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*,*,单击此处编辑母版标题样式,*,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,Physical Examination,of Cardiovascular System,FOR MBBS STUDENTS,Ma Guotian,M.D.,Professor of Cardiology,Department of Diagnostics,The First Affiliated Hospital,of Guangxi Medical University,1,General Consideration,During lifetime, the heart contracts more than 4 billion times.,Pumping 200 million L blood to systemic circulation.,Cardiac output varies under physiologic conditions from 3 to 30L/min. Heart rate varies from 60 to 150 beats/min.,2,Physical Examination of Cardiovascular system,In the present era of technological advances, particularly in the various imaging modalities, physical examination of the heart still provides useful information.,3,Physical Examination of Cardiovascular system,It is simple, convenient, cheap as premier assessment of the severity and an etiology of the lesions and also serves as an clue to use advanced,techniques for the diagnosis of CVD.,4,Review the A,natomy,5,Routine and Techniques of PE of the Heart,Patients exposure and position (sitting or lying down) , with enough light and appropriate temperature,Four parts:,inspection, palpation, percussion, and auscultation,6,Part one,Inspection,7,Inspection,Precordium,is the region of the anterior surface of the body covering the heart and lower thorax.,8,Contents of Inspection,Thoracic cage,deformity,Apical impulse,Abnormal pulsations in,precordium,9,Methods of Inspection,Inspect the obverse side.,Then obverse the patients lateral surface,10,Thoracic Cage,Deformity,（,inspection）,Asymmetry of the thoracic cage due to a convex bulging of the precordium suggests the presence of heart disease since,childhood,11,Thoracic Cage,Deformity,（,inspection）,such as congenital heart disease and rheumatic heart disease, with skeletal molding to accommodate cardiac enlargement.,12,Apical Impulse,（,inspection）,Apical impulse m,ainly results from the left ventricular contraction, when LV contracts, the apical knocks at the correspondent position of anterior chest wall, resulting in intercostal impulse outward movement.,13,Apical Impulse,（,inspection）,Normal apical impulse,Position,:,left border of sternum, fifth intercostal space, inside the midclavicular,Range,:,in diameter,14,Apical Impulse,（,inspection）,Apical impulse displacement,Changes of intensity and area of apical impulse,Inward impulse,15,Apical Impulse,（,inspection）,Apical impulse displacement,(1). extra-heart factors,(2). cardiac enlargement,(3). body posture,16,Apical Impulse Displacement,Extra-heart factors:,Obesity, pregnancy, etc. cause elevation of diaphragm, apical impulse shifts to outward and upward, at left the 4th intercostal space outside midclavicular line.,17,Apical Impulse Displacement,Extra-heart factors:,Abdominal disease: abdominal tumor, a large number of ascites, etc. elevation of diaphragm, apical impulse shifts to outward and upward,18,Apical Impulse Displacement,Extra-heart factors:,Leptosome; severely pulmonary emphysema. Then apical impulse shifts to inward and downward, reaches at the 6th intercostal space.,19,Apical Impulse Displacement,Extra-heart factors:,Single side pleural thickening, or adhesion, or atelectasis result in mediastinum and heart shifting to the sick side, and the apical impulse shifts to the sick side , too.,aortic arch,LV,to the,sick side,20,Normal,Apical Impulse Displacement,heart shifts to the healthy side,Pleural effussion in the right,to the health,side,21,Apical Impulse Displacement,Cardiac enlargement,Right ventricle enlargement. Apical impulse shifts to the left but not downward.,Left ventricle enlargement. Apical impulse shifts to the left and downward at the same time.,22,Left Ventricle Enlargement,Normal,LV enlargement,23,Both Ventricles Enlargement,Both,ventricles enlargement,Normal,24,Apical Impulse Displacement,Body posture,Dorsal decubitus. Apical impulse moves a little upward, if left lateral decubitus the apical impulse shifts to the left 23cm.,Right lateral decubitus. The apical impulse shifts to the right 12.5cm.,25,Apical Impulse,（,inspection）,Changes of intensity and area of,apical impulse,(1).,Physical conditions,(2).,Pathological,conditions,26,Physical conditions,Thickness of the chest wall,Emotion excited,Strong physical activity,Changes of Intensity and Area of Apical Impulse,27,Changes of intensity and area of apical impulse,Pathological,conditions,Enhanced apical impulse :,left ventricular enlargement,hyperthyroidism,fever, anemia,Pathological,conditions,Weakened apical impulse,:,dilated,myocardiopathy,hydropericardium,left pleural effusion,pulmonary emphysema,28,Inward Impulse,Inward impulse. The apex depresses far from the chest instead of striking the chest during systole. Broadbents sign is of value in the diagnosis of adherent pericardium. It is also seen in RVH.,29,Abnormal Pulsations in Precordium,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,30,Abnormal Pulsations in Precordium,In ascending or arch aortic aneurysm, one may detects 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.,31,Abnormal Pulsations in Precordium,Marked pulsation at the base of the heart is seen in aortic insufficiency, in a dilated aorta or a saccular aneurysm.,32,Reference,诊断学第8版， 全国规划教材， 陈文彬 主编， 人民卫生出版社， 2013年,诊断学医学英文原版改编双语教材， 吕卓人 主编， 科学出版社， 2006年,History and Examination, James Marsh, Chief Editor,科学出版社， 2007年,33,Thank you！,34,
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