Chapter V Thorax
D. Heart and blood vessels
by Dr. Zhuo-ren Lu
l Observe protrusion of precordium and
apical impulses with tangential lighting.
Check other pulsation in the anterior chest.
l The normal impulse is located generally
in the fifth intercostal space, 0.51cm
within the midclavicular line.
l An abnormal position of impulse generally indicates
cardiac enlargement, but the causes of cardiac
displacement such as scoliosis, funnel sternum, pleural
effusion and pulmonary fibrosis, a big mass in
abdominal cavity should be eliminated.
l Left ventricular hypertrophy results in downward
(6th space) and outward displacement of the apex beat.
Right ventricular hypertrophy causes strong pulsation
under the xiphoid or/and a change of apex beat in
position towards left (5th space).
l A feeble diffuse impulse ( more than 22.5cm in
diameter) may suggest dilation. If the thrust is forcible,
hypertrophy is suggested.
1. The hand should then be placed on the all areas of
the precordium in order to detect any abnormal
pulsation, vibrations or thrill, and pericardium
2. The pulsation of the abdominal aorta may often
be felt in the epigastric area. Also, the impulse
from right ventricle can be felt by the fingertips
placed under the xiphoid process while inspiration.
A thrill is a palpable murmur from the heart or
great vessels. The main reason is the obstruction to
blood flow through a narrowed valve or the certain
abnormal congenital defects. Thrills may be
systolic, diastolic or may occur continuous in time.
l In aortic stenosis and aneurysm of the great
vessels at the root of the neck, a powerful systolic
thrill may be palpable over the 2nd interspace,
usually spreading upwards to the neck.
l To the left of the sternum in the 2nd interspace,
pulmonary stenosis gives rise to a similar systolic
l In the left 3rd or 4th parasternal area,
systolic thrills are due to congenital lesions of
the interventricular septum of heart.
l Diastolic thrills at the apex are usually due to
l The combination of a systolic and diastolic
thrill occurs over the base of the heart in
patients with patent ductus arteriosus.
l Timing a thril is best accomplished by either
the apex beat or the carotid artery palpation,
both of which correspond to ventricular systole.
4. Pericardial friction rub
Pericardial friction rub is caused by a fibrinous
l It is present during both phases of the cardiac
cycle. In the presence of pericardial effusion the
rub will disappear because of the separation of
the visceral and parietal layers by the fluid.
lOften rubs are more readily palpated with
sitting erect and leaning forward.
l They are best palpated in the left 3rd and 4th
intercostal spaces at the sternal border.
l Percussion of cardiac dullness border starts to
the left on the chest, from 23cm apart from the
apical impulse towards cardiac dullness (relative
cardiac dullness). Percussion is performed from
left towards cardiac dullness in the 4th, 3rd and
2nd intercostal spaces. Next, to the right of the
chest, percussion is done in the midclavicular line
down to a dull point (the upper margin of liver).
Then, percuss from right towards cardiac dullness
in the 4th (above the liver dullness), 3rd, and 2nd
l Measure the vertical distances from each point of
cardiac dullness to the mid-sternal line with a stiff
l When the left border of cardiac dullness falls
outside the midclavicular line, it usually indicates
that the left ventricle is enlarged.
l If the left border of cardiac dullness goes out of
left midclavicular line (the left cardiac border
towards left in the 5th intercostal space), it suggests
that the right ventricle enlarged.
l The cardiac dullness enlarged towards two sides:
(1)both left and right ventricles enlarged, (2) a large
volume of fluid in the cavity of pericardium. In this
case, the cardiac borders will be changed following
the change of the patient's position.