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The Physical Examination of Heart

The Physical Examination of Heart 1 st Affiliated Hospital Liaoning Medical College He Xin. Anatomy. 一、 Inspection with tangential lighting 1 、 Thoracic deformity 2 、 Apical impulse

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The Physical Examination of Heart

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  1. The Physical Examination of Heart 1st Affiliated Hospital Liaoning Medical College He Xin

  2. Anatomy

  3. 一、Inspection with tangential lighting 1、Thoracic deformity 2、Apical impulse 3、Abnormal pulsations of precardium

  4. 1、Thoracic deformity ---protrusion of precordium --Right ventricular hypertrophy (L3-5) congenital heart disease( tetralogy of Fallot) valvular heart disease( MS,PS) --pericardial effusion(large , childhood) --The second right intercostal space (2nd ICS-RS) aneurysm of aortic arch dilatation of ascending aorta ---flat chest ---pigeon chest/ funnel chest

  5. 2 Apical impulse ---Normal --Position : in the left fifth intercostal space about 0.5-1.0cm medial from the midclavicular line --Range: no larger than 2.0-2.5cm in diameter

  6. ---Abnormal （1）Location • Posture • Diaphragm • Mediastinum • Enlargement of the heart • Dextrocardia(右位心): 5-ICS—RS

  7. Posture: ---Recumbent(仰) position—upper ---left lateral(侧) position—to the left 2-3cm ---right lateral position—to the right 1.0-2.5cm

  8. Diaphragm: ---“transverse position” upper,outward obesity ,child, pregnacy ascites; tumor of abdominal cavity ---“vertical position” inferior,inner thin, high, emphysema

  9. mediastinum: • one side pleural effusion or pneumothorax ---to the healthy side • one side atelectasis or pleural adhesion ---to the affected side

  10. Enlargement of the heart • right ventricular dilatation – displaced to the left or slightly upper • left ventricular dilatation— displaced to the left inferior • LV &RV dilatation –left inferior (both side dilatation)

  11. (2) Intensity and extent changes A feeble diffuse impulse ( more than 22.5cm in diameter) may suggest dilation. If the thrust is forcible, hypertrophy is suggested.

  12. (3)Inward impulse(负性心尖搏动): apex excavation in the systole --adhesive pericarditis --prominent RV hypertrophy

  13. 3、Abnomal pulsations of percardium (1)left third-forth intercostal space lateral to the sternum (3,4ICS-LS) ---RV hypertrophy (2)xiphoid process ---RV hypertrophy ---Abdominal aorta (aneurysm) (The pulsation of the abdominal aorta may often be felt in the epigastric area. Also, the impulse from right ventricle can be felt by the fingertips placed under the xiphoid process while inspiration.)

  14. 3、Abnomal pulsations of percardium (3)basal part of the heart ---2 ICS-LS: dilatation of the pulmonary artery or pulmonary hypertensin, occasionally healthy young man ---2 ICS-RS: aneurysm of aortic arch or dilatation of ascending aorta

  15. 二、Palpation 1 Apical impulse and pulsation of precardium 2 Thrill 3 Pericardial friction rub

  16. 1、 Apical impulse and pulsation of precardium ---Exact position of apex ---The beginning of systole of ventricle first sound ---Heaving apex impulse: reliable of LV hypertrophy

  17. 2、Thrill ---Mechanism : the flow of blood→narrowed orifice→vortices→vibration→chest wall ---One of characteristic signs of organic heart disease：CHD or valvular stenosis, occasionally insurficiency ---thrill - high frequency murmurs - low frequency ---Key point:position, phase of cardiac cycle, clinical significance

  18. Clinical significance of thrill

  19. 3、 Pericardil friction rub ---Precardium -4th ICS-LS ---both phases of the cardiac cycle ---systolic period, sitting erect and leaning forward, the end of expiration ---mechanism: rub of the visceral and parietal layers of pleura ---seen: acute pericarditis

  20. 三、Percussion ---Aim: to determine the size and shape of the heart ---Absolute dullness: contain no gas Relative dullness : real size

  21. 1、maneuver of percussion ---patient in erect position –the pleximeter is vertical with the intercostal space ---patient in the recumbent position –the pleximeter is parallel with the intercostal space

  22. 2、order : ---left—right ; upwards ; inward ---left margin : from 2-3 cm lateral to the apex beat up to the 2nd ICS ---right margin : one intercostal space higher than the border of liver dullness up to the 2nd ICS ---size: vertical distance from margin to the anterior midline

  23. Percussion of cardiac dullness border starts tothe left on the chest, from 23cm apart from theapical impulse towards cardiac dullness (relativecardiac dullness). Percussion is performed fromleft towards cardiac dullness in the 4th, 3rd and2nd intercostal spaces. Next, to the right of thechest, percussion is done in the midclavicularline down to a dull point (the upper margin ofliver). Then, percuss from right towards cardiacdullness in the 4th (above the liver dullness), 3rd,and 2nd intercostal spaces.

  24. Measure the vertical distances from each point of cardiac dullness to the mid-sternal line with a stiff ruler • When the left border of cardiac dullness falls outside the midclavicular line, it usually indicates that the left ventricle is enlarged • If the left border of cardiac dullness goes out of left midclavicular line (the left cardiac border towards left in the 5th intercostal space), it suggests that the right ventricle enlarged • The cardiac dullness enlarged towards two sides: (1)both left and right ventricles enlarged, (2) a large volume of fluid in the cavity of pericardium. In this case, the cardiac borders will be changed following the change of the patient's position

  25. ② ④ ③ ①

  26. 3、Normal heart borders (area of relative dullness)

  27. 4、The composition of various parts of theborder of the heart

  28. ---The upper border –the lower border of the anterior end of the third rib↑ ---The basal part —the second intercostal space upward left: aortic node and PA ---Concave part –between the aorta and the left ventricle

  29. 5、Changes in the area of cardiac dullness and its significance （1）body’s position: 1) recumbent position：widening of base of the heart 2) erect position:“triangular shape”

  30. （2）Cardiac factors : 1)LV enlargement: “boot shape”Seen:aortic valvular disease , hypertension heart disease 2)RV enlargement :slightly↑--absolute dullness↑ Prominent↑--relative dullness↑ to the left side prominently Seen:PHD, MS

  31. 3)Two ventricle ↑: “generally enlarged heart” seen:DCM , Kashan cardiomyopathy 4)LA and/or pulmonary artery: “pear shape” LA:concave part disappear LA+PA:2,3 ICS-LS outwards Seen: MS--- “mitrial type”

  32. 5)pericardial effusion: enlargement of both sides of the border 6)dilatation of the aorta /ascending aortic aneurysm: widening if the dull area of first and second intercostal space (with systolic pulsation)

  33. （3）Extacardial factors :1)large pleural effusions and pneumothorax → to the healthy side2)atelectasis /pleural pachynsis →to the affected3)a large amount of ascites or big abdominal tumor: diaphragm elevated→transverse position →left side enlargement

  34. 四、Auscultation 1、Cardiac valve areas for precordial auscultation 2、Order 3、Contents

  35. 1、cardiac valve areas forprecordial auscultation 1)ausclutatory mitral area: apical area 2)auscultatory pulmonary area:2 ICS-LS 3)ausclutatory aortic area: 2 ICS-RS 4)second ausclutatory aortic area: 3rd ICS LS—Erb area 5)tricuspid area :4,5 ICS-LS

  36. Pulmonic valve area Aortic valve areas Mitral valve area Tricuspidvalve area Cardiac valve areas

  37. 2、Order: Apical area Pulmonary valve area Aortic valve area 2 nd aortic valve area Tricuspid valve area MV---PV---AV1---AV2---TV

  38. 3、Contents : 1) rate 2)rhythm 3)heart sound 4)extra heart sound 5)murmurs 6)pericardial friction sound

  39. (1)heart rate • Normal heart rate is 60-100/min (adult) • above 100/min (below 3 years old) • Tarchycardia : above 100/min (adult) above 150/min (infant) • Bradycardia: below 60/min

  40. (2)cardiac rhythm: sinus arrythmia—affected by breath premature beat—frequently:＞6 bpm occasionally: ＜6 bpm atrial fibrillation: —absolute irregular rhythm S1 intensity inequality Pulse deficit

  41. (3)cardiac sound

  42. (4)Abnormal cardiac sound1)Intensity: cardiac sound is influenced by a number of factor ---position of the atrioventricular valve ---Ventricular contractility and output ---Valvular integrity and activity

  43. S1 Accentuation: ---MS ---HR↑contractility↑ fever,anemia,hyperthyroidism ---complete AVB →cannon sound

  44. S1 attenuation : ---MI ---P-R interval enlong ---AI ---myocarditis,myopathy,MI,HF S1 inequality: ---AF ---III°-AVB

  45. S2---A2+P2 S2 ↑---pressure and flow of blood ↑A2 : hypertensin, arterisclerosis P2 : PHD,CoHD(L--R),LVF S2 ↓---pressure↓ flow ↓ Seen:hypotension,AS/AL,PS/PI

  46. 2)Quality mono rhythm pendular rhythm---embryocardia

  47. 3)Splitting of heart sound S1 splitting: seen—RBBB, right heart failure Ebetein malformation ,MS LA myxoma

  48. S2 splitting: physiological splitting :end of inspiration general splitting : most commonlyseen: CRBBB, PS, MS,MI ,VSD fixed splitting :ASD paradoxical splitting(reversed splitting) : pathologicalseen: CLBBB ,AS, hypertension

  49. (5)extra cardiac sound 1)Diastolic period ①gallop rhythm: --protodiastolic gallop: S1+S2+S3 the third sound gallop (sign of organic heart disease) seen : HF（AMI, severe myocarditis , myopathy） -- late diastolic gallop: atrial gallop S1+S2+S4 seen : HBP ,HCM ,AS ,CHD -- summation gallop: quadruple rhythm seen:HF,cardiomyopathy

  50. ②opening snap :MS ③pericardial knock: constrictive pericarditis ④tumor plop: LA myxoma

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