The Physical Examination of Heart.docx

1、The Physical Examination of HeartThe Physical Examination of HeartIn the present era of technological advances, particularly in the various imaging modalities, there is a growing conception among practicing physicians in cardiovascular medicine that bedside physical examination is unnecessary and do

2、es not provide useful information. It should be emphasized, however, that for proper application and interpretation of various new and old tests that are available for cardiovascular evaluation in a given patient. Bedside clinical examination should be performed and practiced in the same way followi

3、ng similar sequences. Preparing the patientThe heart examination should be made as easy as possible for the patient, who usually expects it to be a relatively distasteful experience. If the physician is considerate and gentle, the patient should feel when it is all over, that most of his or her fear

4、s on that score were unfounded. The ideal examining room is private, warm enough to avoid chilling, and free from distracting noise and sources of interruption. Adequate (preferably fluorescent or natural) light is essential. The examining table may be placed with its head against the wall, but both

5、 sides (particularly the right) and the foot should be accessible to the examiner. And the results should be recorded carefully.Inspection 1. Observe precordiumInspection of the precordium should begin at the foot of the bed. The subject should be supine with the legs horizontal and the head and tru

6、nk elevated to approximately 15-30 degrees. Asymmetry of the thoracic cage due to a convex bulging of the precordim suggests the presence of heart disease since childhood, such as congenital heart disease and rheumatic heart disease, with skeletal molding to accommodate cardiac enlargement. In the a

7、dult, precordial bulge may be produced from the massive pericardial effusion.2. Apical impulse The apical impulse is occurring early in systole. In adults the apical impulse normally is located in the left fifth intercostal space, either at or medial to the mvl and about 2-2.5 cm diameter, it serves

8、 the examiner as a marker for the onset of cardiac contraction.Displacement of the apical impulse:a) Heart disease:Some heart diseases cause the left ventricular hypertropy dilatation or both, the apical impulse is displaced laterally and inferiorly and sustained, and it may be shifted to the left a

9、nd upward in right ventricular hypertrophy, dilatation or both. It can be found at the right fifth intercostal space in dixtrocardiac and can not be found in massive pericardial effusion.b) Thoracic disease: pneumothorax and pleural effusion will displace the apical impulse to the normal side. Pleur

10、aladhesion and ateleotasis will result in a displacement of impulse toward the diseased side.c) Abdominal disease: The apical impulse also can be displaced by large mass, massive ascites.d) The apical impulse may have increased amplitued and duration in those persons with a thin chest, anemia, fever

11、, hyperthyroidism and anxiety. The examiner should always observe the shape and contour of patints chest. Depressions of the sternum, Kyphosis of dorsal spine, scoliosis often alter the shape and position of the apical impulse.Abnormal pulsations in the other areas.a) Right vertricular hypertophy (R

12、BH). The impulse is clearly seen in left third fourth intercostal space.b) Pulmonary emphysema with RVH, usually the pulsation can be found inferior the xiphoid process.c) In asending or arch aortic aneurysm, one may detect abnormal pulsations in aortic area, with bulging or pulsation in systole.d)

13、Pulmonary hypertension with dilatation the pulsation in systole may be detected in left second intercostal space to the edge of sternum.palpation Usually inspection and palpation are discussed together because there is an intimate relationship between these two processes in the heart examination. Pa

14、lpation not only confirms the results in inspection, but also discovers diagnostic signs. Through careful palpation, the examiner should aim to determine the location and size of the cardiac apex impulse, characterize its contour, and identify any abnormal precordial pulsations. The palm of the hand

15、, ventral surface of the proximal metacarpals, and fingers should all be used for palpation because each is useful for optimal appreciation of certain movements. 1) Usage of the palpation confirms the precordial pulsations location. Amplitude, duration and intensity. In left ventricular hypertrophy

16、(LVH) the impulses are very forceful, sustained throughout systole and has a great amplitude. The apical impulse may have decreased amplitude and duration in those patients with myocarditis. In massive pericardial effusion the impulse cannot be palpable.2) Thrills are actually palpable fine vibratio

17、ns, most commonly produced by blood from one chamber of the heart to another through a restricted or narrowed orifice, it may occur in systole, diastole, presystole and at times may be continuous. Any thrill should be described as to its location, its time in cardiac cycle, and its mode of extension

18、 or transmission. The intensity of the thrill varies according to the velocity of the blood, the degree of narrowing of the orifice and which it is produced and difference in pressure between the two chambers of the heart. Quality of a thrill depends on the frequency of vibration producing it, rapid

19、 vibrations result in fine thrills whereas slower vibrations produce coarser thrill.3) Pericardial friction rub is a to-and-fro grating sensation, which is usually present during both phases of cardiac cycle, often rubs are more readily palpated with the patient sitting erect and leaning forward dur

20、ing the end period of deep inspiration. The rub is caused by a fibrinous pericarditis. In the presence of pericardial effusion the rub will usually disappear because of the separation of visceral and parietal layers by the accumulated fluid.Percussion The chest is percussed to confirm the cardiac bo

21、rders, size contour and position in the thorax, patient should lie supine on an examining table or sit on the chair, with the physician at his right side. Usually we employ indirect percussion for percussing heart borders. It is outlined by percussing in the 5th, 4th, 3rd and 2nd interspace on the l

22、eft sequentially, starting near the axilla and moving medially until cardiac dullness is encountered. The beginner should mark with a skin pencil where the note changes. The distance from left midsternal line to the left border should be measured and recorded, measurement should be made along a stra

23、ight line paralleled to the transverse diameter in the thorax.1) The heart borders(1) The base of the heart, formed by both atria, corresponds to a line crossing the sternum obliquely, from the lower border of the second left costal cartilage, at a point just to the left of its juction with the ster

24、num, to upper border of the third right costal cartilage, at a point 2 cm lateral to its sternal junction.(2) The right border of the heart: It confirms with a curved line with its convexity toward the right, extending from the upper border of the third right costal cartilage 2 cm lateral to its jun

25、ction with the sternum, to the sixth right chondrosternal articulation.(3) The left border of heart. It is formed by the left ventricle and the atrium and is represented by a curved line with its convexity directed upward and toward the left, extending from the 5th left interspace 1.5 cm medial to t

26、he Mvl, to the lowerborder of the second left costal cartilage 1-2 cm, to the left of its articulation with the sternum.(4) The inferior border: It is formed by the RV and a lesser extent by the L V, is represented by a line drawn from the 5th chondrosternal articulation to the site of the cardiac i

27、mpulse in the left 5th intercostal space 1-2 cm to the M. V. I.2) Normal relative dullness of the heartRight Intercostal space Left (cm)2-3 II 2-32-3 III 3.5-4.53-4 IV 5-6 (cm) V 7-9In normal person the distance from the 5th to the midsternal line is about 7-9 cm.3) Changing cardiac dullnessHeart di

28、seaseLeft ventricular enlargement, the cardiac dullness will be extended to the left and downward, the heat silhouette is like a shoe. It is frequently seen in aortic regurgitation and called aortic heart.Right ventrucular enlargement, the cardiac dullness will extended to left and upward. The right

29、 ventricular is severely enlarged the right border of the hert will extended to the right.Left atrium and pulmonary dilatationBoth the left artrium and pulmonary artery enlarged, the pulmonary artery will be exaggerated to leftward. The cardiac silhoutte is like a pear and called mitral heart, it is

30、 frequentlyseen in mitral valve stenosis. Aortic dilation, aneurysm of aorta, pericardial effusion, all those diseases may cause the base border of heart enlargement, so that the base border of the heart will be widened. Congestive heart failure, myocarditis, myocardiopathy and pericardial effusion

31、may cause the heart silhouette extending both to right and left. Especially in presence of pericardial effusion, percussion at times may be helpful in outlinging the changing cardiac silhouette resulting from a change in the patients position.AUSCULTATION OF THE HEART The purpose of auscultation of

32、the heart is to find the normal and abnormal sounds of the heart. It plays a very important role in the diagnosis of heart disease. It is a very interesting thing to master the auscultation, but it is difficult. For a thorough examination, auscultation must be done with the patient in a sitting, lying, and left lateral recumbent position, and change the position of patient in order to detect some abnormal sounds and murmurs. while the patient roll onto his left side, the murmur at the apex will be hear more clearly. Exercise is valuable for increasin