Inspection and Palpation of the heart

Surface anatomy of the heart

Surface anatomy

The position of the heart in the mediastinum can be projected onto the overlying skeleton

The heart is enclosed by a rectangle with angles at left 5th intercostal space in midclavicular line;2nd left costal cartilage;3rd right costal cartilage and 6th right costal cartilage

Surface anatomy

• Right ventricle occupies most of the anterior cardiac surface behind and to the left of the sternum

• Left ventricle lies to the left and behind the right ventricle.it makes only a small portion of the anterior cardiac surface

• But it forms the border of the heart and produces the apical impulse in 5th left intercostal space 7-9 cm from the mid sternal line

Surface Anatomy

• The right border of the heart is formed by the right atrium;a chamber not usually identifiable on physical examination

• The left atrium is most posterior and cannot be examined directly

• But its small atrial appendage may make up a segment of the left cardiac border between the pulmonary artery and the left ventricle

AUSCULTATORY AREAS

• They do not correspond with the surface markings of the heart valves ,but are areas where transmitted sounds and murmurs are best heard

• Mitral valve:Apex (left 5th intercostal space)

• Tricuspid valve :Tricuspid area (lower left sternal border )

AUSCULTATORY AREAS

• Aortic valve :Aortic area (2nd right intercostal space )

• Pulmonary valve:Pulmonary area (2nd left intercostal space )

INSPECTION AND PALPATION

• Patient position– Supine, head elevated 30 degree

• From patient right side examine chest wall paying attention to 5 areas– Apex– Epigastrium– Left sternal border (right ventricular areas)– Left 2nd intercostal space– Right 2nd intercostal space

Inspection and palpation

• Look for• Chest deformity• Surgical scars• Apex beat• Visible pulsations

CHEST DEFORMITIES

• Precordial bulge

• Pectus excavatum :posterior displacement of the lower sternum

• Pectus carinatum :Pigeon chest

– Chest deformities may displace the heart

APEX BEAT

• SITE

• DIAMETER

• AMPLITUDE

• DURATION

• THRILL

• S3 AND S4

SITE

• Feel with patient supine and in left lateral decubitus

• Lay whole hand flat over precordium :general impression

• Lay fingers on chest parallel to rib space to locate the apex

APEX

• The cardiac impulse results the heart rotating ,moving forwards and striking against the chest wall during systole

• Normal apex :5th left intercostal space medial to the mid clavicular line– Count the ribs from the sternal angle– Midclavicular line is half way between the

suprasternal notch and the acromioclavicular joint

APEX

• The apex is the most lateral and inferior position where the cardiac impulse can be felt

• The normal apex briefly lifts the palpating fingers and is localised

SITE OF THE APEX

• DISPLACEMENT OF THE APEX• A- Conditions outside the heart

Fibrosis and collapse of the lung PULL the heart towards the lesion

Pleural effusion and pneumothorax PUSH the heart away from the lesion

Abdominal distention (ascites,pregnancy) can displace the apex upwards and to the left

DISPLACEMENT OF THE HEART

• B-Cardiac enlargement

–IN LVH : Apex is displaced down and out

–IN RVH: Apex is displaced outwards

SITE OF APEX

• INVISIBLE APEX• Obesity• Thick west wall• Emphysema• Pericardial effusion• Weak dilated heart

DIAMETER OF APEX

• Normal :2.5cm with patient supine3 cm in left lateral position

Increased diameter in left ventricular enlargement

AMPLITUDE AND DURATION

• The amplitude is increased with cardiac overload• In pressure overload as in Aortic stenosis and

Hypertension :Duration is also increased :SUSTAINED or HEAVING apex

• In volume over load as in Mitral regurge or Aortic regurge :Duration is not increased :HYERKINETIC apex

• Tapping apex in Mitral stenosis represents a palpable 1st heart sound

THRILL

• Palpable murmur like placing the hand on a purring cat

• Systolic thrill of Aortic stenosis on the base

• Diastolic thrill of Mitral stenosis on apex

• Systolic thrill of ventricular septal defect on left sternal border

PRECORDIAL PULSATION

1-At left STERNAL BORDER in 3rd,4th, 5th interspaces ( RIGHT VENTRICULAR AREA)

With patient supine place tips of curved fingers in 3rd 4th and 5th spaces and try to feel the systolic impulse of the right ventricle

Ask the patient breath out then briefly stop breathing to improve observation

If an impulse is palpable assess location ,amplitude and duration

LEFT PARASTERNAL PULSATION

• Brief systolic tap of low or slightly increased amplitude in thin individuals

• Increased amplitude with no change in duration in right ventricular volume overload as in ASD

• Increased amplitude with increased duration in right ventricle pressure overload as in Pulmonary stenosis ,Pulmonary hypertension

EPIGASTRIC PULSATION

• RIGHT VENTRICULAR

• With hand flattened press index finger under the rib cage upwards to the left shoulder

• PULSATIONS OF ABDOMINAL AORTA

• LIVER PULSATION

PULSATIONS IN LEFT 2ND SPACE

• It overlies the pulmonary artery

• Feel during held expiration

• Prominent pulsation :dilated pulmonary artery

• In thin individual pulmonary artery pulsations may be seen

• Palpable 2nd sound in pulmonary hypertension

PULSATION IN RIGHT 2ND SPACE

• Prominent pulsations :dilated or aneurysmal aorta

PULSATIONS TO RIGHT OF STERNUM

• Aortic aneurysm

• Enlarged right atrium

SUPRASTERNAL PULSATIONS

• Hyperkinetic states

• High aortic arch or aortic arch aneurysm

• Aortic regurge

• Coarcatation of aorta

• Kinking of carotids due to atherosclerosis