Inspection and Palpation of

the heart
Surface anatomy of the heart
 Surface anatomy
The position of the heart in the mediastinum
can be projected onto the overlying
skeleton
The heart is enclosed by a rectangle with
angles at left 5th intercostal space in
midclavicular line;2nd left costal cartilage;3rd
right
costal cartilage and 6th right costal
cartilage
 Surface anatomy
• Right ventricle occupies most of the anterior
cardiac surface behind and to the left of the
sternum
• Left ventricle lies to the left and behind the right
ventricle.it makes only a small portion of the
anterior cardiac surface
• But it forms the border of the heart and produces
the apical impulse in 5th left intercostal space 7-9
cm from the mid sternal line
 Surface Anatomy
• The right border of the heart is formed by
the right atrium;a chamber not usually
identifiable on physical examination
• The left atrium is most posterior and
cannot be examined directly
• But its small atrial appendage may make
up a segment of the left cardiac border
between the pulmonary artery and the left
ventricle
 AUSCULTATORY AREAS
• They do not correspond with the surface
markings of the heart valves ,but are
areas where transmitted sounds and
murmurs are best heard
• Mitral valve:Apex (left 5th intercostal space)
• Tricuspid valve :Tricuspid area (lower left
sternal border )
 AUSCULTATORY AREAS
• Aortic valve :Aortic area (2nd right
intercostal space )
• Pulmonary valve:Pulmonary area (2nd left
intercostal space )
 INSPECTION AND PALPATION
• Patient position
– Supine, head elevated 30 degree
• From patient right side examine chest wall paying attention
to 5 areas
– Apex
– Epigastrium
– Left sternal border (right ventricular areas)
– Left 2nd intercostal space
– Right 2nd intercostal space
 Inspection and palpation
• Look for
• Chest deformity
• Surgical scars
• Apex beat
• Visible pulsations
 CHEST DEFORMITIES
• Precordial bulge
• Pectus excavatum :posterior displacement
of the lower sternum
• Pectus carinatum :Pigeon chest

– Chest deformities may displace the heart

 APEX BEAT
• SITE
• DIAMETER
• AMPLITUDE
• DURATION
• THRILL
• S3 AND S4
 SITE
• Feel with patient supine and in left lateral
decubitus
• Lay whole hand flat over precordium
:general impression
• Lay fingers on chest parallel to rib space
to locate the apex
 APEX
• The cardiac impulse results the heart
rotating ,moving forwards and striking
against the chest wall during systole
• Normal apex :5th left intercostal space
medial to the mid clavicular line
– Count the ribs from the sternal angle
– Midclavicular line is half way between the
suprasternal notch and the acromioclavicular
joint
 APEX
• The apex is the most lateral and inferior
position where the cardiac impulse can be
felt
• The normal apex briefly lifts the palpating
fingers and is localised
 SITE OF THE APEX
• DISPLACEMENT OF THE APEX
• A- Conditions outside the heart
Fibrosis and collapse of the lung PULL the heart towards the
lesion
Pleural effusion and pneumothorax PUSH the heart away from
the lesion
Abdominal distention (ascites,pregnancy) can displace the apex
upwards and to the left
 DISPLACEMENT OF THE HEART
• B-Cardiac enlargement
–IN LVH : Apex is displaced down
and out
–IN RVH: Apex is displaced outwards
 SITE OF APEX
• INVISIBLE APEX
• Obesity
• Thick west wall
• Emphysema
• Pericardial effusion
• Weak dilated heart
 DIAMETER OF APEX
• Normal :2.5cm with patient supine
3 cm in left lateral position

Increased diameter in left ventricular

enlargement
 AMPLITUDE AND DURATION

• The amplitude is increased with cardiac overload

• In pressure overload as in Aortic stenosis and
Hypertension :Duration is also increased
:SUSTAINED or HEAVING apex
• In volume over load as in Mitral regurge or Aortic
regurge :Duration is not increased
:HYERKINETIC apex
• Tapping apex in Mitral stenosis represents a
palpable 1st heart sound
 THRILL
• Palpable murmur like placing the hand on
a purring cat
• Systolic thrill of Aortic stenosis on the
base
• Diastolic thrill of Mitral stenosis on apex
• Systolic thrill of ventricular septal defect on
left sternal border
 PRECORDIAL PULSATION
1-At left STERNAL BORDER in 3rd ,4th, 5th
interspaces ( RIGHT VENTRICULAR AREA)
With patient supine place tips of curved fingers
in 3rd 4th and 5th spaces and try to feel the
systolic impulse of the right ventricle
Ask the patient breath out then briefly stop
breathing to improve observation
If an impulse is palpable assess location
,amplitude and duration
 LEFT PARASTERNAL
PULSATION
• Brief systolic tap of low or slightly
increased amplitude in thin individuals
• Increased amplitude with no change in
duration in right ventricular volume
overload as in ASD
• Increased amplitude with increased
duration in right ventricle pressure
overload as in Pulmonary stenosis
,Pulmonary hypertension
 EPIGASTRIC PULSATION
• RIGHT VENTRICULAR
• With hand flattened press index finger
under the rib cage upwards to the left
shoulder

• PULSATIONS OF ABDOMINAL AORTA

• LIVER PULSATION
PULSATIONS IN LEFT 2ND SPACE
• It overlies the pulmonary artery
• Feel during held expiration
• Prominent pulsation :dilated pulmonary
artery
• In thin individual pulmonary artery
pulsations may be seen
• Palpable 2nd sound in pulmonary
hypertension
PULSATION IN RIGHT 2ND SPACE
• Prominent pulsations :dilated or
aneurysmal aorta
 PULSATIONS TO RIGHT OF
STERNUM
• Aortic aneurysm
• Enlarged right atrium
 SUPRASTERNAL PULSATIONS
• Hyperkinetic states
• High aortic arch or aortic arch aneurysm
• Aortic regurge
• Coarcatation of aorta
• Kinking of carotids due to atherosclerosis