Examination and palpation of the heart

General examination may be of decisive importance for the diagnosis. The position of the patient sitting or with an elevated head (orthopnea) is a characteristic symptom of heart failure with stagnation of blood in the lungs. At the same time, the flow of blood from the great circle of blood circulation and the phenomenon of stagnation decrease. Sometimes you should specifically ask the patient if it is not easier for him to breathe with a raised head. When exuding pericarditis patients sometimes sit, leaning forward.

General inspection

Constitution (physique) is relatively small for diagnosis, but stocky men (hypersthenics) are considered more likely candidates for the development of coronary disease. Very tall thin men with long fingers can have heart disease (aortic vice) at an early age, which is regarded as one of the symptoms of Marfan syndrome.

Skin and mucous membranes often change in diseases of the heart. The most characteristic symptom - cyanosis - cyanotic coloration of the skin, especially the fingers, tip of the nose, lips, auricles - acrocyanosis. Cyanosis can be more common and significantly increased with physical exertion, which is accompanied by coldness of the skin (in contrast to warm cyanosis in patients with pulmonary insufficiency). As with lung diseases, cardiac cyanosis is associated with a decrease in hemoglobin oxygenation, an increase in the circulation of reduced hemoglobin. In diseases of the heart, more oxygen is extracted from oxyhemoglobin in peripheral tissues.

With long-term heart failure with congestion in the liver, jaundice can occur , which is combined with cyanosis. Petechial hemorrhagic eruptions on the limbs, a peculiar skin color resembling the color of coffee with milk, give grounds to assume infectious endocarditis, especially in patients with a previously existing valvular heart disease. Xanthelasms - slightly rising, whitish spots on the skin of the eyelids - are associated with the deposition of cholesterol and a violation of lipid metabolism, which is characteristic of coronary atherosclerosis. Some importance is attached to premature graying and baldness, which is often found among young patients with coronary heart disease.

Subcutaneous fatty tissue, its severity has a certain significance. Its excessive development, overall completeness, is an important risk factor for atherosclerosis. Exhaustion is observed in severe dystrophic stage of heart failure. Swelling of the legs, especially the shins and feet, is a characteristic sign of stagnation in the great circle of blood circulation. Edema of one of the shins is typical for the phlebitis of the deep veins of the lower legs. For its detection, it is useful to measure the circumference of the shins at the same level, because on the side of the phlebitis the circumference will be greater.

Examination of the extremities sometimes yields significant data. The fingers and toes in the form of drumsticks are found in congenital heart defects of the cyanotic type, as well as in infectious endocarditis. Characteristic external changes in the skin, various joints can be detected in many diseases (for example, systemic lupus, scleroderma, thyrotoxicosis, etc.), often accompanied by heart damage.

Changes in the lungs with heart failure are expressed in the rapidity of breathing and the appearance of moist, non-vertebral rales in the lower lateral and posterior regions.

Heart area examination

It is better to conduct simultaneously with palpation, which, in particular, facilitates the detection of pulsations. Some pulsations are better perceived visually, others are predominantly palpable. On examination, a cardiac hump associated with deformation of the chest as a result of early enlargement of the heart chambers due to its defect can be detected. The most important pulsations in the region of the heart are the apical impulse and a heart beat, on which one can judge of hypertrophy and an increase in the left and right ventricles of the heart, respectively.

The apical impulse is seen in most of the healthy people in the fifth intercostal space inward by 1 cm from the mid-clavicular line. To determine it, the palm of the right hand is superimposed on the indicated area, and further the features of the apical impulse are refined with the tips of the fingers of the right hand, with the help of which its width, height, and resistance are established. Usually it is determined on an area of 1-2 cm ². The apical impulse is associated not only with contraction of the left ventricle, but more with the rotation of the heart around its axis, which leads to a jerky movement of the heart toward the chest. The apical impulse is not visible and is not palpable if its localization corresponds to the rib (rather than the intercostal space), as well as with severe emphysema. The increase in the size of the apical impulse more than 3 cm in diameter corresponds to dilatation of the left ventricle. Amplification (increase in amplitude) and increased resistance of the apical impulse correspond to hypertrophy of the left ventricle. In both cases, at the same time, there is a shift in the apical impulse outside the mid-clavicular line, and with pronounced hypertrophy and dilatation, even in the sixth intercostal space.

The heart beat is determined outside of the left edge of the sternum at the level of the IV rib and the fourth intercostal space. Normally, it is usually not visible and palpation is not determined or determined with great difficulty in lean individuals with wide intercostal spaces. It begins to be clearly identified with hypertrophy of the right ventricle, with its systole connected. With severe emphysema, a cardiac shock may be absent even with significant right ventricular hypertrophy. In this case, pulsation can be detected in the epigastric region, which may be associated with pulsation of the aorta or liver.

The widespread cardiac pulsation can be defined a little to the inside of the apical impulse in patients with transmural infarction, with aneurysm of the left ventricle.

Trembling of the chest wall in a restricted area corresponding to the point of listening to one or the other valve can be determined for heart defects. This tremor is called "cat purring", as it resembles the feeling that occurs when stroking a purring cat. This symptom almost corresponds to the fluctuations that cause the appearance of noise in the heart due to difficulty in the movement of blood through the atrioventricular and aortic orifice during systole or diastole. In accordance with this, the tremor may be systolic or diastolic. At the same time, an appropriate noise characteristic of a vice is heard. For example, diastolic tremor at the apex of the heart is determined with mitral stenosis simultaneously with diastolic noise.

When pressure in large vessels (aorta or pulmonary artery) increases, the corresponding semilunar valves close at the beginning of the diastole more quickly. This causes a small palpable push at the edge of the sternum in the first - second intercostal space, respectively, on the left due to closure of the valves of the pulmonary artery and to the right as a result of slamming the aortic valves.

Pulsation in the second intercostal space to the right of the sternum or behind the sternum can be determined by the development of an aneurysm of the aortic arch. Pulsation of the abdominal aorta can be detected in thin patients in the epigastric region and below.

At present, precardial pulsation at various points can be recorded with the help of a special technique in the form of a curve (kineto-cardiogram), the analysis of which allows to establish violations of the movement of the heart wall in different phases of the cardiac cycle.