Table 4

Features of the Physical Examination Pertinent to the Evaluation of PH

SignImplication
Physical Signs That Reflect Severity of PH
Accentuated pulmonary component of S2(audible at apex in over 90%)High pulmonary pressure increases force of pulmonic valve closure
Early systolic clickSudden interruption of opening of pulmonary valve into high-pressure artery
Midsystolic ejection murmurTurbulent transvalvular pulmonary outflow
Left parasternal liftHigh right ventricular pressure and hypertrophy present
Right ventricular S4(in 38%)High right ventricular pressure and hypertrophy present
Increased jugular “a” wavePoor right ventricular compliance
Physical Signs That Suggest Moderate to Severe PH
Moderate to severe PH
 Holosystolic murmur that increases with inspirationTricuspid regurgitation
 Increased jugular v waves
 Pulsatile liver
 Diastolic murmurPulmonary regurgitation
 Hepatojugular refluxHigh central venous pressure
Advanced PH with right ventricular failure
 Right ventricular S3(in 23%)Right ventricular dysfunction
 Distention of jugular veinsRight ventricular dysfunction or tricuspid regurgitation or both
 HepatomegalyRight ventricular dysfunction or tricuspid regurgitation or both
 Peripheral edema (in 32%)
 Ascites
 Low blood pressure, diminished pulse pressure, cool extremitiesReduced cardiac output, peripheral vasoconstriction
Physical Signs That Suggest Possible Underlying Cause or Associations of PH
Central cyanosisAbnormal V/Q, intra-pulmonary shunt, hypoxemia, pulmonary-to-systemic shunt
ClubbingCongenital heart disease, pulmonary venopathy
Cardiac auscultatory findings, including systolic murmurs, diastolic murmurs, opening snap, and gallopCongenital or acquired heart or valvular disease
Rales, dullness, or decreased breath soundsPulmonary congestion or effusion or both
Fine rales, accessory muscle use, wheezing, protracted expiration, productive coughPulmonary parenchymal disease
Obesity, kyphoscoliosis, enlarged tonsilsPossible substrate for disordered ventilation
Sclerodactyly, arthritis, telangiectasia, Raynaud phenomenon, rashConnective tissue disorder
Peripheral venous insufficiency or obstructionPossible venous thrombosis
Venous stasis ulcersPossible sickle cell disease
Pulmonary vascular bruitsChronic thromboembolic PH
Splenomegaly, spider angiomata, palmary erythema, icterus, caput medusa, ascitesPortal hypertension

PH indicates pulmonary hypertension.