1. 1 The Physical Examination of Heart 1 st Affiliated Hospital Liaoning Medical College He Xin

2. 2 Anatomy

3. 3 一、 Inspection with tangential lighting 1 、 Thoracic deformity 2 、 Apical impulse 3 、 Abnormal pulsations of precardium

4. 4 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

5. 5 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

6. 6 （ 1 ） Location  Posture  Diaphragm  Mediastinum  Enlargement of the heart  Dextrocardia( 右位心 ): 5-ICS—RS ---Abnormal

7. 7  Posture: ---Recumbent( 仰 ) position—upper ---left lateral( 侧 ) position—to the left 2-3cm ---right lateral position—to the right 1.0-2.5cm

8. 8  Diaphragm: ---“transverse position” upper,outward obesity,child, pregnacy ascites; tumor of abdominal cavity ---“vertical position” inferior,inner thin, high, emphysema

9. 9  mediastinum: one side pleural effusion or pneumothorax ---to the healthy side one side atelectasis or pleural adhesion ---to the affected side

10. 10  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)

11. 11 decreaseincrease PhysiologicalChest wall pachynsis, Narrow intercostal space Thin chest wall, Broaden intercostal space, Exertion, emotion pathologicalMyopathy (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 2  2.5cm in diameter) may suggest dilation. If the thrust is forcible, hypertrophy is suggested.

12. 12 (3)Inward impulse( 负性心尖搏动 ): apex excavation in the systole --adhesive pericarditis --prominent RV hypertrophy

13. 13 (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 epigastric 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

14. 14 (3)basal part of the heart ---2 ICS-LS: dilatation of the pulmonary artery or pulmonary hypertensin, occasionally healthy young man ---2 ICS-RS: aneurysm of aortic arch or dilatation of ascending aorta 3 、 Abnomal pulsations of percardium

15. 15 二、 Palpation 1 Apical impulse and pulsation of precardium 2 Thrill 3 Pericardial friction rub

16. 16 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

17. 17 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

18. 18 Clinical significance of thrill LocationphaseDisease 2 ICS-RSSystoleAS (RHD,CHD,senile) 2 ICS-LSSystolePS (CHD) 3,4 ICS-LSSystoleVSD (CHD) ApexSystoleMI (severe) ApexDiastoleMS (RHD) 2 ICS-LSContinousPDA

19. 19 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

20. 20 三、 Percussion ---Aim: to determine the size and shape of the heart ---Absolute dullness: contain no gas Relative dullness : real size

21. 21 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

22. 22 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

23. 23 Percussion of cardiac dullness border starts tothe left on the chest, from 2  3cm 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.

24. 24 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

25. 25 ① ③ ② ④

26. 26 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)

27. 27 Right ICS Left SVC,SA II PA RA III LA RA Ⅳ LV Ⅴ 4 、 The composition of various parts of the border of the heart

28. 28 ---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

29. 29 （ 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

30. 30 （ 2 ） Cardiac factors : 1)LV enlargement: “boot shape” Seen:aortic valvular disease, hypertension heart disease 2)RV enlargement : slightly↑--absolute dullness↑ Prominent↑--relative dullness↑ to the left side prominently Seen:PHD, MS

31. 31 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”

32. 32 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)

33. 33 （ 3 ） Extacardial factors : 1)large pleural effusions and pneumothorax → to the healthy side 2)atelectasis /pleural pachynsis →to the affected 3)a large amount of ascites or big abdominal tumor: diaphragm elevated→transverse position →left side enlargement

34. 34 四、 Auscultation 1 、 Cardiac valve areas for precordial auscultation 2 、 Order 3 、 Contents

35. 35 1 、 cardiac valve areas for precordial 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: 3 rd ICS LS—Erb area 5)tricuspid area :4,5 ICS-LS

36. 36 Aortic valve areas Tricuspid valve area Pulmonic valve area Mitral valve area Cardiac valve areas

37. 37 2 、 Order: Apical area Pulmonary valve area Aortic valve area 2 nd aortic valve area Tricuspid valve area MV---PV---AV1---AV2---TV

38. 38 3 、 Contents : 1) rate 2)rhythm 3)heart sound 4)extra heart sound 5)murmurs 6)pericardial friction sound

39. 39 (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

40. 40 (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

41. 41 (3) cardiac sound

42. 42 (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

43. 43 S1 Accentuation: ---MS ---HR↑contractility↑ fever,anemia,hyperthyroidism ---complete AVB →cannon sound

44. 44 S1 attenuation : ---MI ---P-R interval enlong ---AI ---myocarditis,myopathy,MI,HF S1 inequality: ---AF ---III°-AVB

45. 45 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

46. 46 2)Quality mono rhythm pendular rhythm---embryocardia

47. 47 3)Splitting of heart sound S1 splitting: seen—RBBB, right heart failure Ebetein malformation,MS LA myxoma

48. 48 S2 splitting: physiological splitting : end of inspiration general splitting : most commonly seen: CRBBB, PS, MS,MI,VSD fixed splitting : ASD paradoxical splitting(reversed splitting) : pathological seen: CLBBB,AS, hypertension

49. 49 (5)extra cardiac sound 1)Diastolic period ① gallop 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

50. 50 ② opening snap :MS ③ pericardial knock: constrictive pericarditis ④ tumor plop: LA myxoma

51. 51 2)Systolic period ① early systolic ejection sound(click) ---pulmonary :pulmonary hypertension; pulmonary artery dilatation ， PS, ASD, VSD ---Aortic: hypertension, aneurysm, AS, AI,aorta constriction ② mid and late systolic click: S1----mid ＜ 0.08″ late ＞ 0.08″ seen: mitral prolapse

52. 52 3)iatrogenic ① prosthetic valvular sound ② pacemaker

53. 53 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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55. 55

56. 56 2 ） characterization of murmur and ausclutatory key points ① Location and Transmission ② Timing ③ Quality ④ Intensity ⑤ Effect of position, respiration and exercise on intensity of murmurs

57. 57 ① Location 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

58. 58 ② Timing ---Murmurs are timed according to the phase of cardiac cycle during which they occur. ---SM, DM, CM. ---Early, middle, late

59. 59

60. 60

61. 61 ③ Quality ---Depend on: frequency and intensity of sound 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

62. 62 ④ Intensity Six-point scale of for grading the intensity of heart murmur Grade Ⅰ: basely audible Grade Ⅱ: usually readily heard Grade Ⅲ: loud Grade Ⅳ: quite loud Grade Ⅴ: even most pronounced Grade Ⅵ: can be heard with thestethoscope removed from the chest wall

63. 63 ⑤ Effect of position, respiration and exercise on intensity of murmurs ---body position: MS--left lateral position AI--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 ↑

64. 64 3 ） The clinical value of heart murmur ① systolic murmurs ② Diastolic murmurs ③ continuous murmurs

65. 65 ① systolic murmurs Mitral valve area ： functional:exercise,fever,anemia,pregnan cy,hyperthyroidism Soft, blowing SM, Grade II/VI well localized wethout transmission. S1 normal.

66. 66 ① systolic murmurs Mitral 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.

67. 67 ① systolic murmurs Mitral 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.

68. 68 ① systolic murmurs Aortic 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

69. 69 ① systolic murmurs Aortic valve areas ： Functional ： due to relative aorticstenosis ( dilatation of aorta, severe hypertension atherosclerosis of aorta) ---Soft ---A2 accentuated

70. 70 ① systolic murmurs Pulmonary valve areas ： Physiology ： (children) ---Soft blowing SM ---Grade II/VI ---shorter

71. 71 ① systolic murmurs Pulmonary 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

72. 72 ① systolic murmurs Pulmonary 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.

73. 73 ① systolic murmurs Tricuspid valve areas ： relative ： RV enlarged ---Soft blowing SM ---Grade III/VI organic ： rare other location : 3-4nd I.c.s left to sternum (VSD,ventricular septal defect) ---Loud, harsh SM, ejection ---accompanied by a thrill

74. 74 ② Diastolic murmurs mitral 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.

75. 75 ② Diastolic murmurs mitral valve area relative MS ： Austin Flint murmur: In severe aortic 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

76. 76 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

77. 77 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

78. 78 ③ continuous 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

79. 79 ---both phases, unaffected by respiration ---seen: pericarditis RHD,AMI,renal failure （ 7 ） pericardial friction sound

80. 80 THANK YOU ！