Investigation of the heart and great vessels. Inspection, palpation

Investigation of the heart and
great vessels. Inspection,
palpation, and percussion of
the heart. Apical impulse
Dr. Szathmári Miklós
Semmelweis University
First Department of Medicine
17. Oct. 2011.
Surface projection of the heart
and great vessels
– Right ventricle occupies
most of the anterior
cardiac surface
– The inferior border of the
right ventricle lies below
the junction of the sternum
and the xiphoid process
– The right ventricle narrows
superiorly and meets the
pulmonary artery at the
level of the 3rd left costal
cartilage to the sternum :
base of the heart.)
Surface projection of the heart
and great vessels
• The left ventricle forms the left
lateral margin of the heart. Its
tapered tip is termed the
cardiac apex. It produces
apical impulse (the point of
maximal impulse). This
impulse locates the left border
of the heart and is usually
found in the 5th interspace
7-9 cm lateral to the
midsternal line.
• The right heart border is
formed by the right atrium
behind the sternum. Normally
the right heart border does not
exceed the right border margin
of the sternum.
Surface projection of the heart
and great vessels
• The pulmonary artery
bifurcates quickly into its
left and right branches.
• The aorta curves upward
from the left ventricle to
the level of sternal angle,
where it arches backward
and then down
• On the right, the superior
and inferior vena cava
empties in the right
Cardiac valves
• Because of their positions, the tricuspid
and mitral valves are often called
atrioventricular valves.
• The aortic and pulmonic valves are called
semilunar valves because each of their
leaflets is shaped like a half moon.
• At the heart valves close, the heart sounds
arise from vibrations emanating from the
leaflets, the adjacent cardiac structures,
and the flow of blood.
Events in the cardiac cycle.
Interrelationships of the pressures in the
left atrium, left ventricle, and aorta
During the diastole, pressure in
left atrium slightly exceeds that
in the relaxed left ventricle, and
blood flows from left atrium to
left ventricle across the open
mitral valve
During the systole, the left
Az ejekció
ventricle starts to contract
után csökken
ventricular pressure exceeds
a bal kamrai
atrial pressure, thus shutting
mitral valve. Closure of
az the
mitral valve produces billentyű
the first
heart sound (S1).
Events in the cardiac cycle.
Interrelationships of the pressures in the
left atrium, left ventricle, and aorta
As the left ventricular
pressure continues to
rise, it exceeds the
pressure in the aorta and
forces the aortic valve
open. Normally
is not
As the left ventricle ejects
most of its blood,
ventricular pressure
begins to fall. When left
ventricular pressure drops
below aortic pressure, the
aortic valve shuts. Aortic
valve closure produces the
second heart sound (S2).
Events in the cardiac cycle.
Interrelationships of the pressures in the left
atrium, left ventricle, and aorta
In diastole left ventricular pressure
drops and falls below left atrial
pressure. The mitral valve opens
(usually silent event).
After mitral valve opens there is a
period rapid ventricular filling. In
young adults it can produces the
third heart sound (S3).
In normal adults not often
heard the fourth heart (S4)
sound, marks atrial
Inspection of cardiac area
• Anteriorly displaced chest wall above the cardiac
area indicates hereditary cardiac failure,
because of the plasticity of the chest wall during
the childhood.
• Careful inspection of the anterior chest may
reveal the location of the apical impulse
(tangential light much improves your chances of
seeing impulses.
• Systolic retraction at the site of apical impulse
indicates pericardial accretio (a form of adhesive
pericarditis in which adhesions extend from the
pericardium to the chest wall)
Inspection of cardiac area
• Apical impulse.
– The brief early systolic pulsation
of the left ventricle
– May not be visible in the supine position
ask the patient to roll partly onto the left side
• Right ventricular hypertrophy often results in a sustained
systolic lift at the lower left parasternal area
• Pulmonary artery pulsation is often visible (and palpable)
in the left second interspace indicating pulmonary
• Epigastrical pulsation: sign of the right ventricle
hypertrophy (also in case of emphysema)
Palpation of the apical impulse
• Represents the brief early pulsation of the left ventricle
as it moves anteriorly during contraction and touches the
chest wall. The apical impulse is the point of maximal
– Location: in the 5th interspace, 9 cm laterally from the
midsternal line. Lateral displacement in patients with a left
ventricular volume overload (aortic regurgitation or dilated
– Diameter: less than 2.5 cm. Larger in case of left ventricle
– Amplitude: usually small. Increased in case of hyperkinetic
circulation. (anemia, hyperthyroidism).
– Duration: normally it lasts through the first two thirds of systole.
• Sustained, normally located apical impulse indicates left ventricle
hypertrophy (pressure overload as in hypertension)
• Sustained and laterally dislocated apical impulse suggests volume
overload of left ventricle (such as in case of aortic regurgitation)
Thrills: palpable, low frequency vibrations
associated with heart murmurs
• Thrill at cardiac apex: systolic murmur of mitral
• Thrill in the third or fourth intercostal spaces
near to the left sternal border: ventricular
septal defect
• Thrill of aortic or pulmonal stenosis: the palm
of the hand is placed over the precordium
– The thrill crosses the palm toward the right side of the
neck: aortic stenosis
– The thrill crosses the palm toward the left side of the
neck: pulmonal stenosis
Percussion of cardiac dullnes
• The percussion of relative
cardiac dullnes has a general
clinical significance. The
significance of the percussion
of absolute cardiac dullnes: in
case of pericardial effusion
• The mode of percussion:
• The direction of the
percussion: from outside to
inside (from resonance toward
• The position of pleximeter
finger is always paralell with
the expected border
Percussion of relative cardiac
1. Lower border:
percussion the position
of the diaphragma on
the right side. 5-6th
interspace in the
midclavicular line.
2. Right border: does not
exceed the right border
of the sternum.
3. Upper border: 3d
interspace parasternally
on the left side
4. Left border: 7-9 cm from
the midline
The arterial pulse
• To count the rate of the heart
– With the pads of your index and middle fingers, compress the radial
artery until a maximal impulse is detected
• To determine the rhythm
– Is it regular or irregular?
– If irregular, try to identify a pattern:
• Do early beats appear in a basically regular rhythm?
• Does the irregularity vary consistently with respiration?
• Is the rhythm totally irregular?
• To asses the amplitude and contour of the pulse vave
– The palpation of carotid or brachial artery are suggested
– Try to asses:
• The amplitude of the pulse
• The contour of the pulse wave
• Any variations in amplitude
– From beat to beat (pulsus alternans)
– With respiration (paradoxical pulsusu)
• Sometimes to detect obstruction to blood flow
Techniques of examination of
carotid artery
Your thumb should press just inside the
medial border of the relaxed
sternomastoid muscle, at the level of
cricoid cartilage
• Avoid pressing on the carotid sinus – at
the level of the top of thyroid cartilage
• Do not press on the both carotids at the
same time
Palpation of peripheral arterial
• Brachial pulse:
– Flex the elbow slightly, and with the thumb of your opposite hand palpate
the artery just medial to the biceps tendon at the antecubital crease
• Radial pulse:
– palpate on the flexor surface of the wrist laterally
• Femoral pulse:
– Press deeply, below the inguinal ligament and about midway between
the anterior superior iliac spine and the symphysis pubis
• Popliteal pulse:
– The patient’s knee should be somewhat flexed, the leg relaxed. Place
the fingertips of both hands so that they just meet in the midline behind
the knee and press them deeply into the popliteal fossa.
• Dorsalis pedis pulse:
– Feel the dorsum of foot just lateral to the extensor tendon of the great
• Tibialis posterior pulse:
– Curve your finger behind and slightly below the medial malleolus of the
Examples of abnormalaties of
arterial pulse
• Decrease or absent of arterial pulse – indicates
partial or complete occlusion proximally, most
commonly due to arteriosclerosis obliterans
• Exaggerated or widened pulse suggest
pathologic dilatation of artery
• Sudden arterial occlusion (embolism or
thrombosis) causes pain and numbness.The
limb distal to the occlusion becomes cold, pale,
and pulseless.
Examination of a veins
• Are the veins unusually prominent?
– The standing posture allows any varicosity to fill with blood and
makes them visible
• Is the swelling unilateral or bilateral?
– Unilateral edema with venous distension suggest venous cause
of edema
– Local swelling, redness, warmth, and a subcutaneous cord
suggest superficial thrombophlebitis
– Painful, pale, swollen leg, together with tenderness of the
femoral vein, suggest deep iliofemoral thrombosis
– Calf tenderness and cords deep in the calf suggest deep vein
thrombosis there
• Brownish areas near the ankles – chronic venous
• Feel the thickness of the skin
– Thickened skin in lymphedema and advanced venous
External jugular vein distention
Markedly distended right external jugular vein (EJV). This is the result of
elevated central venous pressure (CVP). In practice the EJV is not as
reliable in determining CVP as the internal jugular vein due to the fact that it
sometimes has valves and is not in a direct line with the right atrium.
Pressure on the liver, however, will have similar impact on the appearance of
the IJV as for the EJV. This is referred to as hepatojugular reflux.

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