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The Physical Examination

of Heart

1st Affiliated Hospital Liaoning Medical College

He Xin

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Anatomy

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一、 Inspection with tangential lighting

1 、 Thoracic deformity

2 、 Apical impulse

3 、 Abnormal pulsations of precardium

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1 、 Thoracic deformity---protrusion of precordium

--Right ventricular hypertrophy (L3-5)

congenital heart disease( tetralogy of Fallot)

valvular heart disease( MS,PS)

--pericardial effusion (large , childhood)

--The second right intercostal space (2nd ICS-RS)

aneurysm of aortic arch

dilatation of ascending aorta

---flat chest

---pigeon chest/ funnel chest

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2 Apical impulse---Normal --Position : in the left fifth intercostal space about

0.5-1.0cm medial from the midclavicular line --Range: no larger than 2.0-2.5cm in diameter

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（ 1 ） Location Posture Diaphragm Mediastinum Enlargement of the heart Dextrocardia( 右位心 ): 5-ICS—RS

---Abnormal

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Posture: ---Recumbent( 仰 ) position—upper ---left lateral( 侧 ) position—to the left 2-3cm ---right lateral position—to the right 1.0-2.5cm

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Diaphragm: ---“transverse position” upper,outward obesity ,child, pregnacy ascites; tumor of abdominal cavity ---“vertical position” inferior,inner thin, high, emphysema

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mediastinum: • one side pleural effusion or pneumothorax ---to the healthy side • one side atelectasis or pleural adhesion ---to the affected side

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Enlargement of the heart • right ventricular dilatation – displaced

to the left or slightly upper • left ventricular dilatation— displaced to

the left inferior • LV &RV dilatation –left inferior (both

side dilatation)

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decrease increase

Physiological Chest wall pachynsis,

Narrow intercostal space

Thin chest wall,

Broaden intercostal space,

Exertion, emotion

pathological Myopathy (AMI, DCM),

Pericardial effusion,

Emphysema,

Constrictive pericarditis,

Left side massive pleural effusion or pneumothorax

LVhypertrophy,

Hyperthyroidism,

Fever,

anemia

(2) Intensity and extent changes

A feeble diffuse impulse ( more than 22.5cm in diameter) may suggest dilation. If the thrust is forcible, hypertrophy is suggested.

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(3)Inward impulse( 负性心尖搏动 ): apex excavation in the systole

--adhesive pericarditis --prominent RV hypertrophy

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(1)left third-forth intercostal space lateral to the sternum (3,4ICS-LS)

---RV hypertrophy(2)xiphoid process

---RV hypertrophy ---Abdominal aorta (aneurysm) (The pulsation of the abdominal aorta may often be felt in the epig

astric area. Also, the impulse from right ventricle can be felt by the fingertips placed under the xiphoid process while inspiration.)

3 、 Abnomal pulsations of percardium

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(3)basal part of the heart ---2 ICS-LS: dilatation of the pulmonary arter

y or pulmonary hypertensin, occasionally healthy young man

---2 ICS-RS: aneurysm of aortic arch or dilatation of ascending aorta

3 、 Abnomal pulsations of percardium

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二、 Palpation

1 Apical impulse and pulsation of precardium

2 Thrill

3 Pericardial friction rub

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1 、 Apical impulse and pulsation of precardium

---Exact position of apex

---The beginning of systole of ventricle

first sound

---Heaving apex impulse: reliable of LV

hypertrophy

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2 、 Thrill---Mechanism : the flow of blood→narrowed

orifice→vortices→vibration→chest wall

---One of characteristic signs of organic heart

disease ： CHD or valvular stenosis, occasionally

insurficiency

---thrill - high frequency

murmurs - low frequency

---Key point: position, phase of cardiac cycle,

clinical significance

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Clinical significance of thrill

Location phase Disease

2 ICS-RS Systole AS (RHD,CHD,senile)

2 ICS-LS Systole PS (CHD)

3,4 ICS-LS Systole VSD (CHD)

Apex Systole MI (severe)

Apex Diastole MS (RHD)

2 ICS-LS Continous PDA

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3 、 Pericardil friction rub---Precardium -4th ICS-LS

---both phases of the cardiac cycle

---systolic period, sitting erect and leaning

forward, the end of expiration

---mechanism: rub of the visceral and

parietal layers of pleura

---seen: acute pericarditis

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三、 Percussion ---Aim: to determine the size and shape of the heart ---Absolute dullness: contain no gas

Relative dullness : real size

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1 、 maneuver of percussion ---patient in erect position

–the pleximeter is vertical with the intercostal space

---patient in the recumbent position

–the pleximeter is parallel with the intercostal space

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2 、 order :---left—right ; upwards ; inward

---left margin : from 2-3 cm lateral to

the apex beat up to the 2nd ICS

---right margin : one intercostal space

higher than the border of liver dullness

up to the 2nd ICS

---size: vertical distance from margin to

the anterior midline

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Percussion of cardiac dullness border starts tothe left on the chest, from 23cm apart from theapical impulse towards cardiac dullness (relativecardiac dullness). Percussion is performed fromleft towards cardiac dullness in the 4th, 3rd and2nd intercostal spaces. Next, to the right of thechest, percussion is done in the midclavicularline down to a dull point (the upper margin ofliver). Then, percuss from right towards cardiacdullness in the 4th (above the liver dullness), 3rd,and 2nd intercostal spaces.

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一． Measure the vertical distances from each point of cardiac dullness to the mid-sternal line with a stiff ruler

二． When the left border of cardiac dullness falls outside the midclavicular line, it usually indicates that the left ventricle is enlarged

三． If the left border of cardiac dullness goes out of left midclavicular line (the left cardiac border towards left in the 5th intercostal space), it suggests that the right ventricle enlarged

四． The cardiac dullness enlarged towards two sides: (1)both left and right ventricles enlarged, (2) a large volume of fluid in the cavity of pericardium. In this case, the cardiac borders will be changed following the change of the patient's position

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①

③

②④

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Right(cm) ICS Left(cm)

SVC,SA 2~3

Ⅱ 2~3 PA

RA 2~3 III 3.5~4.5 LA

RA 3~4 Ⅳ 5~6 LV

Ⅴ 7~9 LV

3 、 Normal heart borders (area of relative dullness)

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Right ICS Left

SVC,SA II PA

RA III LA

RA Ⅳ LV

Ⅴ LV

4 、 The composition of various parts of theborder of the heart

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---The upper border –the lower border of the anterior end of the third rib↑---The basal part —the second intercostal space upward left: aortic node and PA---Concave part –between the aorta and the left ventricle

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（ 1 ） body’s position: 1) recumbent position ： widening of base

of the heart 2) erect position:“triangular shape”

5 、 Changes in the area of cardiac dullness and its significance

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（ 2 ） Cardiac factors :

1)LV enlargement: “boot shape” Seen:aortic valvular disease ,

hypertension heart disease2)RV enlargement :

slightly↑--absolute dullness↑ Prominent↑--relative dullness↑ to the left side prominently Seen:PHD, MS

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3)Two ventricle ↑:

“generally enlarged heart”

seen:DCM , Kashan cardiomyopathy

4)LA and/or pulmonary artery:

“pear shape”

LA:concave part disappear

LA+PA:2,3 ICS-LS outwards

Seen: MS--- “mitrial type”

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5)pericardial effusion:

enlargement of both sides of the border

6)dilatation of the aorta /ascending aortic

aneurysm:

widening if the dull area of first and

second intercostal space (with systolic

pulsation)

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（ 3 ） Extacardial factors :1)large pleural effusions and pneumothorax → to the healthy side2)atelectasis /pleural pachynsis →to the affected3)a large amount of ascites or big abdominal tumor:

diaphragm elevated→transverse position →left side enlargement

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四、 Auscultation

1 、 Cardiac valve areas for precordial

auscultation

2 、 Order

3 、 Contents

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1 、 cardiac valve areas forprecordial auscultation

1)ausclutatory mitral area: apical area

2)auscultatory pulmonary area:2 ICS-LS

3)ausclutatory aortic area: 2 ICS-RS

4)second ausclutatory aortic area: 3rd ICS

LS—Erb area

5)tricuspid area :4,5 ICS-LS

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Aortic valve areas

Tricuspid valve area

Pulmonic valve area

Mitral valve area

Cardiac valve areas

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2 、 Order: Apical area Pulmonary valve area

Aortic valve area 2 nd aortic valve area Tricuspid valve area

MV---PV---AV1---AV2---TV

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3 、 Contents :

1) rate

2)rhythm

3)heart sound

4)extra heart sound

5)murmurs

6)pericardial friction sound

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(1)heart rate

Normal heart rate is 60-100/min (adult)

above 100/min (below 3 years old)

Tarchycardia : above 100/min (adult)

above 150/min (infant)

Bradycardia: below 60/min

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(2)cardiac rhythm:

sinus arrythmia—affected by breath

premature beat—frequently: ＞ 6 bpm

occasionally: ＜ 6 bpm

atrial fibrillation: —absolute irregular rhythm S1 intensity inequality Pulse deficit

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(3) cardiac sound Cycle Nature Duration Site Mechanism

S1 Isovolumetric contraction phase

Blunt 0.1″ Apical area

Closure of the MV and TV

S2 Isovolumetric relaxation phase

Distinct 0.08″ Basal part

Closure of the AV and PV

S3 The end of ventricular rapid filling phase

Weak Blunt

0. 04″ after S2 0.12~0.18″

Apex (inner-upper)

Ventricular vibration

S4 The end of ventricular diastolic phase

Weak 0. 1″ forward S1

Apex Atrium contraction

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(4)Abnormal cardiac sound 1)Intensity:

cardiac sound is influenced by a number of factor

---position of the atrioventricular valve

---Ventricular contractility and output

---Valvular integrity and activity

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S1 Accentuation: ---MS

---HR↑contractility↑

fever,anemia,hyperthyroidism

---complete AVB →cannon sound

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S1 attenuation : ---MI ---P-R interval enlong ---AI ---myocarditis,myopathy,MI,HFS1 inequality: ---AF ---III°-AVB

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S2---A2+P2

S2 ↑ ---pressure and flow of blood ↑ A2 : hypertensin, arterisclerosis P2 : PHD,CoHD(L--R),LVF

S2 ↓ ---pressure↓ flow ↓

Seen:hypotension,AS/AL,PS/PI

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2)Quality

mono rhythm

pendular rhythm---embryocardia

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3)Splitting of heart sound

S1 splitting:

seen—RBBB, right heart failure Ebetein malformation ,MS LA myxoma

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S2 splitting:

physiological splitting :end of inspiration

general splitting : most commonly seen: CRBBB, PS, MS,MI ,VSD

fixed splitting :ASD

paradoxical splitting(reversed splitting) : pathologicalseen: CLBBB ,AS, hypertension

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(5)extra cardiac sound 1)Diastolic period

①gallop rhythm:

--protodiastolic gallop: S1+S2+S3 the third

sound gallop (sign of organic heart disease) seen : HF （ AMI, severe myocarditis , myopathy ）

-- late diastolic gallop: atrial gallop S1+S2+S4 seen : HBP ,HCM ,AS ,CHD

-- summation gallop: quadruple rhythm

seen:HF,cardiomyopathy

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②opening snap :MS

③pericardial knock: constrictive

pericarditis

④tumor plop: LA myxoma

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2)Systolic period

①early systolic ejection sound(click) ---pulmonary :pulmonary hypertension;

pulmonary artery dilatation ， PS, ASD,

VSD

---Aortic: hypertension, aneurysm ,

AS, AI ,aorta constriction

②mid and late systolic click: S1----mid ＜ 0.08″ late ＞ 0.08″

seen: mitral prolapse

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3)iatrogenic

① prosthetic valvular sound

② pacemaker

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1 ） Mechanism ---acceleration of blood flow --- Blood viscosity --- Valve: narrowed or incompetent; organic or relative ---abnormal passage ---foreign body ---dilatation of vessles(aneurysm)

（ 6 ） Cardiac murmurs

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2 ） characterization of murmur and

ausclutatory key points

①Location and Transmission

②Timing

③Quality

④Intensity

⑤Effect of position, respiration and exercise

on intensity of murmurs

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①Location and Transmission ---location: where it is audible most significantly

L3,4 –VSD L2,3—PDA ---transmission: which direction it come from MI ---left axilla AS---neck

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②Timing---Murmurs are timed according to the phase of cardiac cycle during which they occur.---SM, DM , CM.---Early, middle, late

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③Quality ---Depend on: frequency and intensity of so

und wave ---Related to: pathology and hemodynamic changes of the heart---Soft ， harsh, musical.---SM: blowing, harsh, musical (seagull)---DM: blowing, sigh-like, rumbling. ---CM: machine-like, hum

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④IntensitySix-point scale of for grading the intensity ofheart murmur

Grade Ⅰ: basely audible Grade Ⅱ: usually readily heardGrade Ⅲ: loudGrade Ⅳ: quite loudGrade Ⅴ: even most pronounced Grade Ⅵ: can be heard with thestethoscope removed from the chest wall

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⑤Effect of position, respiration and exercise on intensity of murmurs ---body position:

MS--left lateral positionAI--sitting erected and forward MI,TI,PVS--lie on one’ back Lie → stand: HCM

---breath: expiration--LV murmurs inspiration --RV murmurs valsalva--HCM ---exercise: HR↑murmurs ↑

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3 ） The clinical value of heart murmur

① systolic murmurs

② Diastolic murmurs ③continuous murmurs

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① systolic murmursMitral valve area ： functional:exercise,fev

er,anemia,pregnancy,hyperthyroidism

Soft, blowing SM, Grade II/VI well localized wethout transmission. S1 normal.

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① systolic murmursMitral valve area ： relative:HBP,CHD,DCM,anemia

Dilatation of LV and mitral valve relative insufficiency

---blowing SM

---Grade II-III/VI with or without transmission

---S1 usually normal.

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① systolic murmursMitral valve area ： organic ： MI(RHD),mitral prolapse

Pansystolic murmur, blowing or harsh, Grade III/VI or more, transmited toward axilla or left back, S1 masked, the SM can be intensified by lying on left lateral position.

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① systolic murmursAortic valve areas ：Organic ： aortic stenosis

---harsh ejection SM

---Grade III-IV/VI, often accompanied by a thrill

---crescendo-decrescendo type (diamond shaped)

---transmitted toward neck and apex

---A2 diminished or absent

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① systolic murmursAortic valve areas ：Functional ： due to relative aorticstenosis

( dilatation of aorta , severe

hypertension atherosclerosis of aorta)

---Soft

---A2 accentuated

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① systolic murmursPulmonary valve areas ：Physiology ： (children)

---Soft blowing SM

---Grade II/VI

---shorter

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① systolic murmursPulmonary valve areas ：relative ： MS 、 ASD Dilatation of pulmonary artery ( pulmonary hypertension or large outflow from RV) ---Soft blowing SM ---Grade II/VI,well location ---Shorter ---P2 accentuated

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① systolic murmursPulmonary valve areas ：organic ： pulmonary stenosis

---harsh ejection SM,

---Grade III-IV/VI, often accompanied

by a thrill

---crescendo-decrescendo type

(diamond shaped)

---P2 diminished or absent.

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① systolic murmursTricuspid valve areas ：relative ： RV enlarged ---Soft blowing SM ---Grade III/VIorganic ： rare

other location: 3-4nd I.c.s left to sternum (VSD,ventricular septal defect) ---Loud, harsh SM, ejection ---accompanied by a thrill

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② Diastolic murmursmitral valve area

Organic ： rheumatic mitral stenosis

---S1 loud and snappy OS audible

---well localized to the apex

---rumbling in quality in middle-late

of diastole crescendo characte

---In many instances, it is

accompanied by a thrill.

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② Diastolic murmurs

mitral valve arearelative MS ： Austin Flint murmur: In severe aorti

c insufficiency, reduced overload of left ventricular in diastolic there may be heard a rumbling DM over the apex which can be distinguished from the organic MS by following points

--- not accompanied by a loud snappy S1 , or a thrill

---(There are unequivocal fingings compatible with AR,i.e.blowing DM of AR over aortic valve areas ， lift ventricular enlargement, peripheral vascular signs

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② Diastolic murmurs

Aortic valve areas. aortic insurfficiency

---decrescendo, sighing DM

---best heard in sitting position, leaning

forward,holding breath in expiration

---transmitted downward along both sides of

sternum

---A2 diminished

---In cases of severe degree of AR, there may be

present: DM (Austin Flint) over apex and peripheral

vascular signs

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② Diastolic murmurs

pulmonary valve areas Relative ： Graham Steel murmur:dilate of

pulmonary artery relative pulmonary

insufficiency

---decrescendo

---Blowing,soft

---P2 accentuated

---Seen in mitral stenosis

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③continuous murmurs

PDA (patent ducuts arteriosus)

---Continuous murmur PDA, characteristic murmur of PDA is a comtinuous , machinary murmur

---at 2 nd i.c.s. Left to sternum

---with an accentuated P2

---A systolic thrill may be present

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---both phases , unaffected by

respiration

---seen: pericarditis

RHD ,AMI ,renal failure

（ 7 ） pericardial friction sound

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