Dr. Judit Vgh

1
Physical examination of the heart Part I.

• Dr. Judit Végh
• DE OEC
• 3rd Department of Internal Medicine

2
CARDIAC CHAMBERS, VALVES AND CIRCULATION
Mitral valve
Aortic valve
Tricuspid valve
Tricuspid valve Mitral valve Aortic
valve Pulmonic valve
atrioventricular semilunar
Pulmonic valve
3
CARDIAC CYCLE
Closure of the aortic valve produces the 2nd
heart sound
Aortic valve closed
Mitral valve opened
Mitral valve closed
Closure of the mitral valve produces the 1st
heart sound
Aortic valve opened
4
COMPREHENSIVE HEALTH HISTORY FOCUSED HEALTH
HISTORY
THE HEALTH HISTORY
Common or concerning symptoms ,,Du you have any
dyscomfort or unpleasant feelings in your chest?,,

• chest pain (or dyscomfort)
• location quality quantityseverity
  timing-onset, duration, frequency factors that
  have aggravated or relieved the symptoms
• (myocardium, pericardium, aorta, trachea and
  large bronchi, parietal pleura, chest wall,
  oesophagus, stomach, gallbladder)
• palpation (unpleasant awareness of the heartbeat)
• (skipping, racing, fluttering, pounding, stopping
  of the heart)
• heart rhythm regular - unregular

5
COMPREHENSIVE HEALTH HISTORY FOCUSED HEALTH
HISTORY
THE HEALTH HISTORY
Common or concerning symptoms

• shortness of breath
• dyspnoea (uncomfortable awareness of breathing)
• ortopnoea (lying done)
• paroxizmal nocturnal dyspnoea (after going to
  bed)
• swelling or edema
• (accumulation of excessive fluid in the
  interstitial tissue)
• location (both side?), timing, setting of the
  swelling, associated symptoms
• Caused by not only cardiac alterations !

6
COMPREHENSIVE HEALTH HISTORY FOCUSED HEALTH
HISTORY
THE HEALTH HISTORY

• Risk factors
• smoking status
• alcohol intake
• diet
• physical activity

Global risk estimation for CVD

• age, sex, weight
• smokig status
• blood pressure
• total/LDL/HDL cholesterol
• diabetes
• physical activity

• Medications-allergies
• Name, dose, route and frequency of use
• Vitamins, mineral-herbal supplements
• Oral contraceptives
• Specific allergic reactions side effect

7
THE HEALTH HISTORY
Risk factors and screening frequency for adults
(beginning at age 20)
FREQUENCY
RISK FACTOR Family history of coronary heart
disease (CHD) Smoking status Diet Alcohol
intake Physical activity Blood pressure Body
mass index Waist circumference Pulse (to detect
atrial fibrillation) Fasting lipoprotein
profile Fasting glucose
Update regularly
At each routine visit
At each routine visit (at least every 2 years)
At least every 5 years If other risk factor,
every 2 years
8

• inspection/observation
• palpation
• percussion
• auscultation !

PHYSICAL EXAMINATION
PATIENTS POSITION Supine, with the upper body
30-45 degrees Left lateral decubitus (roll
partly onto the left) Supine, with the upper
body 30-45 degrees Sitting, leaning forward,
after deep exspiration
EXAMINATION Inspect-palpate-percuss precordium
right ventricle left ventricle apical
impulse Palpate apical impulse Listen all the
areas Listen the areas
9

• inspection/observation
• palpation
• percussion
• auscultation !

PHYSICAL EXAMINATION
10
PHYSICAL EXAMINATION

• INSPECTION/OBSERVATION

The heart is a generator of vibrations from "0"
to about 2000 Hz (the low frequency vibrations
may be visible) CAREFUL INSPECTION

• cardiac apex impulse -5th interspace, midclav.
  antihoral rotation of the heart in early systole
  and tapping of the apex on the chest wall
• pulmonary area -2nd interspace left parasternal
  (hyperkinetic circulation,volume overload, VSD)
• sternoclavicular joint (left or right dissecting
  aneurysm of the aorta)

Left ventricular movement
Apex pulse
11
PHYSICAL EXAMINATION

• INSPECTION/OBSERVATION

• TAKE YOUR TIME LOOK AT THESE AREAS

• Assessment for distension of the
• right Internal Jugular vein
• Manometer
• distension indicate the elevation of
  Central Venous Pressure (CVP)
• important marker of intrvascular volume status

12
PHYSICAL EXAMINATION
Chest wall Apical impulse Vessels

• PALPATION

General palpation of the chest wall with
fingerpads (light pressure for heaves,
lifts) - with all hand (pressing
firmly for thrills) Apical impulse with
palm Vessels with 2nd-3rd fingerpads
13
PHYSICAL EXAMINATION

• PALPATION

• Point of the maximal impulse (PMI)
• Location
• (normally midclav line in5th intercostal space)
• (laterally hypertension, hypertrophy)
• Diameter (2,5 cm)
• Amplitude (small, tap)

The apical impulse

• Duration (fistr 2 third)
• longer period hypertrophy
• Thrill vibratory sensation
• (valvular abnormalities)

• Supine with the upper body elevated 30 to 45
  degrees
• Your palm placed across the patient's left ches
  (covers the area over the heart)

14
PHYSICAL EXAMINATION

• PALPATION

Right ventricle area

• with tips of curved fingers
• in the 3rd, 4th and 5th intercostal space
  (subxyphoid area)
• breath out stop breathing during a short period

15
PHYSICAL EXAMINATION

• PALPATION

• Pulsation of the vessels
• amplitude of the pulse
• contour of the pulse wave
• variation in amplitude

You need to push because of the subcutaneus fat,
BUT ! Do not push on both side simultaneously !
16

• INTERNAL JUGULAR PULSATION
• rarely palpable
• soft, rapid, undulating quality
• pulsation eliminated by light pressure on the
  vein
• leves of the pulsation changes with position

• CAROTID PULSATION
• palpable
• more vigirous thrust with a single outward
  component
• not eliminated by light pressure
• unchanges with position
• not affected by inspiration

• level of the pulsation descend with inspiration

17
PHYSICAL EXAMINATION

• PERCUSSION

Percuss the borderline of the heart
18
Relative and absolute dulness of the heart
Auenbuger 1761 Corvisart direct
percussion 1808 Piory indirect use of
plessimeter 1828
19

• percuss using your 3rd finger of your left had
  like a board. Bit your finger with other hands
  3rd finger
• percuss on the surface of the chest from
  resonance to dullness
• left border usually within the left midclavicular
  line
• compare the left lateral border of the heart
  with the impulse area which detect using
  palpation
• in old textbooks you find relative and absolute
  dullness

20

• The outer limits of cardiac dullness
• 1.to the left when the diaphragm is higher
• 2.within the midclav.line in concentric
  hypertrophy
• 3.displacement to the right in left sided PTX or
  right sided atelectasis(collapse of the
  lung)
• 4.situs inversus
• 5.historic significance valvular diseases
  before the invention of X-ray

21
Thanks for Your attention!
22
PHYSICAL EXAMINATION

• PALPATION

(Pulsation of the vessels)
Arteria carotid pulsation
Jugular venous pulsation
23

• INTERNAL JUGULAR PULSATION
• rarely palpable
• soft, rapid, undulating quality
• pulsation eliminated by light pressure on the
  vein
• leves of the pulsation changes with position
• level of the pulsation descend with inspiration

• CAROTID PULSATION
• palpable
• more vigirous thrust with a single outward
  component
• not eliminated by light pressure
• unchanges with position
• not affected by inspiration

24
CARDIAC CYCLE