Transcript Examination of the Heart3

Percussion
The chest is percussed to confirm the
cardiac borders, size, contour and position
in the thorax.
Relative cardiac dullness(心相对浊音界)
Absolute cardiac dullness(心绝对浊音界)
Method of percussion for heart
Patient should lie supine on an
examining table or sit on the chair,
with the physician at his right side.
Usually we employ indirect
percussion(间接叩诊法) for
percussing heart borders.
Many beginners, in attemptng to
outline the cardiac dullness, strike too
forcibly and thus fail to hear the slight
change in the percussion note caused
by the thin layer of overlying lung.
One should use the lightest percussion
possible and, with experience, rely
more and more upon the vibratory
sense.
Percussion with finger parallel
to cardiac outlines
Percussion with finger at right
angle to cardiac outline
The orthopercussion(直指叩诊
法) method of Plesch is
carried out by flexing the left
middle finger to a right angle,
placing the pulp of the finger
on the area to be percussed,
and then striking the flexed
finger at the distal end of the
first phalanx.
This method is recommended in the
percussion of absolute cardiac
dullness, and give excellent results
comparing with ordinary methods.
It is outlined by percussing in the 5th,
4th, 3rd and 2nd interspace on the left
sequentially, starting near the axilla
and moving medially until cardiac
dullness is encountered.
Percussion
The beginner 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.
Heart borders
Right border of the heart
formed by
sup vena(上腔静脉), ascending
aorta(升主动脉), right atrium(右心
房)
Left border of the heart
formed by
aorta arch(主动脉弓), pulmonary
arterial trunk(肺动脉段), left atria
appendage(左心房), LV(左心室)
Inferior border of the heart
formed by
RV(右心室), lesser extent LV

Normal heart dullness
right(cm) ICS,MSL left(cm)
2-3
2-3
3-4
Ⅱ
Ⅲ
Ⅳ
Ⅴ
2-3
3.5-4.5
5-6
7-9
Normally from midsternal line to MCL is about 8-10cm
Physiologic changes in the area
of cardiac dullness
The position of the heart, and with it
the area of cardiac dullness, is
influenced by the level of the
diaphragm.
In deep inspiration the diaphragm
descends, producing a decrease in
cardiac dullness, while in forced
expiration the diaphragm rises and
produces an increase in the cardiac
dullness.
In the later months of pregnancy the
diaphragm is pushed upward, causing
the heart to lie more horizontally and
closer to the chest wall, thus increasing
the area of cardiac dullness.
Cardiac dullness in
abdominal distention
A variety of pathologic conditions such
as ascites, an ovarian cyst(卵巢囊肿),
or peritonitis(腹膜炎) may cause an
elevation of the diaphragm with an
increase in the area of cardiac dullness.
Changes in position of
cardiac dullness
A left-sided pleural effusion(胸腔积液)
will push the heart to the right, and
increase the cardiac dullness to the right
of sternum, the left border in such cases
can usually not be made out. A rightsided pleural effusion increase the
cardiac dullness on left side.
In pneumothorax the heart is displaced
toward the normal side, but in massive
collapse of the lung(肺萎缩) the heart
is displaced toward the affected side.
Pleural adhesions(胸膜粘连) may pull
the heart to the affected side with
resulting changes in cardiac dullness
similar to those produced by collapse
of the lung.
Decrease in the area of
cardiac dullness
A decrease in the relative cardiac
dullness may occur in pulmonary
emphysema(肺气肿). The absolute
cardiac dullness is usually decreased in
such cases, since the lung is increased
in size and covers a greater area of the
heart than normal.
Increase in the area of
cardiac dullness
An increase in the area of cardiac
dullness is most strikingly seen in
patients with cardiac disease. we
cannot detect by percussion an
appreciable increase of the cardiac
dullness in hypertrophy of the heart
unless there is an accompanying
dilatation.
Cardiac enlargement
Enlargement of the left ventricle
produces an increase in the relative
cardiac dullness to the left and often
downward on this side.
The heart silhouette looks like a shoe
Enlargement of the left ventricle
appears in aortic insufficiency, in aortic
stenosis, in mitral insufficiency, in
longstanding hypertension and in
chronic nephritis(慢性肾炎). It is
called aortic heart(主动脉型心).
Right 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. It is
seen in cor pulmonale, in mitral
stenosis, in tricuspid insufficiency etc.
Both the left atrium and pulmonary
artery enlarged, the pulmonary artery
will be exaggerated to leftward. The
cardiac silhouette is like a pear and
called mitral heart(二尖瓣型心), it is
frequently seen in mitral valve
stenosis.
The heart silhouette is like a pear
Aortic dilation(主动脉扩张), aneurysm
of aorta(主动脉瘤), pericardial
effusion, all those diseases may cause
the base border of heart enlargement,
so that the base border of the heart will
be widened.
Congestive heart failure, severe
myocarditis, Keshan disease(克山病),
dilated myocardiopathy(扩张性心肌病)
may cause the heart silhouette extending
both to right and left(普大心).
Pericardial effusion
The cardiac dullness is increased in all
directions and assumes the form of a
triangle with the apex at the level of
the first or second intercostal space or
a general globular enlargement.
The heart silhouette is like a flask
The heart silhouette is like a globe
Adhesive pericarditis
The degree of enlargement depends on
the extent of the adhesive process. The
relative, and especially the absolute,
cardiac dullness are both markedly
increased to left and to the right.
Increase in the absolute
cardiac dullness
Increase in the absolute cardiac
dullness without demonstrable cardiac
enlargement occurs when the left lung
is retracted and a larger area of the
ventricle is exposed.
It also occurs in mediastinal tumors
when the heart is pushed up against the
chest wall and a large area of the
ventricle comes into direct contact with
the anterior surface of the chest.
复习
 心界叩诊的顺序
 正常心浊音界的组成
 心脏浊音界改变及临床意义
重要名词
 主动脉型心(靴形心)
 普大型心
 二尖瓣型心(梨形心)
 烧瓶形心
 球形心
单选题
心浊音界改变的论述,正确的是
A. 一侧大量胸水积液可使心界移向患
侧
B. 一侧大量气胸可使心界移向患侧
C. 肺气肿时心界变大
D. 一侧肺不张可使心界移向患侧
E. 以上均不是
心脏叩诊浊音界向左下扩大、心腰加深，
见于
A. 二尖瓣狭窄
B. 高血压性心脏病
C. 三尖瓣狭窄
D. 心肌病
E. 克山病
心脏叩诊左心房和肺动脉段增大,使心
腰部饱满或膨出可见于
A. 主动脉瓣关闭不全
B. 二尖瓣狭窄
C. 二尖瓣关闭不全
D. 心包积液
E. 房间隔缺损
心包积液的特征为
A. 心浊音界向左下增大
B. 心浊音界向右增大
C. 梨形心
D. 心界向两侧扩大,同时浊音界可随体
位而改变
E. 以上均不是
标准配伍型题
A. 靴形心
B. 胸骨右缘第1,2肋间浊音界增宽
C. 普大型心
D. 梨形心
E. 三角形烧瓶样心
扩张性心肌病?
二尖瓣狭窄?
高血压性心脏病? 心包积液?