EXAMINATIONS OF THE CARDIOVASCULAR SYSTEM

Heart examination should be complemented with the examination of arterial pulses and jugular venous pulse.

 
INSPECTION AND PALPATION: A good examination of the heart is done by inspection, palpation and auscultation, percussion plays a minor role. The patient was examined on the right side.The inspection is to see, first, the apex beat of the heart (cardiac apex), which is due to the contraction of the left ventricle in systole. Usually found in the fifth left intercostal space (or fourth space), in the midclavicular line (or 7 cm to 9 cm lateral line midsternal). It is not always possible to see. Then, it is felt. The location of the apex beat gives an idea of ​​the size of the heart. If you are not supine, may be more evident in the left semi-lateral decubitus. Should find it with the heel of your fingers. If necessary, the patient is asked to hold their breath in expiration for a few seconds. When the heart is dilated, the apex is outside the midclavicular line and below the fifth intercostal space, the area where you can feel the heartbeat may be increased. In obese patients, very muscular, emphysematous, or with a pericardial effusion of a certain size, you can not detect it. It is of greater amplitude (hyperkinetic) in paintings such as severe anemia, hyperthyroidism, mitral or aortic insufficiency. In aortic stenosis, or if there is hypertrophy of the left ventricle, the apex beat is more sustained. Sometimes you can see and feel a throbbing in the lower region of the sternum or under the xiphoid to be due to the activity of the right ventricle. If this beat is also when the patient inhales, the more sure is the right ventricle and not the transmission of the heartbeat of the descending aorta.When pulmonary hypertension could be felt something in the 2nd or 3 ^rd intercostal space at the left sternal border.If there is a severe heart murmur, you can feel a thrill that feels strongly supporting the pads of the fingers or palm.

 

PERCUSSION: When the apex beat of the heart can not see or touch, can make a drum to mark the size of the heart. There is much emphasis on this because the performance is more limited. Is struck at the 3 rd, 4 th and 5 th intercostal space (possibly the 6 th), from lateral to medial on the left side, trying to identify when the sound moves from sonorous mate.


AUSCULTATION: To make listening to your heart's room must be silent. The stethoscope is applied directly over the precordium. Most noises are heard along with the stethoscope diaphragm, which supports putting some pressure. The campaign identifies best low-pitched sounds, as the third (S ₃₎ and fourth sounds (S_4), and the murmur of mitral stenosis. Must apply sufficient pressure to produce a seal that isolates of background noise, but without exerting much pressure because in these conditions, the skin stretches and acts as a membrane, being able to stop listening to sounds such as S ₃ and S _4. The membrane is used to listen to all the cardiac area, and a hood, preferably, to the apex and left sternal border in its lower portion. Auscultation should begin with the patient supine and then move to a left semi-lateral position in which it can better detect S _3, S ₄ and mitral murmurs (listening with diaphragm and bell). After listening with the patient should be sitting up and leaning forward, asking  to hold your breath a few seconds during expiration, is looking for murmurs of aortic insufficiency and pericardial rub.It should examine the heart in a specific order so as to properly identify the different sounds and murmurs, and follow his path: Where are best heard and where they are irradiated. Some people prefer starting from the apex auscultation and others from the base of the heart, and so move the stethoscope cover the entire chest area. Also need to be methodical to identify the different sounds: from recognizing the first and second sound, then sounds and murmurs that occur in systole and diastole then. You must be able to subtract from other sounds auscultation that stand, like breathing.
 
SITES FOR AUSCULTATION: The sounds tend to listen better in the direction of blood flow: an aortic murmur in the direction of blood into the aorta, a pulmonary murmur, following the direction of the pulmonary artery, a murmur of mitral regurgitation, toward the left armpit; etc. Some sounds are best heard in places. In considering it runs through the stethoscope from the apex to the base, or vice versa. Although many noises are heard throughout the chest area, some are heard only in some places. So, sounds and murmurs from the mitral valve are better recognized in the cardiac apex and its surroundings (mitral). The coming of the tricuspid valve are best heard in the lower left sternal border (tricuspid focus). If you are from the pulmonary valve at the second intercostal space along the left sternal border (pulmonary area), or third left parasternal intercostal space (secondary pulmonary focus), but could also hear a little above or below these benchmarks . Sounds and murmurs arising from the aortic valve are heard in the second right intercostal space along the sternal border (aortic area) but can be heard all the way to the apex of the heart. The second intercostal space along the left sternal border has also been called accessory aortic focus. As you can see, there is overlap auscultation sites, and often, to recognize the cause of the murmur, it is necessary to use other elements (eg, characteristics of arterial or venous pulse, breathing changes or changes of position).