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Precordial buldge Scar Dilated veins Pigmentation Pulsation Inspection & Palpation With the patient in the recumbent position, look tangentially while standing at the feet and the side of the patient •
Causes of precordial buldge 1. Disease since early childhood à congenital or rheumatic heart disease 2. Underlying disease as pericardial effusion and RVH Median sternotomy (open heart surgery) •
Valve replacement •
Valve repair (vulvoloplasty) à Valve regurge •
CABG Lateral thoracotomy (clsed mitral vulvulotomy) •
Site: Left infra mammary •
Mitral restenosis may be suspected •
MR due to overcorrection may be suspected SVC obstruction IVC obstruction •
Mediastinal mass •
SV thrombus Causes of pigmentation in malar area (butterfly pigmentation) •
MS •
SLE •
Pellagra •
Pregnancy 1. Apex 2. Left parasternal 3. Pulmonary 4. Aortic 5. Epigastric •
Site Extent Character Thrill Absent apex pulse Apex pulsation Left 5th intercostal space, midclavicular line, 3.5’’ or 9 cm from midline (normal) •
LVH à outward and downward •
RVH à outward •
Child à 4th intercostal space •
Thin and tall person à 6th intercostal space •
Detrocardia à right side pulsation at 5th intercostal space •
Ascites , pregnancy à above than 5th intercostal space Localized : the maximal intensity constitute one space •
LVH Diffuse : the maximal intensity of pulsation at more than one space •
RVH •
LV aneurysm Double apex (Rocking movement) à both ventricle hypertrophy, myocardial aneurysm Normal No special character •
Forceful but non sustain •
It indicates LV volume overload Hyperdynamic •
Can be felt in case of 1. AR 2. Hyperdynamic circulation à pregnancy, anemia, etc •
Forceful and sustain pulse Heaving •
It indicates left ventricle pressure over load •
Can be felt in case of obstruction at LV ejection à AS, coarctation of aorta, systemic HTN Slapping •
Brief apical impulse + palpable S1 •
Cause by mitral stenosis •
Any abnormalities = organic murmur •
Systolic thrill with the apical beat as in MR, with carotid pulsation •
Diastolic thrill after the apical beat as in MS, away from carotid pulsation •
Thrill at the base (aortic & pulmonary) as in AS, PS, PDA •
Thrill at the parasternal à small muscular VSD •
Thrill at the tricuspid area à diastolic: TS, systolic: TR 1. Obese 2. Apex behind rib 3. Left pleural effusion or thickening or left pneumothorax 4. Emphysema 5. Pericardial effusion 6. Weak contraction or systolic retraction 7. Dextrocardia 8. Myxedema Site Structure Hepatic pulsation Abdominal aorta pulsation Right ventricle pulsation Site Causes Site Structure Causes Site Structure Causes Right parasternal pulsation Suprasternal pulsation Area Apex (mitral area) Left parasternal Tricuspid Right border Pulmonary First aortic (A1) Second aortic (A2) Waist Left infraclavicular Bare Epigastric Epigastric pulsation Between xyphisternal junction and umbilicus 1. Liver 2. Abdominal aorta 3. Right ventricle • TR (systolic) • RVF (wavy) • TS (presystolic) • High vascular hepatoma (systolic) • Aortic aneurysm (if tender à high risk to rupture) • Causes of big pulse volume à AR and others • • RVH causes • Low diaphragm in emphysema Pulmonary area Left second intercostal space • Pulsation: o Pulmonary hypertension o Pulmonary artery dilatation o Aortic aneurysm o Left atrial enlargement • Palpable S2 = diastolic shock = pulmonary hypertension • Systolic thrill à pulmonary stenosis, AS, VSD, PDA Left parasternal area Left sternal border to left midclavicular line at 3rd, 4th , 5th intercostal space Right ventricular Pulsation à RVH , marked LA dilatation due to severe MR Systolic thrill à VSD, AS, PS, TR, MR Aortic area Right second intercostal space Ascending aorta Pulsation à aortic dilatation except post stenotic Palpable S2 = systemic hypertension Systolic thrill à AS, PS VSD Others area • Marked right atrial dilatation • Ascending aortic aneurysm • Dextrocardia • Huge left atrium • Unfolding (or aneurysm) of aortic • High aortic arch arch or aneurysm • Short obese person • Causes of visible carotid pulsation • Coaractation of aorta • Hyperdynamic circulation Structure Apex of left ventricle 1. Right ventricle 2. Interventricular septum 3. Left atrium Tricuspid valve Upper ½: ascending aorta & SVC Lower ½: right border of right atrium Pulmonary artery Ascending aorta Left ventricular outflow tract 1. Left atrial appendage 2. Pulmonary artery 3. Left ventricular outflow tract Ductus atriosus Right ventricle Right ventricle Abdominal aorta Liver Anatomical location Left 5th ICS, just inside MCL (below nipple) Left sternal border to left MCL 3rd, 4th , 5th ICS Lower end of left sternal border Just behind or 1 cm lateral to right sternal border Left 2nd ICS, in parasternal line Right 2nd ICS, in parasternal line Left 3rdICS, in parasternal line Left 3rd space and It measures from midline ½ space between midline and apex Below medial 1/3 of left clavicle 4th, 5th ICS, Mid sternal line to left parasternal line (4cm) From xyphisternal junction & umbilicus (upper half) Percussion Dullness at right sternal border à normal Dullness inside right sternal border à heart is shifted to the left (left fibrosis/collapse) Dullness outside right sternal border o Right atrial enlargement o Severe left atrial enlargement o Pericardial effusion o Dextrocardia o Aneurysm in aortic arch root o Giant aneurysmal dilatation of left atrium o Pushed heart by left pleural effusion or pneumothorax Causes of dullness outside the apex Apex of the heart 1. Ventricular aneurysm 2. Pericardial effusion 3. Lung causes Causes of dullness at pulmonary area 1. Pulmonary artery dilatation Pulmonary area 2. Pericardial effusion 3. Aortic aneurysm 4. Left atrial dilatation or enlargement 5. Lung causes (collapse, fibrosis, tumor, consolidation) Causes of dullness at aortic area Aortic area 1. Aortic dilatation 2. Lung causes Causes of dullness of cardiac waist 1. Left atrial dilatation Cardiac waist 2. Pulmonary dilatation 3. Pericardial effusion 4. Lung causes Causes of large bare are Causes of small (or resonant) bare area Bare area of 1. Right ventricular enlargement 1. Emphysema heart 2. Pericardial effusion 2. Left pneumothorax 3. Retraction of lung by collapse or fibrosis 3. Dextrocardia Causes of stony dullness Lower end of 1. Marked RVH sternum 2. Pericardial effusion 3. Right lung causes Right border of heart 1.
2.
3.
Apex Base Borders of the heart 3rd right costal cartilage, 0.5’’ from the edge of the sternum, (1’’ from midline) 6th right costal cartilage, 0.5’’ from the edge of the sternum 2nd left costal cartilage, 0.5’’ from the edge of the sternum 3rd left ICS, 1.5’’ from the edge of the sternum 5th left ICS, 3.5’’ from the midline 5th left ICS, 3.5’’ from the midline at MCL Opposite T7 – T10