The Physical Examination of Heart.docx

The Physical Examination of Heart.docx

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ThePhysicalExaminationofHeart

ThePhysicalExaminationofHeart

Inthepresenteraoftechnologicaladvances,particularlyinthevariousimagingmodalities,thereisagrowingconceptionamongpracticingphysiciansincardiovascularmedicinethatbedsidephysicalexaminationisunnecessaryanddoesnotprovideusefulinformation.Itshouldbeemphasized,however,thatforproperapplicationandinterpretationofvariousnewandoldteststhatareavailableforcardiovascularevaluationinagivenpatient.Bedsideclinicalexaminationshouldbeperformedandpracticedinthesamewayfollowingsimilarsequences.

Preparingthepatient

Theheartexaminationshouldbemadeaseasyaspossibleforthepatient,whousuallyexpectsittobearelativelydistastefulexperience.Ifthephysicianisconsiderateandgentle,thepatientshouldfeelwhenitisallover,thatmostofhisorherfearsonthatscorewereunfounded.Theidealexaminingroomisprivate,warmenoughtoavoidchilling,andfreefromdistractingnoiseandsourcesofinterruption.Adequate（preferablyfluorescentornatural）lightisessential.Theexaminingtablemaybeplacedwithitsheadagainstthewall,butbothsides（particularlytheright）andthefootshouldbeaccessibletotheexaminer.Andtheresultsshouldberecordedcarefully.

Inspection

1.Observeprecordium

Inspectionoftheprecordiumshouldbeginatthefootofthebed.Thesubjectshouldbesupinewiththelegshorizontalandtheheadandtrunkelevatedtoapproximately15-30degrees.Asymmetryofthethoraciccageduetoaconvexbulgingoftheprecordimsuggeststhepresenceofheartdiseasesincechildhood,suchascongenitalheartdiseaseandrheumaticheartdisease,withskeletalmoldingtoaccommodatecardiacenlargement.Intheadult,precordialbulgemaybeproducedfromthemassivepericardialeffusion.

2.Apicalimpulse

Theapicalimpulseisoccurringearlyinsystole.Inadultstheapicalimpulsenormallyislocatedintheleftfifthintercostalspace,eitheratormedialtothemvlandabout2-2.5cmdiameter,itservestheexaminerasamarkerfortheonsetofcardiaccontraction.

Displacementoftheapicalimpulse:

a）Heartdisease:

Someheartdiseasescausetheleftventricularhypertropydilatationorboth,theapicalimpulseisdisplacedlaterallyandinferiorlyandsustained,anditmaybeshiftedtotheleftandupwardinrightventricularhypertrophy,dilatationorboth.Itcanbefoundattherightfifthintercostalspaceindixtrocardiacandcannotbefoundinmassivepericardialeffusion.

b）Thoracicdisease:

pneumothoraxandpleuraleffusionwilldisplacetheapicalimpulsetothenormalside.Pleuraladhesionandateleotasiswillresultinadisplacementofimpulsetowardthediseasedside.

c）Abdominaldisease:

Theapicalimpulsealsocanbedisplacedbylargemass,massiveascites.

d）Theapicalimpulsemayhaveincreasedamplituedanddurationinthosepersonswithathinchest,anemia,fever,hyperthyroidismandanxiety.Theexaminershouldalwaysobservetheshapeandcontourofpatint’schest.Depressionsofthesternum,Kyphosisofdorsalspine,scoliosisoftenaltertheshapeandpositionoftheapicalimpulse.

Abnormalpulsationsintheotherareas.

a）Rightvertricularhypertophy（RBH）.Theimpulseisclearlyseeninleftthirdfourthintercostalspace.

b）PulmonaryemphysemawithRVH,usuallythepulsationcanbefoundinferiorthexiphoidprocess.

c）Inasendingorarchaorticaneurysm,onemaydetectabnormalpulsationsinaorticarea,withbulgingorpulsationinsystole.

d）Pulmonaryhypertensionwithdilatationthepulsationinsystolemaybedetectedinleftsecondintercostalspacetotheedgeofsternum.

palpation

Usuallyinspectionandpalpationarediscussedtogetherbecausethereisanintimaterelationshipbetweenthesetwoprocessesintheheartexamination.Palpationnotonlyconfirmstheresultsininspection,butalsodiscoversdiagnosticsigns.Throughcarefulpalpation,theexaminershouldaimtodeterminethelocationandsizeofthecardiacapeximpulse,characterizeitscontour,andidentifyanyabnormalprecordialpulsations.Thepalmofthehand,ventralsurfaceoftheproximalmetacarpals,andfingersshouldallbeusedforpalpationbecauseeachisusefulforoptimalappreciationofcertainmovements.

1）Usageofthepalpationconfirmstheprecordialpulsation’slocation.Amplitude,durationandintensity.Inleftventricularhypertrophy（LVH）theimpulsesareveryforceful,sustainedthroughoutsystoleandhasagreatamplitude.Theapicalimpulsemayhavedecreasedamplitudeanddurationinthosepatientswithmyocarditis.Inmassivepericardialeffusiontheimpulsecannotbepalpable.

2）Thrillsareactuallypalpablefinevibrations,mostcommonlyproducedbybloodfromonechamberofthehearttoanotherthrougharestrictedornarrowedorifice,itmayoccurinsystole,diastole,presystoleandattimesmaybecontinuous.Anythrillshouldbedescribedastoitslocation,itstimeincardiaccycle,anditsmodeofextensionortransmission.Theintensityofthethrillvariesaccordingtothevelocityoftheblood,thedegreeofnarrowingoftheorificeandwhichitisproducedanddifferenceinpressurebetweenthetwochambersoftheheart.Qualityofathrilldependsonthefrequencyofvibrationproducingit,rapidvibrationsresultinfinethrillswhereasslowervibrationsproducecoarserthrill.

3）Pericardialfrictionrubisato-and-frogratingsensation,whichisusuallypresentduringbothphasesofcardiaccycle,oftenrubsaremorereadilypalpatedwiththepatientsittingerectandleaningforwardduringtheendperiodofdeepinspiration.Therubiscausedbyafibrinouspericarditis.Inthepresenceofpericardialeffusiontherubwillusuallydisappearbecauseoftheseparationofvisceralandparietallayersbytheaccumulatedfluid.

Percussion

Thechestispercussedtoconfirmthecardiacborders,sizecontourandpositioninthethorax,patientshouldliesupineonanexaminingtableorsitonthechair,withthephysicianathisrightside.Usuallyweemployindirectpercussionforpercussingheartborders.Itisoutlinedbypercussinginthe5th,4th,3rdand2ndinterspaceontheleftsequentially,startingneartheaxillaandmovingmediallyuntilcardiacdullnessisencountered.Thebeginnershouldmarkwithaskinpencilwherethenotechanges.Thedistancefromleftmidsternallinetotheleftbordershouldbemeasuredandrecorded,measurementshouldbemadealongastraightlineparalleledtothetransversediameterinthethorax.

1）Theheartborders

（1）Thebaseoftheheart,formedbybothatria,correspondstoalinecrossingthesternumobliquely,fromthelowerborderofthesecondleftcostalcartilage,atapointjusttotheleftofitsjuctionwiththesternum,toupperborderofthethirdrightcostalcartilage,atapoint2cmlateraltoitssternaljunction.

（2）Therightborderoftheheart:

Itconfirmswithacurvedlinewithitsconvexitytowardtheright,extendingfromtheupperborderofthethirdrightcostalcartilage2cmlateraltoitsjunctionwiththesternum,tothesixthrightchondrosternalarticulation.

（3）Theleftborderofheart.Itisformedbytheleftventricleandtheatriumandisrepresentedbyacurvedlinewithitsconvexitydirectedupwardandtowardtheleft,extendingfromthe5thleftinterspace1.5cmmedialtotheMvl,tothelowerborderofthesecondleftcostalcartilage1-2cm,totheleftofitsarticulationwiththesternum.

（4）Theinferiorborder:

ItisformedbytheRVandalesserextentbytheLV,isrepresentedbyalinedrawnfromthe5thchondrosternalarticulationtothesiteofthecardiacimpulseintheleft5thintercostalspace1-2cmtotheM.V.I.

2）Normalrelativedullnessoftheheart

RightIntercostalspaceLeft（cm）

2-3II2-3

2-3III3.5-4.5

3-4IV5-6（cm）

V7-9

Innormalpersonthedistancefromthe5thtothemidsternallineisabout7-9cm.

3）Changingcardiacdullness

Heartdisease

Leftventricularenlargement,thecardiacdullnesswillbeextendedtotheleftanddownward,theheatsilhouetteislikeashoe.Itisfrequentlyseeninaorticregurgitationandcalledaorticheart.

Rightventrucularenlargement,thecardiacdullnesswillextendedtoleftandupward.Therightventricularisseverelyenlargedtherightborderofthehertwillextendedtotheright.

Leftatriumandpulmonarydilatation

Boththeleftartriumandpulmonaryarteryenlarged,thepulmonaryarterywillbeexaggeratedtoleftward.Thecardiacsilhoutteislikeapearandcalledmitralheart,itisfrequentlyseeninmitralvalvestenosis.Aorticdilation,aneurysmofaorta,pericardialeffusion,allthosediseasesmaycausethebaseborderofheartenlargement,sothatthebaseborderoftheheartwillbewidened.

Congestiveheartfailure,myocarditis,myocardiopathyandpericardialeffusionmaycausetheheartsilhouetteextendingbothtorightandleft.Especiallyinpresenceofpericardialeffusion,percussionattimesmaybehelpfulinoutlingingthechangingcardiacsilhouetteresultingfromachangeinthepatient’sposition.

AUSCULTATIONOFTHEHEART

Thepurposeofauscultationoftheheartistofindthenormalandabnormalsoundsoftheheart.Itplaysaveryimportantroleinthediagnosisofheartdisease.Itisaveryinterestingthingtomastertheauscultation,butitisdifficult.

Forathoroughexamination,auscultationmustbedonewiththepatientinasitting,lying,andleftlateralrecumbentposition,andchangethepositionofpatientinordertodetectsomeabnormalsoundsandmurmurs.whilethepatientrollontohisleftside,themurmurattheapexwillbehearmoreclearly.Exerciseisvaluableforincreasin