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,
Examination of the Heart
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,
Examination of the Heart
Preparing the patient
The heart examination should be made
as easy as possible for the patient,
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,
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
?Observe precordium
Precordial bulge
congenital heart disease(before
puberty)
pericardical effusion (adult life)
Inspection
?Pulsation
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
the examiner as a marker for the onset of
cardiac contraction,
Normal apical impulse,
It’s location
duration
intensity
amplitude
Displacement of the apical impulse
heart disease
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 dextrocardiac
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
The apical impulse may have
increased amplitued and duration in
those persons with a thin chest,
anemia,fever,hyperthyroidism and
anxiety,
Abdominal disease
large mass
massive ascites
Inward impulse
pericardial-adhesion
RVH
Abnormally pulsation on the other area
RVH,left parasternal area
Emphysema + RVH,subxiphoid
Asending or arch aneurysm:aortic area
Pulmonary hypertension with dilatation,
pulmonary area
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,
Palpation
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,
Palpation
?Precordial pulsation
Apical impulse,
location duration
amplitude intensity
frequency regularity
Precordial pulsation
Precordial lift or heave,LVH
forceful,sustained,throughout
systole with great amplitude more
than 2cm diameter
Sustained sensation,RVH
Decrease amplitude,myocarditis
Massive pericardial effusion,
impulse cannot be palpable
Palpation
?Thrill
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
?Thrill
Thrill are palpable murmurs some what
similar to the sensation on the throat a
purring cat
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 coarse
Thrill
Any thrill Should be describe as to
it’s location,time in cardiac cycle,
model of extension or transmission
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
to and fro grating sensation
Mechanism,fibrinous pericarditis
disappear,pericardial effusion
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
interspace 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 left midsternal
line to the left border should be
measured and recorded,
Percussion
Method of percussion for heart
indirect light percussing
absolute dullness
relative dullness
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
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
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,
Examination of the Heart
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,
Examination of the Heart
Preparing the patient
The heart examination should be made
as easy as possible for the patient,
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,
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
?Observe precordium
Precordial bulge
congenital heart disease(before
puberty)
pericardical effusion (adult life)
Inspection
?Pulsation
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
the examiner as a marker for the onset of
cardiac contraction,
Normal apical impulse,
It’s location
duration
intensity
amplitude
Displacement of the apical impulse
heart disease
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 dextrocardiac
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
The apical impulse may have
increased amplitued and duration in
those persons with a thin chest,
anemia,fever,hyperthyroidism and
anxiety,
Abdominal disease
large mass
massive ascites
Inward impulse
pericardial-adhesion
RVH
Abnormally pulsation on the other area
RVH,left parasternal area
Emphysema + RVH,subxiphoid
Asending or arch aneurysm:aortic area
Pulmonary hypertension with dilatation,
pulmonary area
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,
Palpation
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,
Palpation
?Precordial pulsation
Apical impulse,
location duration
amplitude intensity
frequency regularity
Precordial pulsation
Precordial lift or heave,LVH
forceful,sustained,throughout
systole with great amplitude more
than 2cm diameter
Sustained sensation,RVH
Decrease amplitude,myocarditis
Massive pericardial effusion,
impulse cannot be palpable
Palpation
?Thrill
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
?Thrill
Thrill are palpable murmurs some what
similar to the sensation on the throat a
purring cat
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 coarse
Thrill
Any thrill Should be describe as to
it’s location,time in cardiac cycle,
model of extension or transmission
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
to and fro grating sensation
Mechanism,fibrinous pericarditis
disappear,pericardial effusion
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
interspace 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 left midsternal
line to the left border should be
measured and recorded,
Percussion
Method of percussion for heart
indirect light percussing
absolute dullness
relative dullness
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
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
