08-the Heart1 10_4_06
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1
An Overview of the Cardiovascular System
2
Figure 20.1
Anatomy of the Heart
3
Heart in mediastinum
4
Figure 20.2a, b
The Superficial Anatomy of the Heart
5
Figure 20.3a
The Superficial Anatomy of the Heart
6
Figure 20.3b, c
Internal Anatomy • Chambers :Atria and ventricles • Septum : Inter atrial and inter ventricular • Valves : Av and SL valves • Chordae tendineae • Papillary muscle and trabeculae carneae
7
The Sectional Anatomy of the Heart
8
Figure 20.6c
Heart Chambers • Atria – right and left – less muscular
• Ventricles – right and left – more muscular
9
Heart Chambers • Septum – interatrial – intraventricular – both: connective tissue and muscle
10
The Sectional Anatomy of the Heart
11
Figure 20.6c
12
Cardiovascular Anatomy – Blood Flow • From the Body – Right Atrium
• To the Lungs – Right Ventricle
• From the Lungs – Left Atrium
• To the Body – Left Ventricle 13
Blood flow through Heart
Animation: Diagrammatic Frontal Section through the Heart
14
Figure 20.6a, b
Basic Heart Examination Inspection Palpation Perdussion Auscultation 15
Inspection of the Heart • Precordium 心前区外形 • Normal apical impulse 正常心尖搏动 • Abnormal apical impulse 异常心尖搏动 • Precordial abnormal impulse 心前区异常搏动
16
Precordium - Inspection • Scars – Median sternotomy • CABG • Valve replacement
– Lateral thoracotomy – Infraclavicular (pacemaker)
• Pectus excavatum • Pacemaker box
Sternotomy scar
Pectus excavatum
• Apex beat 17
Precordium • Precordial bulge – Features: bony bulge 骨骼突起 – Clinical importance: Congenital heart disease with ventricular enlargement
18
Normal Apical Impulse • Location ： 0.5 ~ 1 cm to the left midclavicular line at the 5th ICS outside LSB. • Range:2~2.5cm • Direction: outward when ventricular systole begins 19
Abnormal Apical Impulse • Abnormal location – Physical: posture, pregnancy, etc. – Heart diseases • L.V enlargement: inferior left • R.V enlargement: left • B.V enlargement: inferior left
– Chest and abdominal diseases 20
Abnormal Apical Impulse • Abnormal range or intensity – Increased intensity: LV hypertrophy, hyperthyroidism, fever, anemia, etc. – Decreased—myocardial diseases, pericardial effusion, pleural effusion of left thorax or left-side pneumothorax, emphysema.
• Abnormal direction – Inward impulse—adhesive pericarditis.
21
Precordial Abnormal Impulse • 2nd ICS, LSB——Pulmonary hypertension, youth • 2nd ICS, RSB——Aneurysm of ascending aorta 升主 动脉瘤 • 3rd, 4th ICS, LSB—R.V hypertrophy • xiphoid process——R.V hypertrophy, abdominal aneurysm 腹主动脉瘤
22
Palpation • Contents – Apical impulse 心尖搏动 – Thrill 震颤 – Pericardial friction rub 心包摩擦感
23
Precordium - Palpation •
Apex beat – Location – Character • • • • •
Heaving Thrusting Double Tapping Paradoxical
•
Left parasternal heave
•
Thrills (palpable murmurs) – Systolic – Diastolic
•
Palpable P2 (pulmonary hypertension)
•
Pacemaker box
24
Apical Impulse Clinical significance: signifying the start of the systolic phase Location and range: same as in inspection Increased (heave): Cause ： left ventricular pressure overload and consequent hypertrophy Character ： forceful and sustained Clinical significance ： left ventricular hypertrophy 25
Decreased – Causes: decreased contractibility of the myocardium – Clinical
significance:
heart
failure,
pericardial effusion, myocarditis
26
Pericardial Friction Fremitus – Mechanism: inflammation or irritation of the pericardium 心包表面粗糙 – Typical site: 4th ICS, LSB – Features: It is best palpated with the person sitting up and leaning forward, and with the breath held in expiration – Clinical significance: pericarditis 心包炎
27
Thrill – Mechanism: formation of bloodflow vortices caused by valve stenosis or abnormal pathway. – Types: systole, diastole, continuous – Clinical significance: reliable signs of organic heart diseases
28
Thrill in Systole • 2nd ICS, LSB: Pulmonic stenosis • 2nd ICS, RSB: Aortic stenosis • 3rd, 4th ICS, LSB: Interventricular septal defect
29
Thrill in Diastole – Apex: mitral stenosis
Continuous thrill – 2nd ICS, arteriosus
LSB—
Patent
ductus
30
Percussion of the Heart Border • Technique – Force: light percussion for the relative dullness border of the heart – Position • Supine • Sitting
– Steps • From left to right, lower to upper, outward to inward • Left border: 2~3cm from the apical impulse • Right border: ICS next to the upper border of the liver • Measure: the distance from dullness border to anterior midline
31
Normal Relative Dullness Border of the Heart Distance between dullness border and anterior midline
Right (cm)
ICS
Left (cm)
2-3
Ⅱ
2-3
2-3
Ⅲ
3.5-4.5
3-4
Ⅳ
5-6
Ⅴ
7-9
(the distance between left midclavicular line and anterior midline is 9 cm)
32
Abnormal Dullness Heart Border • Boot-shaped heart: L.V enlargement • Pear-shaped heart: L.A enlargement • General enlarged heart: B.V enlargement • Flask-shaped heart: pericardial effusion • “Shrinked” dullness border: emphysema • Dullness border undetectable: pleural effusion or lung consolidation 33
Boot-shaped Heart – Mechanism: L.V enlargement – Features: the left border extends to the inferior left, waist of the heart is deepened. – Causes: • Aortic insufficiency • hypertensive heart disease 34
35
Pear-shaped Heart • Mechanism: L.A enlargement and distension of pulmonary artery • Features: dullness heart border in the 2nd , 3rd ICS on the LSB extends outside, waist of the heart bulges out • Causes: mitral stenosis 二尖瓣狭窄 36
37
General Enlarged Heart both left • Mechanism: ventricle are enlarged
and
right
• Features: the dullness border extends to both sides, the left border extends to inferior left • Causes: cardiomyopathy, whole heart failure
myocarditis,
38
Flask-shaped Heart • Mechanism: pericardial effusion • Features: – Sitting border
position:
triangular
dullness
– Supine: widened dullness border of the base 39
Auscultation of the heart
Areas for auscultation and sequence to auscultate 40
Content of Heart Auscultation • Heart rate: 60~100/min normally • Rhythm: regular or sinus arrhythmia • Heart sounds: normal, abnormal, • Heart murmurs • Pericardial friction rub 41
Next time
• Aulscultation 42
43
An Overview of the Cardiovascular System
2
Figure 20.1
Anatomy of the Heart
3
Heart in mediastinum
4
Figure 20.2a, b
The Superficial Anatomy of the Heart
5
Figure 20.3a
The Superficial Anatomy of the Heart
6
Figure 20.3b, c
Internal Anatomy • Chambers :Atria and ventricles • Septum : Inter atrial and inter ventricular • Valves : Av and SL valves • Chordae tendineae • Papillary muscle and trabeculae carneae
7
The Sectional Anatomy of the Heart
8
Figure 20.6c
Heart Chambers • Atria – right and left – less muscular
• Ventricles – right and left – more muscular
9
Heart Chambers • Septum – interatrial – intraventricular – both: connective tissue and muscle
10
The Sectional Anatomy of the Heart
11
Figure 20.6c
12
Cardiovascular Anatomy – Blood Flow • From the Body – Right Atrium
• To the Lungs – Right Ventricle
• From the Lungs – Left Atrium
• To the Body – Left Ventricle 13
Blood flow through Heart
Animation: Diagrammatic Frontal Section through the Heart
14
Figure 20.6a, b
Basic Heart Examination Inspection Palpation Perdussion Auscultation 15
Inspection of the Heart • Precordium 心前区外形 • Normal apical impulse 正常心尖搏动 • Abnormal apical impulse 异常心尖搏动 • Precordial abnormal impulse 心前区异常搏动
16
Precordium - Inspection • Scars – Median sternotomy • CABG • Valve replacement
– Lateral thoracotomy – Infraclavicular (pacemaker)
• Pectus excavatum • Pacemaker box
Sternotomy scar
Pectus excavatum
• Apex beat 17
Precordium • Precordial bulge – Features: bony bulge 骨骼突起 – Clinical importance: Congenital heart disease with ventricular enlargement
18
Normal Apical Impulse • Location ： 0.5 ~ 1 cm to the left midclavicular line at the 5th ICS outside LSB. • Range:2~2.5cm • Direction: outward when ventricular systole begins 19
Abnormal Apical Impulse • Abnormal location – Physical: posture, pregnancy, etc. – Heart diseases • L.V enlargement: inferior left • R.V enlargement: left • B.V enlargement: inferior left
– Chest and abdominal diseases 20
Abnormal Apical Impulse • Abnormal range or intensity – Increased intensity: LV hypertrophy, hyperthyroidism, fever, anemia, etc. – Decreased—myocardial diseases, pericardial effusion, pleural effusion of left thorax or left-side pneumothorax, emphysema.
• Abnormal direction – Inward impulse—adhesive pericarditis.
21
Precordial Abnormal Impulse • 2nd ICS, LSB——Pulmonary hypertension, youth • 2nd ICS, RSB——Aneurysm of ascending aorta 升主 动脉瘤 • 3rd, 4th ICS, LSB—R.V hypertrophy • xiphoid process——R.V hypertrophy, abdominal aneurysm 腹主动脉瘤
22
Palpation • Contents – Apical impulse 心尖搏动 – Thrill 震颤 – Pericardial friction rub 心包摩擦感
23
Precordium - Palpation •
Apex beat – Location – Character • • • • •
Heaving Thrusting Double Tapping Paradoxical
•
Left parasternal heave
•
Thrills (palpable murmurs) – Systolic – Diastolic
•
Palpable P2 (pulmonary hypertension)
•
Pacemaker box
24
Apical Impulse Clinical significance: signifying the start of the systolic phase Location and range: same as in inspection Increased (heave): Cause ： left ventricular pressure overload and consequent hypertrophy Character ： forceful and sustained Clinical significance ： left ventricular hypertrophy 25
Decreased – Causes: decreased contractibility of the myocardium – Clinical
significance:
heart
failure,
pericardial effusion, myocarditis
26
Pericardial Friction Fremitus – Mechanism: inflammation or irritation of the pericardium 心包表面粗糙 – Typical site: 4th ICS, LSB – Features: It is best palpated with the person sitting up and leaning forward, and with the breath held in expiration – Clinical significance: pericarditis 心包炎
27
Thrill – Mechanism: formation of bloodflow vortices caused by valve stenosis or abnormal pathway. – Types: systole, diastole, continuous – Clinical significance: reliable signs of organic heart diseases
28
Thrill in Systole • 2nd ICS, LSB: Pulmonic stenosis • 2nd ICS, RSB: Aortic stenosis • 3rd, 4th ICS, LSB: Interventricular septal defect
29
Thrill in Diastole – Apex: mitral stenosis
Continuous thrill – 2nd ICS, arteriosus
LSB—
Patent
ductus
30
Percussion of the Heart Border • Technique – Force: light percussion for the relative dullness border of the heart – Position • Supine • Sitting
– Steps • From left to right, lower to upper, outward to inward • Left border: 2~3cm from the apical impulse • Right border: ICS next to the upper border of the liver • Measure: the distance from dullness border to anterior midline
31
Normal Relative Dullness Border of the Heart Distance between dullness border and anterior midline
Right (cm)
ICS
Left (cm)
2-3
Ⅱ
2-3
2-3
Ⅲ
3.5-4.5
3-4
Ⅳ
5-6
Ⅴ
7-9
(the distance between left midclavicular line and anterior midline is 9 cm)
32
Abnormal Dullness Heart Border • Boot-shaped heart: L.V enlargement • Pear-shaped heart: L.A enlargement • General enlarged heart: B.V enlargement • Flask-shaped heart: pericardial effusion • “Shrinked” dullness border: emphysema • Dullness border undetectable: pleural effusion or lung consolidation 33
Boot-shaped Heart – Mechanism: L.V enlargement – Features: the left border extends to the inferior left, waist of the heart is deepened. – Causes: • Aortic insufficiency • hypertensive heart disease 34
35
Pear-shaped Heart • Mechanism: L.A enlargement and distension of pulmonary artery • Features: dullness heart border in the 2nd , 3rd ICS on the LSB extends outside, waist of the heart bulges out • Causes: mitral stenosis 二尖瓣狭窄 36
37
General Enlarged Heart both left • Mechanism: ventricle are enlarged
and
right
• Features: the dullness border extends to both sides, the left border extends to inferior left • Causes: cardiomyopathy, whole heart failure
myocarditis,
38
Flask-shaped Heart • Mechanism: pericardial effusion • Features: – Sitting border
position:
triangular
dullness
– Supine: widened dullness border of the base 39
Auscultation of the heart
Areas for auscultation and sequence to auscultate 40
Content of Heart Auscultation • Heart rate: 60~100/min normally • Rhythm: regular or sinus arrhythmia • Heart sounds: normal, abnormal, • Heart murmurs • Pericardial friction rub 41
Next time
• Aulscultation 42
43
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