Transcript Examination of the Heart

Palpation
Usually inspection and palpation 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 of the cardiac apex
impulse, characterize its contour, and
identify any abnormal precordial
pulsations.
The various disturbances in rate(心率)
and rhythm(心律) which have been
observed can be confirmed by
palpation.
Palpation gives us a better impression
of the force of the heart beat than does
inspection.
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.
Thrill examination by palm
Apical impulse examination by finger
Apical impulse(心尖搏动)
location
duration
amplitude intensity
frequency regularity
Sustained sensation(抬举性搏动):
LVH Forceful, sustained, through
systole with great amplitude more
than 2cm diameter
Precordial lift or heavy: RVH
Decrease amplitude: myocarditis
Massive pericardial effusion: impulse
cannot be palpable
Thrill
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 occur in systole, diastole,
presystole and at times may be continuous.
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 narrowing of the orifice
and which it is produced and difference
in pressure between the two chambers
of the heart.
Quality of a thrill depends on the
frequency of vibration producing it,
rapid vibrations result in fine thrills
whereas slower vibrations produce
coarser thrill.
Restricted or narrowed orifice
thrill
according
Intensity
to
blood velocity
degree of narrowing
gradient between
two chambers
depends
quality
on
frequency:
rapid
slow
frequency
fine thrill
coarser thrill
Diastolic thrill
The diastolic thrill felt near the apex is
pathognomic of mitral stenosis(二狭).
It may be compared quit accurately to
the vibration which accompanies the
sound of satisfaction which a cat
makes.
It is usually felt only over a small area
at or near the point of maximum
impulse. It may not be felt when the
patient is lying quietly in bed,
but may be brought out by moving the
patient up and down rather rapidly a
few times and thus producing more
active cardiac contractions, and also by
turning the patient on his left side.
Systolic thrill
A systolic thrill may be felt over the
precordium with its maximum intensity
at the aortic area in aortic stenosis(主
狭). This thrill is usually rough and
purring, and commonly of greater
intensity than any other thrill felt over
the heart.
This systolic thrill of aortic stenosis is
felt in the carotid(颈动脉) and brachial
(臂动脉) arteries and its transmitted in
the direction of the blood flow.
Systolic thrill
In pulmonary stenosis(肺动脉瓣狭窄)
a rough systolic thrill is felt over the
pulmonary area and from here is
transmitted upward and diagonally
toward the left clavicle.
Systolic thrill
In aneurysm of the ascending aorta(升
主动脉瘤), which produces a definite
area of pulsation, a systolic thrill may
be felt over this area.
duration
systole
location
disease
second right ICS
AS
second left ICS
PS
third fourth left ICS VSD
diastole
apical area
MS
continuous 2nd left ICS
PDA
Pericardial friction rub
Pericardial friction rub(心包摩擦感) 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 during the
end period of deep inspiration.
The rub is caused by a fibrinous
pericarditis(纤维素性心包炎). In the
presence of pericardial effusion the rub
will usually disappear because of the
separation of visceral and parietal
layers by the accumulated fluid.
Review
 Method
of palpation
 Precordial pulsantion: LVH, RVH,
myocarditis, massive pericardial
effusion
 Mechanism of thrill
 Clinical significance of precordial thrill
单选题
震颤的论述,错误的是
A. 在心尖区触及收缩期震颤可见于二狭
B. 临床上凡触及震颤均可认为心脏有器质
性病变
C. 触诊有震颤的部位多数可听到杂音
D. 在胸骨右缘第2肋间触及收缩期震颤可
见于主狭
E. 在胸骨左缘第2肋间触及收缩期震颤可见
于肺动脉瓣狭窄
心包摩擦感的论述,错误的是
A.为心脏收缩时脏层与壁层心包相互摩擦
而产生
B. 随渗液的增多,心包脏层与壁层分离时摩
擦感消失
C. 多在心前区或胸骨左缘第3、4肋间触及
D. 以收缩期、前倾体位更为明显
E. 以吸气末更为清楚
标准配伍型题
A. 胸骨左缘第二肋间收缩期震颤
B. 胸骨左缘3~4肋间收缩期震颤
C. 胸骨左缘第二肋间连续性震颤
D. 心尖区舒张期震颤
E. 胸骨右缘第二肋间收缩期震颤
主动脉瓣狭窄? 肺动脉瓣狭窄?
动脉导管未闭? 二尖瓣狭窄?