Anatomy In Relation to Physical Diagnosis of the Heart

Patient Data Base

• History
  
• Physical examination
  
• Interpretation of diagnostic findings e.g., EKG
  

Bedside Assessment

• Purposeful, directed
  
• Covert observation
  
• Intellectual capacity to anticipate physiologic impairment
  
• Discriminating, exact
  
• Accuracy, speed and clinical competence
  

The Heart

Locations

• Base – top of the heart (level of the 2nd ICS)
  
• Apex – bottom of the heart (level of the 5th ICS)
  

Surface projections of the Heart

• Helpful to visualize underlying structures as you examine the anterior chest
  
• RV occupies most of the anterior cardiac surface
  
• RV and PA form wedge-like structure behind and to the left of sternum
  
• Inferior border of RV lies below the jnx of the sternum and the xiphoid process
  
• RV narrows superiorly and meets the PA at the level of the 3rd left costal cartilage close to sternum 
  
• The LV – behind the RV and to the left; forms the lateral margin of anterior surface; it produces the apical impulse, locates the left border of the heart, 5th ICS,7 to 9 cm to left of midsternal line
  
• RA – forms the right border of the heart
  
• LA – mostly posterior and cannot be examined directly; its appendage may make up a segment of left cardiac border between the PA and the LV
  
• Above the heart lie the great vessels
  
• PA- bifurcates into right and left branches
  
• Aorta -curves up from the LV to the level of the sternal angle where it arches backward and downward
  
• SVC- to the right of the heart emptying into RA
  
• IVC –also empties into the RA
  
• SVC and IVC –carry venous blood from upper and lower parts of the body respectively
  

Layers of the heart wall

• Endocardium – innermost layer
  
• Myocardium – middle and thickest layer, contains the cardiac muscle fiber (contraction, conduction and blood supply)
  
• Epicardium – external layer
  

Relation of Auscultatory findings to the Chest Wall

• MV ---- heard best at and around the apex
  
• TV------ at or near the lower left sternal border
  
• PV------ usually heard best in the 2nd and 3rd left ICS close to sternum but may also be heard at higher or lower levels
  
• AV---- may be heard anywhere from the ® 2nd ICS to the apex
  

Tips:

1. Tangential light may improve chances of seeing impulses
   
2. For feeling impulses, use your fingerpads 
   
3. Thrills like tactile fremitus-felt best thru bone-ball of your hand pressed firmly on your chest. Thrills may accompany loud,harsh, rumbling murmurs such as AS,PDA,VSD, MS
   
4. Cardiac apex- normally at or medial to midclavicular line in the 5th or possibly 4th ICS; you can see the apical impulse, the brief early systolic pulsation of LV as it moves anterior during contraction and touches chest wall
   
5. Assess location, diameter, amplitude and duration of apical impulse
   
6. Location: 4th or 5th ICS medial to LMCL
   
7. Diameter:2.5cm,occupies one interspace 
   
8. Amplitude:small and feels like gentle tap
   
9. Duration;normally, lasts thru the first 2/3 of systole and often does not continue to S2
   

Techniques of Examination

• Percussion-in most cases, palpation has replaced percussion in cardiac size estimation
  
• When you cannot feel the apical impulse however, percussion may suggest where to look for it.
  
• Auscultation-listen throughout precordium with diaphragm of stet, press firmly on chest
  
• Diaphragm-high pitched sounds(S1,S2, AI, MR murmur)
  
• Bell-sensitive to low pitched sounds (S3, S4, MS murmur)
  
• When doing auscultation of heart sounds- room must be quiet
  
• Listen to the entire precordium with patient supine position. Then ask hiim to roll partly on the left side- accentuates S3, S4 and mitral murmur ( MS)
  
• Sit up-lean forward position-accentuates aortic murmurs ( AR )
  
• Take time in listening to heart sounds
  
• Locate area of maximal intensity (murmur), radiation or transmission from point of maximal intensity ( direction of blood flow)
  
• Grade intensity of sound- use 6 point scale, numerator- loudest ; denominator- indicates the scale 
  
• Intensity may be influenced by thickness of chest wall and presence of intervening tissue
  
• Pitch- categorized as high, medium, or low
  
• Quality- described as blowing, harsh, rumbling and musical
  

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