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Percussion

Percussion. The chest is percussed to confirm the cardiac borders, size, contour and position in the thorax. Relative cardiac dullness( 心相对浊音界 ) Absolute cardiac dullness( 心绝对浊音界 ). Method of percussion for heart.

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Percussion

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  1. Percussion The chest is percussed to confirm the cardiac borders, size, contour and position in the thorax. Relative cardiac dullness(心相对浊音界) Absolute cardiac dullness(心绝对浊音界)

  2. Method of percussion for heart Patient should lie supine on an examining table or sit on the chair, with the physician at his right side. Usually we employ indirect percussion(间接叩诊法) for percussing heart borders.

  3. Many beginners, in attemptng to outline the cardiac dullness, strike too forcibly and thus fail to hear the slight change in the percussion note caused by the thin layer of overlying lung.

  4. One should use the lightest percussion possible and, with experience, rely more and more upon the vibratory sense.

  5. Percussion with finger parallel to cardiac outlines

  6. Percussion with finger at right angle to cardiac outline

  7. The orthopercussion(直指叩诊法) method of Plesch is carried out by flexing the left middle finger to a right angle, placing the pulp of the finger on the area to be percussed, and then striking the flexed finger at the distal end of the first phalanx.

  8. This method is recommended in the percussion of absolute cardiac dullness, and give excellent results comparing with ordinary methods.

  9. It is outlined by percussing in the 5th, 4th, 3rd and 2nd interspace on the left sequentially, starting near the axilla and moving medially until cardiac dullness is encountered.

  10. Percussion The beginner should mark with a skin pencil where the note changes. The distance from midsternal line to the left border should be measured and recorded, measurement should be made along a straight line paralleled to the transverse diameter in the thorax.

  11. Heart borders Right border of the heart formed by sup vena(上腔静脉), ascending aorta(升主动脉), right atrium(右心房)

  12. Left border of the heart formed by aorta arch(主动脉弓), pulmonary arterial trunk(肺动脉段), left atria appendage(左心房), LV(左心室)

  13. Inferior border of the heart formed by RV(右心室), lesser extent LV

  14. Normal heart dullness right(cm) ICS,MSL left(cm) 2-3 Ⅱ 2-3 2-3 Ⅲ 3.5-4.5 3-4 Ⅳ 5-6 Ⅴ 7-9 Normally from midsternal line to MCL is about 8-10cm

  15. Physiologic changes in the area of cardiac dullness The position of the heart, and with it the area of cardiac dullness, is influenced by the level of the diaphragm.

  16. In deep inspiration the diaphragm descends, producing a decrease in cardiac dullness, while in forced expiration the diaphragm rises and produces an increase in the cardiac dullness.

  17. In the later months of pregnancy the diaphragm is pushed upward, causing the heart to lie more horizontally and closer to the chest wall, thus increasing the area of cardiac dullness.

  18. Cardiac dullness in abdominal distention A variety of pathologic conditions such as ascites, an ovarian cyst(卵巢囊肿), or peritonitis(腹膜炎) may cause an elevation of the diaphragm with an increase in the area of cardiac dullness.

  19. Changes in position of cardiac dullness A left-sided pleural effusion(胸腔积液) will push the heart to the right, and increase the cardiac dullness to the right of sternum, the left border in such cases can usually not be made out. A right-sided pleural effusion increase the cardiac dullness on left side.

  20. In pneumothorax the heart is displaced toward the normal side, but in massive collapse of the lung(肺萎缩) the heart is displaced toward the affected side.

  21. Pleural adhesions(胸膜粘连) may pull the heart to the affected side with resulting changes in cardiac dullness similar to those produced by collapse of the lung.

  22. Decrease in the area of cardiac dullness A decrease in the relative cardiac dullness may occur in pulmonary emphysema(肺气肿). The absolute cardiac dullness is usually decreased in such cases, since the lung is increased in size and covers a greater area of the heart than normal.

  23. Increase in the area of cardiac dullness An increase in the area of cardiac dullness is most strikingly seen in patients with cardiac disease. we cannot detect by percussion an appreciable increase of the cardiac dullness in hypertrophy of the heart unless there is an accompanying dilatation.

  24. Cardiac enlargement Enlargement of the left ventricle produces an increase in the relative cardiac dullness to the left and often downward on this side.

  25. The heart silhouette looks like a shoe

  26. Enlargement of the left ventricle appears in aortic insufficiency, in aortic stenosis, in mitral insufficiency, in longstanding hypertension and in chronic nephritis(慢性肾炎). It is called aortic heart(主动脉型心).

  27. Right ventricular enlargement, the cardiac dullness will extended to left and upward. If the right ventricular is severely enlarged, the right border of the heart will extend to the right. It is seen in cor pulmonale, in mitral stenosis, in tricuspid insufficiency etc.

  28. Both the left atrium and pulmonary artery enlarged, the pulmonary artery will be exaggerated to leftward. The cardiac silhouette is like a pear and called mitral heart(二尖瓣型心), it is frequently seen in mitral valve stenosis.

  29. The heart silhouette is like a pear

  30. Aortic dilation(主动脉扩张), aneurysm of aorta(主动脉瘤), pericardial effusion, all those diseases may cause the base border of heart enlargement, so that the base border of the heart will be widened.

  31. Congestive heart failure, severe myocarditis, Keshan disease(克山病), dilated myocardiopathy(扩张性心肌病) may cause the heart silhouette extending both to right and left(普大心).

  32. Pericardial effusion The cardiac dullness is increased in all directions and assumes the form of a triangle with the apex at the level of the first or second intercostal space or a general globular enlargement.

  33. The heart silhouette is like a flask

  34. The heart silhouette is like a globe

  35. Adhesive pericarditis The degree of enlargement depends on the extent of the adhesive process. The relative, and especially the absolute, cardiac dullness are both markedly increased to left and to the right.

  36. Increase in the absolute cardiac dullness Increase in the absolute cardiac dullness without demonstrable cardiac enlargement occurs when the left lung is retracted and a larger area of the ventricle is exposed.

  37. It also occurs in mediastinal tumors when the heart is pushed up against the chest wall and a large area of the ventricle comes into direct contact with the anterior surface of the chest.

  38. 复习 • 心界叩诊的顺序 • 正常心浊音界的组成 • 心脏浊音界改变及临床意义

  39. 重要名词 • 主动脉型心(靴形心) • 普大型心 • 二尖瓣型心(梨形心) • 烧瓶形心 • 球形心

  40. 单选题 心浊音界改变的论述,正确的是 A. 一侧大量胸水积液可使心界移向患侧 B. 一侧大量气胸可使心界移向患侧 C. 肺气肿时心界变大 D. 一侧肺不张可使心界移向患侧 E. 以上均不是

  41. 心脏叩诊浊音界向左下扩大、心腰加深，见于 A. 二尖瓣狭窄 B. 高血压性心脏病 C. 三尖瓣狭窄 D. 心肌病 E. 克山病

  42. 心脏叩诊左心房和肺动脉段增大,使心腰部饱满或膨出可见于心脏叩诊左心房和肺动脉段增大,使心腰部饱满或膨出可见于 A. 主动脉瓣关闭不全 B. 二尖瓣狭窄 C. 二尖瓣关闭不全 D. 心包积液 E. 房间隔缺损

  43. 心包积液的特征为 A. 心浊音界向左下增大 B. 心浊音界向右增大 C. 梨形心 D. 心界向两侧扩大,同时浊音界可随体位而改变 E. 以上均不是

  44. 标准配伍型题 A. 靴形心 B. 胸骨右缘第1,2肋间浊音界增宽 C. 普大型心 D. 梨形心 E. 三角形烧瓶样心 扩张性心肌病? 二尖瓣狭窄? 高血压性心脏病? 心包积液?

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