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Status Objectivus: Inspection, Palpation And Percussion Of The Heart
Inspection of the Heart
Cardiomegaly occurring in early life gives rise to precordial bulge. This is true of congenital heart diseases and juvenile rheumatic heart disease. In the majority of these cases, right ventricle is enlarged. Displacement of the apex beat and abnormal pulsations occurring in ventricular aneurysm or aortic aneurysm can be made out. The epigastrium pulsates in the right ventricular hypertrophy. Liver pulsates in tricuspid incompetence. All these can be observed by mere inspection.
Palpation of the Heart Borders
This is the method to locate the apical impulse. Other valuable informations obtained by palpation are the presence of ventricular hypertrophy, expansile pulsation of aneurysms, abnormally loud heart sounds and thrills produced by loud murmurs.
Normal apex beat is palpable in thin and moderately built individuals. It just lifts the palpating finger. Normally, the apex beat is felt in the fifth left intercostal space 1cm inside the mid-clavicular line. It may be impalpable if the chest wall is thick or if it is behind a rib. Pathological causes include emphysema and pericardial effusion. When the apex beat is not located in the normal position, the right side should be palpated, so as not to miss dextrocardia. When there is volume overload of a ventricle, the impulse is more forced (also called hyperdynamic), but not sustained.
Forced and sustained impulse (heave) is suggestive of pressure overload. Left ventricular hypertrophy is manifested by heaving apex beat, whereas right ventricular hypertrophy manifests as left parasternal heave. Normal pulmonary artery pulsation may be visible in the second and third left parasternal region in thin individuals. If this is prominent, it suggests abnormal pulsation and pulmonary hypertension. Thrills are caused by vibrations imparted to the palpating hand by turbulent blood flow.
Percussion Of The Heart
The precordial dullness is increased in cardiomegaly due to various causes and in pericardial effusion. The cardiac dullness is obliterated in emphysema and left sided pneumothorax. Enlargement of the pulmonary artery, occurring in atrial septal defect of gross pulmonary hypertension can be detected by extension of the dullness outside the normal in the left second intercostal space.
Normal pulmonary artery does not extend beyond 1 cm outside the left sternal edge. Since assessment by percussion can be at best be only approximate, more accurate estimation by radiography or ultrasonography is resorted to in all cases of doubt.
© 2013 Funom Theophilus Makama