilla) (in left lateral position).
    • Mitral prolapse – high-frequency systolic clicks (at the left lower sternal border/heart apex); high-frequency, banded systolic p.m. over the apex of the heart, carried away into the axilla
• In healthy individuals, the cardiac apex bump can be palpated as follows: 4th or 5th ICR on the left, slightly medial to the midclavicular line [in cardiomegaly (cardiac enlargement), for example, from the 5th to the 7th ICR].
• Examination of the lungs
  • Auscultation (listening) of the lungs [in pulmonary edema: moist rales; the breathing sound is attenuated; in severe cases are audible even without a stethoscope (“bubbling of the lungs”)]
  • Bronchophony (check the transmission of high-frequency sounds; the patient is asked to pronounce the word “66” several times in a pointed voice while the doctor listens to the lungs) [increased sound conduction due to pulmonary infiltration / compaction of lung tissue (eg. e.g. in pneumonia) the consequence is, the number “66” is better understood on the diseased side than on the healthy side; in case of decreased sound conduction (attenuated or absent): e.g. in pleural effusion, pneumothorax, emphysema). The result is, the number “66” is barely audible to absent over the diseased part of the lung, because the high-frequency sounds are strongly attenuated]
  • Percussion (tapping) of the lungs [the tapping sound is normal to muffled].
  • Vocal fremitus (checking the conduction of low frequencies; the patient is asked to pronounce the word “99” several times in a low voice while the physician places his hands on the patient’s chest or back) [increased sound conduction due to pulmonary infiltration/compaction of lung tissue (e.g. e.g., in pneumonia) results, the number “99” is better understood on the diseased side than on the healthy side; in decreased sound conduction (attenuated: e.g., atelectasis, pleural rind; severely attenuated or absent: in pleural effusion, pneumothorax, emphysema).The result is, the number “99” is barely audible over the diseased part of the lung to absent, because the low-frequency sounds are strongly attenuated]
• Examination of the abdomen
  • Percussion (tapping) of the abdomen
    • [Attenuation of tapping sound due to enlarged liver or spleen, tumor, urinary retention?
    • Hepatomegaly (liver enlargement) and/or splenomegaly (spleen enlargement): estimate liver and spleen size]
  • Palpation (palpation) of the abdomen (abdomen), etc.
    • Hepatomegaly? Congestive liver) [heart failure (cardiac insufficiency).
    • Splenomegaly? secondary to portal hypertension) [heart failure.]
• Health check

Square brackets [ ] indicate possible pathological (pathological) physical findings. Further notes

• Auscultation of the heart versus echocardiography:
  • Mild valvular defects (sclerosis of the aortic valve or mild regurgitation (heart valves that do not close properly, allowing blood to flow back) at one of the valves): 32% vs. 68%
  • Significant valvular defects (at least moderate regurgitation or mild stenosis (narrowing) of one of the valves): 44% vs. 36
    • 20 Patients without murmur on auscultation but had significant valvular defect: negative predictive value 88%.
    • Slim patients (BMI <25) with major valvular defects tended to have better auscultation results than overweight patients (BMI: 25.0-29.9).
  • Cardiologists did not perform better than primary care physicians on auscultation.