Download Examination of the Heart2

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.
Landmarks and topographic
anatomy
Certain basic landmarks
midsternal line(前正中线)
midclavicular lines(锁骨中线)
anterior, middle, and posterior
axillary lines(腋前、中、后线)
suprasternal notch（胸骨上窝）
identification of various ribs and
intercostal space
precordium（心前区）
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 1530 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（心包积液）.
apical impulse（心尖搏动）
Most part of apex is left ventricle. The
apex strikes the chest during systole.
The apex impulse is normally located in
or about the fifth costal interspace
inside the left midclavicular line when
the patient is supine. The extent of
impulse is about 2~2.5 cm.
Normal apical impulse :
It’s location
duration
intensity
amplitude
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
before the second heart sound.
The apical impulse is normally
exaggerated in thin, young individuals
and when the subject is in the left
lateral decubitus position(左侧卧位).
When a patient takes a deep inspiration
and holds his breath, the apical impulse
moves downward from the fifth to the
sixth interspace.
When the patient lies on his right side,
it moves slightly toward the right (1~
2.5cm), and when he lies on his left
side it moves about 2~3 cm toward the
left.
The absence of mobility leads one to
suspect an adherent pericardium.
However, a deep inspiration may bring
the lungs over the heart so that the
impulse disappears altogether.
Diastolic movements are not
perceptible in most cases, but in
children and young adults an early
diastolic F wave is occasionally
present.
Displacement of the apical impulse
Heart disease
Thoracic disease
Abdominal disease
Heart disease
Some heart diseases cause the left
ventricular dilatation（增大）, the
apical impulse is displaced laterally
and inferiorly and sustained ,
and it may be shifted to the left and
upward in right ventricular dilatation .
In mitral
disease the
impulse is
displaced
laterally.
In aortic
disease the
impulse is
displaced both
laterally and
downward.
It can be found at the right fifth
intercostal space in dextrocardia
（右位心） and can not be found
in massive pericardial effusion.
Thoracic disease
Pneumothorax（气胸） and pleural
effusion（胸腔积液） will displace
the apical impulse to the normal side.
Pleural-adhesion（胸膜粘连） and
atelectasis（肺不张） will result in a
displacement of impulse toward the
diseased side.
Effect of massive right pleural
effusion or pneumothorax
Effect of massive right atelectasis
The examiner should always
observe the shape and contour of
patient’s chest. Depressions of the
sternum, Kyphosis of dorsal spine
（驼背）, scoliosis（脊柱侧凸）
often alter the shape and position
of the apical impulse.
Abdominal disease
The apical impulse also can be
displaced by large mass(肿瘤),
massive ascites(腹水).
The apical impulse may have
increased amplitude and duration in
those persons with a thin chest,
anemia(贫血), fever, hyperthyroidism
(甲亢) and anxiety.
Inward impulse(负性心尖搏动): the
apex depress far from the chest instead
of strikes the chest during systole.
Broadbent’s sign is of value in the
diagnosis of adherent pericardium(粘
连性心包炎). It is also seen in RVH.
Abnormal pulsations in the other areas:
Right vertricular hypertophy (RVH).
The impulse is clearly seen in left third
fourth intercostal space.
Pulmonary emphysema(肺气肿) with
RVH, usually the pulsation can be
found inferior the xiphoid process(剑
突下搏动).
In ascending or arch aortic aneurysm(
主动脉瘤), 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.
Marked pulsation at the base of the
heart is seen in aortic insufficiency(主
闭), in a dilated aorta or a saccular
aneurysm.
Review
 Precordial
bulge (心前区隆起)
congenital heart disease
rheumatic heart disease
(before puberty)
pericardical effusion
(adult life)
Normal apical impulse
The apex impulse is normally located
in or about the fifth costal interspace
inside the left midclavicular line when
the patient is supine. The extent of
impulse is about 2~2.5 cm.
Displacement of the apical impulse
Heart disease
LVD
displaced to
lateral and inferior
Displacement of the apical impulse
RVD
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
What’s the meaning of
 Apical Impulse
 Inward Impulse
 Broadbent’ sign
单选题
正常成人心尖搏动位于
A. 第四肋间,左锁骨中线内侧0.1~0.5cm
B. 第五肋间,左锁骨中线内侧0.5~1.0cm
C. 第五肋间,右锁骨中线内侧0.5~1.0cm
D. 第四肋间,左锁骨中线内侧1.0~1.5cm
E. 第五肋间,右锁骨中线内侧2.0~2.5cm
正常成人心尖搏动范围以直径计算为
A. 1.0~1.5cm
B. 1.5~2.0cm
C. 2.0~2.5cm
D. 2.5~3.0cm
E. 以上都不是
心尖搏动的论述,错误的是
A. 搏动范围以直径计算为1.0~1.5cm
B. 可位于第五肋间左锁骨中线内0.5cm
C. 可位于第四肋间
D. 可位于第六肋间
E. 体位、体型对心尖搏动位置有影响
心尖搏动移位的论述,错误的是
A. 肥胖体型者,心尖搏动可上移至第四肋间
B. 瘦长体型者,心尖搏动可下移至第六肋间
C. 左心室增大时心尖搏动向左下移位
D. 右心室增大时心尖搏动向右移位
E. 一侧胸膜粘连、增厚、心尖搏动向患侧
移位
心前区搏动错误的是
A. 胸骨左缘第3~4肋间搏动可见于右心室肥大
B. 剑突下搏动可见于右心室肥大,亦可见于腹主
动脉瘤
C. 胸骨左缘第2肋间收缩期搏动可见于肺动脉高
压
D. 胸骨右缘第2肋间收缩期搏动可见于主动脉弓
动脉瘤
E. 以上都不是