Explain the Techniques of cardian examination?
Examiner should use the fingertips or the part just proximal to them for palpation. The chest should be completely exposed and elevated to 30 degree the patient should be examined both in supine and in left lateral position (heart moves laterally, and hence is better palpable).
Prccordial movement should be timed with carotid pulse or auscultated heart sounds.
a) Left Ventricular Impulse( Apex beat)
This is the lowest and the outermost point on the chest at which cardiac impulse call be palpated. Normally it is felt in the 5th intercostal space, medial to midclavicular line, occupying an area of 2.5 cm2.
It is palpable as a single, brief outward motion. It may not be palpable in persons with thick chest wall, or when it is hidden behind the rib. If not palpable in supine position, turning the patient to left lateral position may help.
Abnormal Apical, Impulse
i) Site: Displacement of the apex beat lateral to mid-clavicular line or beyond 10 CIIIS lateral to midsternal line is a sensitive but not specific sign of left ventricular enlargement. In left lateral decubitus, if apical impulse is more than 3 cms in diameter; it is an accurate sign of left ventricular enlargement.
In absence of cardiomegaly the apical impulse may be displaced to the left, in patients with pectus excavatum or congenital complete absence of rericardium. In patients with Dextrocardia: apex beat will be palpable on the right hemi thorax.
ii) Character: Heaving apex impulse as in patients with concentric LVH where the apical impulse is sustained and displaced laterally and downwards.
Hyperkinetic apex impulse as in patients with volume overload where it is brisk and larger. Hyperkinetic apex impulse as in patients with low cardiac output. Tapping apical impulse as in patients with MS.
iii) Other conditions : Double apical impulse as in patients with HOCM when a wave (palpable atrial hump) is present, as in severe HOCM, a triple outward movement (triple ripple) can be palpated.
Constrictive pericarditis is usually associated with systolic retraction of chest, especially of ribs in left axilla (Brodbent sign).
b) Right Ventricular Impulse
Normally it is not palpable except in first few months of life. Systolic outward motion in the left parasternal area suggests RV enlargement lhypertrophy. A sustained lcft parastcrnal impulse suggests RVH due to pressure overload as in PS or PH.
On placing the pad of right thumb pointing upward just below the xiphoid process, if an impulse can be palpated hitting the thunib pad, it indicate RV inflow enlargement. In left lateral position RV enlargement is suggested by a dominant lateral retraction.
c) pulmonary artery
Prominent systolic pulsation of pulmonary artery in 2nd ICS just to the left of sternum suggests pulmonary hypertension and or increased pulmonary blood flow. It is often associated with prominent left parasternal pulsation of RV enlargement. Normal pulmonary trunk can sometimes be palpable in patients with narrow anteroposterior diameter.
d) Left artery
Systolic bulging of LA is transmitted through the RV and it begins and terminates after the LV impulse. Left parasteinal nlovellleiit can occur in absence of RV enlargement in patients with dilated LA as in severe MR.
E) Thrills
There are palpable manifestations of loud, harsh murmur having low medium frequency components and is classically described as the purring of a cat. These are best felt with flat of the hand or fingertips. High-pitched murmurs, as those produced by valvar regurgitation are not usually associated with thrills, even when loud.
F ) Percussion
Palpation is more helpful than percussion in determining cardiac size. Percussion aids in determining visceral situs. Percussion of 2nd left ICS is important as a dull, note signifies dilatation of large arteries as in pulmonary artery or aneurysm of ascending aorta.