After the second sound is another interval of silence, the post-diastolic silence. If the period of an entire revolution of the heart from the beginning of one first sound to the beginning of the next first sound, be divided into ten equal parts, the duration of the several periods of sound and silence will be as follows: First Sound — 4; First Silence — i; Second Sound — 2; Second Silence — 3. Examination of the Heart. When we examine a patient's chest, to determine the condition of the heart, we must pay attention to the following things: The size of the Heart. The Impulse. The Rhythm of the heart's movements. The Heart Sounds. Abnormal Sounds or Murmurs.
<Callout type="important" title="Critical Assessment Points">When examining a patient’s chest for heart condition, focus on assessing the heart's size, impulse, rhythm, and sounds.</Callout>
I. To determine the size of the heart you must locate by percussion the upper border of the heart, its right border, and its left border at the level of the nipple, also the position of the apex beat. You mark each of these points, and then, by connecting the marks, you have an outline of the heart. The area of dulness over the heart is increased in size by effusions within the pericardium, by dilatation of the ventricles and auricles, and by hypertrophy of the ventricles.
The Impulse — The apex beat is situated in the fifth interspace, midway between the left edge of the sternum and the line of the nipple. It can usually be felt by the hand, but in many healthy persons does not communicate any perceptible shock to the chest-wall. Its position must then be determined by the stethoscope.
The Rhythm — The heart normally contracts and dilates alternately in a perfectly regular way. The first and second heart sounds and the first and second silences follow each other in regular sequence. In some healthy persons, however, there is a regular intermission of the ventricular systole. The same thing occurs in the tubercular meningitis of children.
The Heart Sounds have already been spoken of. 5. Abnormal Sounds or Murmurs. We distinguish — 1. Pericardial Murmurs. 2. Valvular Murmurs. 3. Ventricular Murmurs. 4. Blood Murmurs.
<Callout type="risk" title="Potential Risks">Pericarditis can cause fluid accumulation, lifting the heart and displacing lungs and diaphragm.</Callout>
I. Pericardial Murmurs are produced by the rubbing of the inflammatory products coating the visceral and parietal pericardium.
Key Takeaways
- Assess heart size, impulse, rhythm, and sounds for a comprehensive evaluation.
- Identify abnormal murmurs to diagnose conditions like pericarditis or valvular disease.
- Recognize the significance of changes in heart rhythm indicative of underlying issues.
Practical Tips
- Use percussion techniques to accurately outline the heart's borders.
- Listen carefully for variations in heart sounds and rhythms using a stethoscope.
- Be aware that some healthy individuals may not have a palpable apex beat.
Warnings & Risks
- Pericardial effusions can significantly alter heart size and position, affecting diagnosis.
- Irregular heart rhythms can indicate serious conditions such as valvular disease or myocarditis.
Modern Application
While the diagnostic methods described here are foundational, modern technology like echocardiography provides more accurate assessments. However, understanding these historical techniques is crucial for emergency situations where advanced equipment may not be available.
Frequently Asked Questions
Q: How do you determine the size of a patient's heart?
To assess the heart’s size, locate its upper border and both sides at the level of the nipple by percussion. Mark these points and connect them to outline the heart.
Q: What are some common causes for an enlarged area of dulness over the heart?
An increased area of dullness can be caused by effusions within the pericardium, dilatation of ventricles or auricles, and hypertrophy of the ventricles.
Q: What distinguishes pericardial murmurs from endocardial murmurs?
Pericardial murmurs are characterized by their rubbing quality, superficial nature, changeability in position and intensity, and greater loudness when the patient leans forward.