PalpationPalpationPalpationPalpation

Usually inspection and palpation are Usually inspection and palpation are discussed together because there is an discussed together because there is an intimate relationship between these intimate relationship between these two processes in the heart examination. two processes in the heart examination. Palpation not only confirms the results Palpation not only confirms the results in inspection, but also discovers in inspection, but also discovers diagnostic signs. diagnostic signs.

Through careful palpation, the examineThrough careful palpation, the examiner should aim to determine the location r should aim to determine the location and size of the cardiac apex impulse, cand size of the cardiac apex impulse, characterize its contour, and identify anharacterize its contour, and identify any abnormal precordial pulsations. y abnormal precordial pulsations.

The various disturbances in rate(The various disturbances in rate( 心率心率 ) ) and rhythm(and rhythm(心律心律 ) which have been o) which have been observed can be confirmed by palpatibserved can be confirmed by palpation.on.

Palpation gives us a better impression Palpation gives us a better impression of the force of the heart beat than does of the force of the heart beat than does inspection.inspection.

The palm of the hand, ventral surface The palm of the hand, ventral surface of the proximal metacarpals, and of the proximal metacarpals, and fingers should all be used for palpation fingers should all be used for palpation because each is useful for optimal because each is useful for optimal appreciation of certain movements. appreciation of certain movements.

Thrill examination by palm Thrill examination by palm

Apical impulse examination by fingerApical impulse examination by finger

Apical impulse(心尖搏动 )Apical impulse(心尖搏动 )

location durationlocation duration

amplitude intensityamplitude intensity

frequency regularityfrequency regularity

Sustained sensation(Sustained sensation( 抬举性搏动抬举性搏动 ): ): LVH Forceful, sustained, thr LVH Forceful, sustained, through ough

systole with great amplitude more systole with great amplitude more

than 2cm diameter than 2cm diameter

Precordial lift or heavy: RVHPrecordial lift or heavy: RVH

Decrease amplitude: myocarditisDecrease amplitude: myocarditis

Massive pericardial effusion: impulse caMassive pericardial effusion: impulse cannot be palpablennot be palpable

ThrillThrill

Thrill are palpable murmurs some what simiThrill are palpable murmurs some what similar to the sensation on the throat a purring clar to the sensation on the throat a purring cat. Thrills are actually palpable fine vibratioat. Thrills are actually palpable fine vibrations, most commonly produced by blood frons, most commonly produced by blood from one chamber of the heart to another throum one chamber of the heart to another through a restricted or narrowed orifice, it may ogh a restricted or narrowed orifice, it may occur in systole, diastole, presystole and at ticcur in systole, diastole, presystole and at times may be continuous. mes may be continuous.

Any thrill should be described as to its lAny thrill should be described as to its location, its time in cardiac cycle, and itocation, its time in cardiac cycle, and its mode of extension or transmission. s mode of extension or transmission.

The intensity of the thrill varies The intensity of the thrill varies according to the velocity of the blood, according to the velocity of the blood, the degree of narrowing of the orifice the degree of narrowing of the orifice and which it is produced and difference and which it is produced and difference in pressure between the two chambers in pressure between the two chambers of the heart.of the heart.

Quality of a thrill depends on the Quality of a thrill depends on the frequency of vibration producing it, frequency of vibration producing it, rapid vibrations result in fine thrills rapid vibrations result in fine thrills whereas slower vibrations produce whereas slower vibrations produce coarser thrill. coarser thrill.

Restricted or narrowed orifice Restricted or narrowed orifice thrillthrill

according blood velocityaccording blood velocity

Intensity degree of narrowingIntensity degree of narrowing

to gradient between to gradient between

two chamberstwo chambers

dependsdepends

quality frequencyquality frequency

onon

frequency:frequency:

rapid fine thrillrapid fine thrill

slow coarser thrillslow coarser thrill

Diastolic thrillDiastolic thrill

The diastolic thrill felt near the apex is The diastolic thrill felt near the apex is pathognomic of mitral stenosis(pathognomic of mitral stenosis( 二狭二狭 ). ). It may be compared quit accurately to tIt may be compared quit accurately to the vibration which accompanies the sohe vibration which accompanies the sound of satisfaction which a cat makes.und of satisfaction which a cat makes.

It is usually felt only over a small area It is usually felt only over a small area at or near the point of maximum at or near the point of maximum impulse. It may not be felt when the impulse. It may not be felt when the patient is lying quietly in bed,patient is lying quietly in bed,

but may be brought out by moving the but may be brought out by moving the patient up and down rather rapidly a patient up and down rather rapidly a few times and thus producing more few times and thus producing more active cardiac contractions, and also by active cardiac contractions, and also by turning the patient on his left side.turning the patient on his left side.

Systolic thrill Systolic thrill

A systolic thrill may be felt over the prA systolic thrill may be felt over the precordium with its maximum intensity aecordium with its maximum intensity at the aortic area in aortic stenosis(t the aortic area in aortic stenosis( 主狭主狭). This thrill is usually rough and purrin). This thrill is usually rough and purring, and commonly of greater intensity thg, and commonly of greater intensity than any other thrill felt over the heart.an any other thrill felt over the heart.

This systolic thrill of aortic stenosis is fThis systolic thrill of aortic stenosis is felt in the carotid(elt in the carotid( 颈动脉颈动脉 ) and brachial ) and brachial ((臂动脉臂动脉 ) arteries and its transmitted i) arteries and its transmitted in the direction of the blood flow.n the direction of the blood flow.

Systolic thrillSystolic thrill

In pulmonary stenosis(In pulmonary stenosis( 肺动脉瓣狭窄肺动脉瓣狭窄) a rough systolic thrill is felt over t) a rough systolic thrill is felt over the pulmonary area and from here is tranhe pulmonary area and from here is transmitted upward and diagonally toward tsmitted upward and diagonally toward the left clavicle.he left clavicle.

Systolic thrillSystolic thrill

In aneurysm of the ascending aorta(In aneurysm of the ascending aorta( 升升主动脉瘤主动脉瘤 ), which produces a definite ), which produces a definite area of pulsation, a systolic thrill may barea of pulsation, a systolic thrill may be felt over this area.e felt over this area.

duration location diseaseduration location disease

systole second right ICS ASsystole second right ICS AS

second left ICS PSsecond left ICS PS

third fourth left ICS VSDthird fourth left ICS VSD

diastole apical area MSdiastole apical area MS

continuous 2nd left ICS PDAcontinuous 2nd left ICS PDA

Pericardial friction rubPericardial friction rub

Pericardial friction rub(Pericardial friction rub( 心包摩擦感心包摩擦感 ) i) is a to-and-fro grating sensation, which s a to-and-fro grating sensation, which is usually present during both phases of is usually present during both phases of cardiac cycle, often rubs are more readicardiac cycle, often rubs are more readily palpated with the patient sitting erect ly palpated with the patient sitting erect and leaning forward during the end perand leaning forward during the end period of deep inspiration. iod of deep inspiration.

The rub is caused by a fibrinous pericarThe rub is caused by a fibrinous pericarditis(ditis( 纤维素性心包炎纤维素性心包炎 ). In the presen). In the presence of pericardial effusion the rub will uce of pericardial effusion the rub will usually disappear because of the separatisually disappear because of the separation of visceral and parietal layers by the on of visceral and parietal layers by the accumulated fluid. accumulated fluid.

ReviewReview

Method of palpationMethod of palpationPrecordial pulsantion: LVH, RVH, myPrecordial pulsantion: LVH, RVH, my

ocarditis, massive pericardial effusionocarditis, massive pericardial effusionMechanism of thrillMechanism of thrillClinical significance of precordial thrill Clinical significance of precordial thrill

单选题单选题

震颤的论述震颤的论述 ,, 错误的是错误的是A. A. 在心尖区触及收缩期震颤可见于二狭在心尖区触及收缩期震颤可见于二狭B. B. 临床上凡触及震颤均可认为心脏有器质临床上凡触及震颤均可认为心脏有器质性病变性病变

C. C. 触诊有震颤的部位多数可听到杂音触诊有震颤的部位多数可听到杂音D. D. 在胸骨右缘第在胸骨右缘第 22 肋间触及收缩期震颤可肋间触及收缩期震颤可见于主狭见于主狭

E. E. 在胸骨左缘第在胸骨左缘第 22 肋间触及收缩期震颤可肋间触及收缩期震颤可见于肺动脉瓣狭窄见于肺动脉瓣狭窄

心包摩擦感的论述心包摩擦感的论述 ,,错误的是错误的是A.A.为心脏收缩时脏层与壁层心包相互摩擦而为心脏收缩时脏层与壁层心包相互摩擦而产生产生

B. B. 随渗液的增多随渗液的增多 ,,心包脏层与壁层分离时摩心包脏层与壁层分离时摩擦感消失擦感消失

C. C. 多在心前区或胸骨左缘第多在心前区或胸骨左缘第 33、、 44肋间触及肋间触及D. D. 以收缩期、前倾体位更为明显以收缩期、前倾体位更为明显E. E. 以吸气末更为清楚以吸气末更为清楚

标准配伍型题标准配伍型题

A. A. 胸骨左缘第二肋间收缩期震颤胸骨左缘第二肋间收缩期震颤B. B. 胸骨左缘胸骨左缘 3~43~4 肋间收缩期震颤肋间收缩期震颤C. C. 胸骨左缘第二肋间连续性震颤胸骨左缘第二肋间连续性震颤D. D. 心尖区舒张期震颤心尖区舒张期震颤E. E. 胸骨右缘第二肋间收缩期震颤胸骨右缘第二肋间收缩期震颤主动脉瓣狭窄主动脉瓣狭窄 ? ? 肺动脉瓣狭窄肺动脉瓣狭窄 ??

动脉导管未闭动脉导管未闭 ? ? 二尖瓣狭窄二尖瓣狭窄 ??