Examination
of the Heart
Examination of the Heart
In 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
does 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 following similar
sequences,
Preparing the patient
The 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
fears 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 sides (particularly the right) and
the foot should be accessible to the
examiner,And the results should be
recorded carefully,
Examination of the Heart
Landmarks and topographic
anatomy
Certain basic landmarks
midsternal line
midclavicular lines
Certain basic landmarks
anterior,middle,and posterior
axillary lines
suprasternal notch
identification of various ribs and
intercostal space
Specific areas for cardiac PE
sternoclavicular area
aortic area
pulmonary area
Specific areas for cardiac PE
anterior precordium
apical area
epigastric area
ectopic area
Inspection
Inspection of the precordium
should begin at the foot of the bed,
The subject should be supine with
the leg horizontal and the head and
trunk elevated to approximately 15-
30 degrees,
Asymmetry of the thoracic cage due
to a convex bulging of the precordium
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 adult,precordial bulge may
be produced from the massive
pericardial effusion,
?Precordial bulge
congenital heart disease
(before puberty)
pericardical effusion
(adult life)
Pulsation
?apical impulse
The apical impulse is occurring early in
systole,The apex impulse is normally
located at or medial to the midclavicular
line in the fourth or fifth intercostal
space when the patient is supine,
Usually it is detectable in only one
intercostal space and is less than 2-2.5
cm in diameter,The normal apex
impulse is characterized by a brief
early systolic out ward thrust of
moderate amplitude,which ends well
before the second heart sound,
The apex impulse is normally
exaggerated in thin,young individuals
and when the subject is in the left
lateral decubitus position,
Diastolic movements are not
perceptible in most cases,but in
children and young adults an early
diastolic F wave is occasionally
present,
Normally apical impulse,
It’s location
duration
intensity
amplitude
Displacement of the apical impulse
?Heart disease
Some heart diseases cause the left
ventricular hypertrophy dilatation or
both,the apical impulse is displaced
laterally and inferiorly and sustained,
and it may be shifted to the left and
upward in right ventricular
hypertrophy,dilatation or both,It can
be found at the right fifth intercostal
space in dextrocardia and can not be
found in massive pericardial effusion,
?Thoracic disease,
Pneumothorax and pleural effusion
will displace the apical impulse to the
normal side,Pleural-adhesion and
atelectasis will result in a displacement
of impulse toward the diseased side,
? Abdominal disease,
The apical impulse also can be
displaced by large mass,massive
ascites,
The apical impulse may have
increased amplitude and duration
in those persons with a thin chest,
anemia,fever,hyperthyroidism
and anxiety,
The examiner should always
observe the shape and contour of
patient’s 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,
Right vertricular hypertophy (RVH),The
impulse is clearly seen in left third fourth
intercostal space,
Pulmonary emphysema with RVH,usually
the pulsation can be found inferior the
xiphoid process,
In ascending or arch aortic aneurysm,one
may detect abnormal pulsations in aortic
area,with bulging or pulsation in systole,
Pulmonary hypertension with dilatation the
pulsation in systole may be detected in left
second intercostal space to the edge of
sternum,
Displacement of the apical impulse
Heart disease
LVH,LVD or both
displaced to
lateral and inferior
Displacement of the apical impulse
RVH,LVD or both
displaced to
left and upward
Displacement of the apical impulse
Congenital dextrocardia
right
CHF,myocarditis,myocardiopathy
apical impulse
decrease intensity
Displacement of the apical impulse
Massive pericardial effusion
apical impulse
disappear
Displacement of the apical impulse
Thoracic disease
pneumothorax,pleural effusion
shifted to
healthy side
Displacement of the apical impulse
Pleural-adhesion,atelectasis
shifted to
disease side
Emphysema with RVH
to
inferior to subxiphoid
Palpation
Usually inspection and palpation
are discussed together because there
is an intimate relationship between
these two processes in the heart
examination,Palpation 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,ventral
surface of the proximal metacarpals,
and fingers should all be used for
palpation because each is useful for
optimal appreciation of certain
movements,
Palpation
?Precordial pulsation
Apical impulse,
location duration
amplitude intensity
frequency regularity
Precordial pulsation
LVH,
lift,Forceful sensation,through
systole with great amplitude more
than 2cm diameter
Precordial sustained or heavy,
RVH
Decrease amplitude,myocarditis
Massive pericardial effusion,
impulse cannot be palpable
Palpation
?Thrill
Thrill are palpable murmurs some what similar
to the sensation on the throat a purring cat,Thrills
are actually palpable fine vibrations,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,
Palpation
Any thrill should be described as to its
location,its time in cardiac cycle,and its
mode of extension 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,
Palpation
Quality of a thrill depends on the
frequency of vibration producing it,
rapid vibrations result in fine thrills
whereas slower vibrations produce
coarser thrill,
Palpation
Restricted or narrowed orifice
thrill
according blood velocity
Intensity degree of narrowing
to gradient between
two chambers
Palpation
depends
quality frequency
on
frequency,
rapid fine thrill
slower coarser
Palpation
duration location disease
systole second right ICS AS
second left ICS PS
third fourth left ICS VSD
diastole apical area MS
continuous 2nd left ICS PDA
Palpation
Pericardial friction rub
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 during the end
period of deep inspiration,
Palpation
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,
Palpation
?Shock (palpable sounds)
valve close as a tapping sensation
2nd left ICS,PH
2nd right ICS,SH
apex, MS
Percussion
Method of percussion for heart
The chest is percussed to confirm the
cardiac borders,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,
Percussion
Usually we employ indirect percussion
for percussing heart borders,It is
outlined by percussing in the 5th,4th,
3rd and 2nd intercostal space on the left
sequentially,starting near the axilla
and moving medially until cardiac
dullness is encountered,
Percussion
The beginner should mark with a skin
pencil where the note changes,The
distance from midsternal line to the left
border should be measured and
recorded,measurement should be
made along a straight line paralleled to
the transverse diameter in the thorax,
Percussion
?Heart borders
Right border of the heart
formed by
sup vean,ascending aorta,
right atrium
Heart borders
Left border of the heart
formed by
aorta arch,pulmonary arterial trunk
left atria appendage,LV
Inferior border of the heart
formed by
RV,lesser extent LV
Percussion
? Normal heart dullness
right(cm) ICS,MSL left(cm)
2-3 Ⅱ 2-3
2-3 Ⅲ 3.5-4.5
3-4 Ⅳ 5-6
Ⅴ 7-9
Normally from midsternal line to MCL is about 7-9cm
Changing cardiac dullness
Left ventricular enlargement,the
cardiac dullness will be extended to
the left and downward,the heart
silhouette is like a shoe,It is
frequently seen in aortic regurgitation
and called aortic heart,
Changing cardiac dullness
Right ventricular enlargement,the
cardiac dullness will extended to left
and upward,If the right ventricular is
severely enlarged,the right border of
the heart will extend to the right,
Changing cardiac dullness
Both the left atrium and pulmonary artery
enlarged,the pulmonary artery will be
exaggerated to leftward,The cardiac silhouette is
like a pear and called mitral heart,it is frequently
seen 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,
Changing cardiac dullness
Congestive heart failure,myocarditis,
myocardiopathy and pericardial effusion
may cause the heart silhouette extending
both to right and left,Especially in presence
of pericardial effusion,percussion at times
may be helpful in outlining the changing
cardiac silhouette resulting from a change in
the patient’s position,
Percussion
?Changing cardiac dullness
AS+AI LVH+LVD
shoe like
MS or ASD RVH
pear like
Percussion
?Changing cardiac dullness
LAD+PE
aortic dilatation
pericardial effusion,
supine
sitting
of the Heart
Examination of the Heart
In 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
does 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 following similar
sequences,
Preparing the patient
The 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
fears 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 sides (particularly the right) and
the foot should be accessible to the
examiner,And the results should be
recorded carefully,
Examination of the Heart
Landmarks and topographic
anatomy
Certain basic landmarks
midsternal line
midclavicular lines
Certain basic landmarks
anterior,middle,and posterior
axillary lines
suprasternal notch
identification of various ribs and
intercostal space
Specific areas for cardiac PE
sternoclavicular area
aortic area
pulmonary area
Specific areas for cardiac PE
anterior precordium
apical area
epigastric area
ectopic area
Inspection
Inspection of the precordium
should begin at the foot of the bed,
The subject should be supine with
the leg horizontal and the head and
trunk elevated to approximately 15-
30 degrees,
Asymmetry of the thoracic cage due
to a convex bulging of the precordium
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 adult,precordial bulge may
be produced from the massive
pericardial effusion,
?Precordial bulge
congenital heart disease
(before puberty)
pericardical effusion
(adult life)
Pulsation
?apical impulse
The apical impulse is occurring early in
systole,The apex impulse is normally
located at or medial to the midclavicular
line in the fourth or fifth intercostal
space when the patient is supine,
Usually it is detectable in only one
intercostal space and is less than 2-2.5
cm in diameter,The normal apex
impulse is characterized by a brief
early systolic out ward thrust of
moderate amplitude,which ends well
before the second heart sound,
The apex impulse is normally
exaggerated in thin,young individuals
and when the subject is in the left
lateral decubitus position,
Diastolic movements are not
perceptible in most cases,but in
children and young adults an early
diastolic F wave is occasionally
present,
Normally apical impulse,
It’s location
duration
intensity
amplitude
Displacement of the apical impulse
?Heart disease
Some heart diseases cause the left
ventricular hypertrophy dilatation or
both,the apical impulse is displaced
laterally and inferiorly and sustained,
and it may be shifted to the left and
upward in right ventricular
hypertrophy,dilatation or both,It can
be found at the right fifth intercostal
space in dextrocardia and can not be
found in massive pericardial effusion,
?Thoracic disease,
Pneumothorax and pleural effusion
will displace the apical impulse to the
normal side,Pleural-adhesion and
atelectasis will result in a displacement
of impulse toward the diseased side,
? Abdominal disease,
The apical impulse also can be
displaced by large mass,massive
ascites,
The apical impulse may have
increased amplitude and duration
in those persons with a thin chest,
anemia,fever,hyperthyroidism
and anxiety,
The examiner should always
observe the shape and contour of
patient’s 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,
Right vertricular hypertophy (RVH),The
impulse is clearly seen in left third fourth
intercostal space,
Pulmonary emphysema with RVH,usually
the pulsation can be found inferior the
xiphoid process,
In ascending or arch aortic aneurysm,one
may detect abnormal pulsations in aortic
area,with bulging or pulsation in systole,
Pulmonary hypertension with dilatation the
pulsation in systole may be detected in left
second intercostal space to the edge of
sternum,
Displacement of the apical impulse
Heart disease
LVH,LVD or both
displaced to
lateral and inferior
Displacement of the apical impulse
RVH,LVD or both
displaced to
left and upward
Displacement of the apical impulse
Congenital dextrocardia
right
CHF,myocarditis,myocardiopathy
apical impulse
decrease intensity
Displacement of the apical impulse
Massive pericardial effusion
apical impulse
disappear
Displacement of the apical impulse
Thoracic disease
pneumothorax,pleural effusion
shifted to
healthy side
Displacement of the apical impulse
Pleural-adhesion,atelectasis
shifted to
disease side
Emphysema with RVH
to
inferior to subxiphoid
Palpation
Usually inspection and palpation
are discussed together because there
is an intimate relationship between
these two processes in the heart
examination,Palpation 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,ventral
surface of the proximal metacarpals,
and fingers should all be used for
palpation because each is useful for
optimal appreciation of certain
movements,
Palpation
?Precordial pulsation
Apical impulse,
location duration
amplitude intensity
frequency regularity
Precordial pulsation
LVH,
lift,Forceful sensation,through
systole with great amplitude more
than 2cm diameter
Precordial sustained or heavy,
RVH
Decrease amplitude,myocarditis
Massive pericardial effusion,
impulse cannot be palpable
Palpation
?Thrill
Thrill are palpable murmurs some what similar
to the sensation on the throat a purring cat,Thrills
are actually palpable fine vibrations,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,
Palpation
Any thrill should be described as to its
location,its time in cardiac cycle,and its
mode of extension 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,
Palpation
Quality of a thrill depends on the
frequency of vibration producing it,
rapid vibrations result in fine thrills
whereas slower vibrations produce
coarser thrill,
Palpation
Restricted or narrowed orifice
thrill
according blood velocity
Intensity degree of narrowing
to gradient between
two chambers
Palpation
depends
quality frequency
on
frequency,
rapid fine thrill
slower coarser
Palpation
duration location disease
systole second right ICS AS
second left ICS PS
third fourth left ICS VSD
diastole apical area MS
continuous 2nd left ICS PDA
Palpation
Pericardial friction rub
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 during the end
period of deep inspiration,
Palpation
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,
Palpation
?Shock (palpable sounds)
valve close as a tapping sensation
2nd left ICS,PH
2nd right ICS,SH
apex, MS
Percussion
Method of percussion for heart
The chest is percussed to confirm the
cardiac borders,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,
Percussion
Usually we employ indirect percussion
for percussing heart borders,It is
outlined by percussing in the 5th,4th,
3rd and 2nd intercostal space on the left
sequentially,starting near the axilla
and moving medially until cardiac
dullness is encountered,
Percussion
The beginner should mark with a skin
pencil where the note changes,The
distance from midsternal line to the left
border should be measured and
recorded,measurement should be
made along a straight line paralleled to
the transverse diameter in the thorax,
Percussion
?Heart borders
Right border of the heart
formed by
sup vean,ascending aorta,
right atrium
Heart borders
Left border of the heart
formed by
aorta arch,pulmonary arterial trunk
left atria appendage,LV
Inferior border of the heart
formed by
RV,lesser extent LV
Percussion
? Normal heart dullness
right(cm) ICS,MSL left(cm)
2-3 Ⅱ 2-3
2-3 Ⅲ 3.5-4.5
3-4 Ⅳ 5-6
Ⅴ 7-9
Normally from midsternal line to MCL is about 7-9cm
Changing cardiac dullness
Left ventricular enlargement,the
cardiac dullness will be extended to
the left and downward,the heart
silhouette is like a shoe,It is
frequently seen in aortic regurgitation
and called aortic heart,
Changing cardiac dullness
Right ventricular enlargement,the
cardiac dullness will extended to left
and upward,If the right ventricular is
severely enlarged,the right border of
the heart will extend to the right,
Changing cardiac dullness
Both the left atrium and pulmonary artery
enlarged,the pulmonary artery will be
exaggerated to leftward,The cardiac silhouette is
like a pear and called mitral heart,it is frequently
seen 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,
Changing cardiac dullness
Congestive heart failure,myocarditis,
myocardiopathy and pericardial effusion
may cause the heart silhouette extending
both to right and left,Especially in presence
of pericardial effusion,percussion at times
may be helpful in outlining the changing
cardiac silhouette resulting from a change in
the patient’s position,
Percussion
?Changing cardiac dullness
AS+AI LVH+LVD
shoe like
MS or ASD RVH
pear like
Percussion
?Changing cardiac dullness
LAD+PE
aortic dilatation
pericardial effusion,
supine
sitting
