Download Palpation of the apical impulse

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
13. Oct. 2015.
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
atrium.
Cardiac chambers, valves and the
direction of the circulation
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
1.
2.
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
and
után csökken
ventricular pressure exceeds
left
a bal kamrai
nyomás, the
atrial pressure, thus shutting
becsapódig
mitral valve. Closure of
az the
aorta
S2
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
diasztolé
audible.
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).
3.
4.
Events in the cardiac cycle.
Interrelationships of the pressures in the left
atrium, left ventricle, and aorta
5.
6.
7.
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
contraction.
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 accretion (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
hypertension
• 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
impulse.
– 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
cardiomyopathy)
– Diameter: less than 2.5 cm. Larger in case of left ventricle
hypertrophy.
– Amplitude: usually small. Increased in case of hyperkinetic
circulation. (anaemia, 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
regurgitation
• 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 dullness has a general
clinical significance. The
significance of the percussion
of absolute cardiac dullness: in
case of pericardial effusion
• The mode of percussion:
heavier
• The direction of the
percussion: from outside to
inside (from resonance toward
dullness)
• The position of pleximeter
finger is always parallel with
the expected border
Modification of the percussion
technique according to the expected
physical finding
Small power, short
pleximeter
Superficial solid
organ, that gives
absolute dullness
Larger power, longer
pleximeter
Deeply localized
solid organ gives
relative dullness
Szarvas F, Csanády M:: Belgyógyászati fizikális diagnosztika, Semmelweis Kiadó, 1993.
Percussion of relative cardiac
dullness
1. Lower border:
percussion the position
of the diaphragm 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 changes of absolute and relative
dullness of the heart
Normal
Enlargement to the left
Triangle-shape dullness
The apical impulse is
not palpable
Enlargement to the right
Pericardial fluid
Szarvas F, Csanádi M :Belgyógyászati fizikális vizsgálat. Semmelweis Kiadó 1993.
Techniques of examination of
carotid artery
The carotid can be located by sliding the 2nd and
3rd fingers of either hand along the side of the
trachea at the level of thyroid cartilage (Adams
apple). The carotid pulsation is palpable just to
the groove formed by the trachea and the
surrounding soft tissue.
• 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 as this may compromise cerebral blood flow
Assessment for distension of the
right internal jugular vein (IJ)
• The IJ is in straight-line communication
with the right atrium.
• The IJ can function as a manometer, with
distension indicating elevation of central
venous pressure.
• The IJ is an important marker of
intravascular volume status an related
cardiac function.
Examination of right internal
jugular vein
• The IJ lies deep to skin and soft tissues. This blood
vessel is under much lower pressure than the adjacent
pulsating carotid artery.
• The right IJ runs between the two heads of the
sternocleidomastoid muscle and up in front of the ear.
• Ask the patient to turn their head to the left. The two
heads of muscle form the sides of a small triangle, with
the clavicle making up the bottom edge
• You are trying to identify impulses originating from IJ and
transmitted to the overlying skin in this area
• The carotid artery is adjacent to the IJ, lying just medial
to it. The venous impulse has three components that are
visible diffusely. (carotid – single upstroke)
Examination of right internal
jugular vein
• Search along the entire projected course
of the IJ as the top of the pressure wave
may be higher then where you are looking.
• If the patient’s CVP is markedly elevated,
you may not able to identify the top of the
wave unless the patient is positioned with
the trunk elevated at 45 degrees or more.
• If you identify JVD, try to estimate how
high in cm the top of the column is above
the angle of Louis.
External jugular vein distension
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.
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 wave
– 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 pulsus)
• Sometimes to detect obstruction to blood flow
Palpation of peripheral arterial
pulses
• 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
toe
• Tibialis posterior pulse:
– Curve your finger behind and slightly below the medial malleolus of the
ankle
Examples of abnormalities 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 oedema with venous distension suggest venous
cause of oedema
– 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
insufficiency
• Feel the thickness of the skin
– Thickened skin in lymphoedema and advanced venous
insufficiency