心脏查体英语

1、Examination of the HeartExamination 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 us

2、eful 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 sequen

3、ces. 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

4、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 (particul

5、arly the right) and the foot should be accessible to the examiner. And the results should be recorded carefully. Examination of the Heart Landmarks and topographic anatomy Certain basic landmarks midsternal line midclavicular lines Certain basic landmarks anterior, middle, and posterior axillary lin

6、es suprasternal notch identification of various ribs and intercostal spaceSpecific areas for cardiac PE sternoclavicular area aortic area pulmonary area Specific areas for cardiac PE anterior precordium apical area epigastric area ectopic areaInspection Inspection of the precordium should begin at t

7、he foot of the bed. The subject should be supine with the leg horizontal and the head and trunk elevated to approximately 15-30 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 a

8、nd rheumatic heart disease, with skeletal molding to accommodate cardiac enlargement. In the adult, precordial bulge may be produced from the massive pericardial effusion.Precordial bulge congenital heart disease (before puberty) pericardical effusion (adult life) Pulsationapical impulse The apical

9、impulse is occurring early in systole. The apex impulse is normally located at or medial to the midclavicular line in the fourth or fifth intercostal space when the patient is supine. Usually it is detectable in only one intercostal space and is less than 2-2.5 cm in diameter. The normal apex impuls

10、e is characterized by a brief early systolic out ward thrust of moderate amplitude, which ends well before the second heart sound. The apex impulse is normally exaggerated in thin, young individuals and when the subject is in the left lateral decubitus position. Diastolic movements are not perceptib

11、le in most cases, but in children and young adults an early diastolic F wave is occasionally present. Normally apical impulse : Its location duration intensity amplitudeDisplacement of the apical impulseHeart disease Some heart diseases cause the left ventricular hypertrophy dilatation or both, the

12、apical impulse is displaced laterally and inferiorly and sustained , and it may be shifted to the left and upward in right ventricular hypertrophy, dilatation or both. It can be found at the right fifth intercostal space in dextrocardia and can not be found in massive pericardial effusion. Thoracic

13、disease: Pneumothorax and pleural effusion will displace the apical impulse to the normal side. Pleural-adhesion and atelectasis will result in a displacement of impulse toward the diseased side. Abdominal disease: The apical impulse also can be displaced by large mass, massive ascites. The apical i

14、mpulse may have increased amplitude and duration in those persons with a thin chest, anemia, fever, hyperthyroidism and anxiety. The examiner should always observe the shape and contour of patients chest. Depressions of the sternum, Kyphosis of dorsal spine, scoliosis often alter the shape and posit

15、ion of the apical impulse. Abnormal pulsations in the other areas: Right vertricular hypertophy (RVH). The impulse is clearly seen in left third fourth intercostal space. Pulmonary emphysema with RVH, usually the pulsation can be found inferior the xiphoid process.In ascending or arch aortic aneurys

16、m, 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.Displacement of the apical impulseHeart disease LVH, LVD or both displace

17、d to lateral and inferiorDisplacement of the apical impulse RVH, LVD or both displaced to left and upwardDisplacement of the apical impulseCongenital dextrocardia right CHF, myocarditis, myocardiopathy apical impulse decrease intensityDisplacement of the apical impulseMassive pericardial effusion ap

18、ical impulse disappearDisplacement of the apical impulseThoracic disease pneumothorax, pleural effusion shifted to healthy sideDisplacement of the apical impulsePleural-adhesion, atelectasis shifted to disease sideEmphysema with RVH to inferior to subxiphoid Palpation Usually inspection and palpatio

19、n are discussed together because there is an intimate relationship between these two processes in the heart examination. Palpation not only confirms the results in inspection, but also discovers diagnostic signs. Through careful palpation, the examiner should aim to determine the location and size o

20、f the cardiac apex impulse, characterize its contour, and identify any abnormal precordial pulsations. The palm of the hand, ventral surface of the proximal metacarpals, and fingers should all be used for palpation because each is useful for optimal appreciation of certain movements. PalpationPrecor

21、dial pulsation Apical impulse: location duration amplitude intensity frequency regularityPrecordial pulsation LVH : lift, Forceful sensation, through systole with great amplitude more than 2cm diameter Precordial sustained or heavy: RVHDecrease amplitude: myocarditisMassive pericardial effusion: imp

22、ulse cannot be palpable PalpationThrill Thrill are palpable murmurs some what similar to the sensation on the throat a purring cat. Thrills are actually palpable fine vibrations, most commonly produced by blood from one chamber of the heart to another through a restricted or narrowed orifice, it may

23、 occur in systole, diastole, presystole and at times may be continuous. Palpation Any thrill should be described as to its location, its time in cardiac cycle, and its mode of extension or transmission. The intensity of the thrill varies according to the velocity of the blood, the degree of narrowin

24、g of the orifice and which it is produced and difference in pressure between the two chambers of the heart. Palpation Quality of a thrill depends on the frequency of vibration producing it, rapid vibrations result in fine thrills whereas slower vibrations produce coarser thrill. Palpation Restricted

25、 or narrowed orifice thrill according blood velocityIntensity degree of narrowing to gradient between two chambersPalpation dependsquality frequency on frequency: rapid fine thrill slower coarser Palpation duration location disease systole second right ICS AS second left ICS PS third fourth left ICS

26、 VSD diastole apical area MScontinuous 2nd left ICS PDAPalpationPericardial friction rub Pericardial friction rub is a to-and-fro grating sensation, which is usually present during both phases of cardiac cycle, often rubs are more readily palpated with the patient sitting erect and leaning forward d

27、uring the end period of deep inspiration. Palpation The rub is caused by a fibrinous pericarditis. In the presence of pericardial effusion the rub will usually disappear because of the separation of visceral and parietal layers by the accumulated fluid. PalpationShock (palpable sounds) valve close a

28、s a tapping sensation 2nd left ICS: PH 2nd right ICS: SH apex : MSPercussionMethod of percussion for heart The chest is percussed to confirm the cardiac borders, size, contour and position in the thorax, patient should lie supine on an examining table or sit on the chair, with the physician at his r

29、ight side. Percussion Usually we employ indirect percussion for percussing heart borders. It is outlined by percussing in the 5th, 4th, 3rd and 2nd intercostal space on the left sequentially, starting near the axilla and moving medially until cardiac dullness is encountered. Percussion The beginner

30、should mark with a skin pencil where the note changes. The distance from midsternal line to the left border should be measured and recorded, measurement should be made along a straight line paralleled to the transverse diameter in the thorax. PercussionHeart bordersRight border of the heart formed b

31、y sup vean, ascending aorta, right atriumHeart bordersLeft border of the heart formed by aorta arch, pulmonary arterial trunk left atria appendage, LVInferior border of the heart formed by RV, lesser extent LVPercussion Normal heart dullness right(cm) ICS,MSL left(cm) 2-3 2-3 2-3 3-4 5-6 7-9Normally

32、 from midsternal line to MCL is about 7-9cmChanging cardiac dullness Left ventricular enlargement, the cardiac dullness will be extended to the left and downward, the heart silhouette is like a shoe. It is frequently seen in aortic regurgitation and called aortic heart.Changing cardiac dullness Righ

33、t ventricular enlargement, the cardiac dullness will extended to left and upward. If the right ventricular is severely enlarged, the right border of the heart will extend to the right. Changing cardiac dullness Both the left atrium and pulmonary artery enlarged, the pulmonary artery will be exaggera

34、ted to leftward. The cardiac silhouette is like a pear and called mitral heart, it is frequently seen in mitral valve stenosis. Aortic dilation, aneurysm of aorta, pericardial effusion, all those diseases may cause the base border of heart enlargement, so that the base border of the heart will be wi

35、dened. Changing cardiac dullness Congestive heart failure, myocarditis, myocardiopathy and pericardial effusion may cause the heart silhouette extending both to right and left. Especially in presence of pericardial effusion, percussion at times may be helpful in outlining the changing cardiac silhou

36、ette resulting from a change in the patients position.PercussionChanging cardiac dullness AS+AI LVH+LVD shoe like MS or ASD RVH pear likePercussionChanging cardiac dullness LAD+PE aortic dilatation pericardial effusion: supine sitting鈫幢嬰穇晆撬蹙榸堯涷馫谛绷齸戇耶鐀伔哢蚕唹居敌攎鼇蛞揼騷畀嫈殶瓈腮舘洼擒阸埂狩趟瞯坲啩惩晜籠秓觽砜鹳條癇圗鈤埓楆宬峋踪瑽罂絘補碵塸徔

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