have found them of great service in diagnosis. Cardiac Murmurs, Aortic Obstructive Systolic. <Callout type="important" title="Important">When heard behind, it is most distinct at left of third and fourth vertebrae, close to their spines.</Callout> When not heard in this place, but in 'left axilla and in the region of the left scapula,' regurgitation is not indicated; or, in other words, it is a non-regurgitant murmur. <Callout type="warning" title="Warning">An aneurismal murmur may be heard within the said limits but follows the aorta downwards, gradually decreasing in intensity.</Callout> LESSON XII. Synopsis of the Physical Signs of Pericarditis. —Hypertrophy, dilatation, and Fatty Degeneration of Heart, and Cineisms of Thoracic Aorta. <Callout type="tip" title="Tip">Inspect for a prominence or arching forward of the precordial region in pericarditis.</Callout> Synopsis of the Physical Signs of Hypertrophy of the Heart. The physical signs of hypertrophy of the heart vary with the seat and amount of the hypertrophy. When the hyper- trophy is general, inspection shows the action of the heart to be regular; the extent of the visible impulse to be increased; the apex beat lower, and more to the left than natural; and in children there is a visible prominence of the precordial region. Palpation, — The area greatly exceeds that within which the normal apex beat is felt, and the impulse has a heaving, lifting character, sometimes felt three inches below, and three or four to the left of its normal position. Percussion. — The area of both the superficial and deep- seated didness increases laterally and downwards. If the hyper- trophy is confined to the left ventricle, the area of the dulness on percussion may extend considerably beyond the left nipple ; if, on the other hand, the hypertrophy is confined to the right ventricle, the area of dulness may extend consider- ably to the right of the sternum ; if the hypertrophy is general, the area of dulness will be increased both to the right and left. Auscultation. — The first sound is dull, muffled, and pro- longed, and in some cases greatly increased in intensity. The second sound is also increased in intensity, and more diffused than in health, and there is a diminution or an entire absence of the respiratory murmur over the normal precordial region. In Hypertrophy of the Heart with extensive Dilatation, the action of the heart is still regular, but the extent of the visible impulse is greatly increased, extending sometimes from the third intercostal space to the epigastrium. The apex beat may be felt as low as the ninth rib, and to the left of the nipple, and is of a pecuhar heaving character, so as sometimes to shake the bed of the patient. The area of dulness may extend vertically from the third to the eighth rib ; and laterally two inches or more to the left of the left nipple. Both sounds of the heart are loud and pro- longed, and are often audible over the whole chest, even to the right of the spine. Dilatation of the Heart -without Hypertrophy of its Walls. — Inspection and palpation disclose indistinctness, or entire absence of the cardiac impulse, and an irregular and often intermittent action of the heart. Percussion shows an increase in the area of precordial dulness downwards and laterally. Auscultation shows the first sound to be unnaturally short, abrupt, and feeble ; while the second sound is often inaudible at its apex ; the two sounds appear to be of equal duration. Fatty Dsgeneration of the Heart. — The physical signs of fatty degeneration of the heart are nearly identical with those of dilatation without hypertrophy of the walls. The area of precordial dulness is normal ; tlie impulse weak or impercep- tible ; the apex beat indistinct, and often invisible. The action of the heart is irregular ; the first sound is short and feeble, and sometimes inaudible ; the second sound prolonged and intensified. Aneuinsms of tJie Tlioracic Aorta. The thoracic aorta is affected by aneurism with varying de- grees of frequency in the different parts of its course. According to Sibson, who has collected the statistics of 703 cases, 87 were at the commencement of the aorta in the sinuses of valsalva ; 193 at the ascending arch, extra pericardial ; 14 at the ascending and transverse arch ; 12 at the transverse arch ; 72 at the descending arch ; and 71 at the descending aorta. The physical methods employed in ascertaining the exist- ence of aneurisms are impection, palpation, permssion, and ans- cultaiion. Inspection. — If the aneurism presses on the superior vena cava, you will observe the face, neck, and upper extremities to be swoUen, hvid, and occasionally oedematous ; while the veins of these parts are turgid and varicose. But if the pres- sure is only on the innominata veins, these effects will be ob- served only on the corresponding side. In some instances, there is, as it were, a thick fleshy collar surrounding the lower part of the neck, due to cajoillary turgescence. As you inspect the chest, a more or less exten- sive bulging may be observed at some point along the course of the aorta. The bulging may in some cases attain the size of a cocoa-nut, wliile in others it may be perceptible only on close examination. The non-existence of a tumor does not, however, prove that there is no aneurism, for if the aneuris- mal enlargement springs from the posterior wall of the arch, or from the descending arch or descending aorta, parts which are deeply seated, there may be no visible anterior bulging. <Callout type="risk" title="Risk">Aneurisms can cause sudden and severe complications, including rupture.</Callout> Palpation. — By the application of the hand, you can ap- preciate better the size of the tumor, the nature of its con- tents (whether mostly fluid or so solid), the condition of the walls as regards perforation of the sternum or ribs, and the char- acter of the pulsation, which is usually that of a blow equally diffused in all directions. Besides the systoHc impulse, a diastolic one sometimes occurs ; generally it is slight, some- times, however, it is quite forcible. In some cases you will obtain the impulse by pressing with one hand on the sternum, and the other on the back, when by ordinary palpation you would not detect it. Again, a thrill may be communicated to the hand, if the aneurism is at the upper portion of the arch ; by pressing the fingers down behind the sternum a distinct im- pulse will be felt. You may also ascertain whether there is a 114 PHYSICAL DIAGNOSIS. cessation or diminution of the expansive movement over tlie whole or part of one lung, and whether the vocal fremitus is lost over that side, and over the tumor. The non-expansion and loss of vocal fremitus over the lung is due generally to the pressure of the aneurism on the air passages, or on the lung itself. When the aneurism presses on the carotid arteries, or when they are obstructed by coagula, a difference between the pulse of these arteries and theu' bronchi on the two sides will be noticed. Percussion. — There will be dulness over the prominence, or over a circumscribed space, in the neighborhood of the course, of the aorta, not, however, corresponding to the size of the aneurism, unless more forcible percussion be made than is safe. The resistance is increased in proportion to the amount of the fibrin in the sac. "^^Tien the lung is condensed by in- flammation, or collapsed by obstruction of the bronchus, there will be a greater area of dulness. Auscultation. — Connected with an aneurism there are usually certain sounds or murmurs. In some cases neither are audible, owing either to the position of the aneurism, to the solidity of its contents, or to the nature of its orifice. These sounds resemble those of the heart, and are similarly called systohc and diastolic ; they may be either equal to, or weaker or louder than, those of the heart : the systolic may exist alone, either or both sounds may be replaced by a murmur ; for instance, there may be a systohc murmur only, or you may have both a systolic and a diastohc sound. The character of the murmur varies. It is usually short, abrupt, of low pitch, and as loud as or louder than the loudest heart murmur. It may be rasping, sawing, filing, etc. The dias- tohc murmur is rarer than the systohc, and is usually of a softer quahty. "Where the aneurism compresses a large bronchus, the respiratory murmur over the whole or a part of one side will be weak or suppressed ; on the opposite side it will be exaggerated. There is also loss of vocal resonance over the aneurism, and over the lung whose bronchus is ob- structed. Where the lung is condensed from pressure, the breathing will be bronchial ; where there is pressure over the trachea or bronchi, the breathing may be stridulous, and be rightly referred to a lower point of production than the larynx. Where there is irritation of the recurrent laryngeal nerve, this type of breathing may come from spasm of the glottis. Differential Diagnosis.— You will find that the principal difficulties in diagnosis are between aneurisms and intra-tho- racic tumors. The latter are rare : they rarely pulsate, or, if they should, they will communicate to the hand a mere hfting pulsation ; in some instances malignant tumors have, however, a true expansive impulse. Again, intra-thoracic tumors are not usually developed entirely in the tract of the aorta ; their area of dulness is large, and the resistance communicated to the finger on percussion is usually great. As a rule there are no sounds or murmurs connected with them, though in some cases where a tumor is placed over the aorta, a murmur may occur. Tumors are more apt to produce persistent swelling, and oedema of the upper extremities, neck, and face. In a case of aneurism, this latter sign may become developed, and then disappear, owing to a change in the direction of the pres- sure. Tubercular consolidation of one apex, if associated with a murmur in the sub-clavian or pulmonary artery, might be mistaken for an aneurism. In the former we have the physi- cal signs of phthisis. The murmur is heard in the course of the pulmonary or sub-clavian artery. The dulness is not cir- cumscribed, and extends outwards, and not across the median line. Pulsatile Empyema, it seems to me, could hardly be mis- taken for aneurism, although such instances are on record, 116 PHYSICAL DIAGNOSIS for it does not occupy the position of an aneurism. Then you have the physical signs of effusion into the plural sac, and it is attended by no sounds or murmurs. Aneurism of the Arteria Innominata is distinguished from aneurism of the thoracic aorta, by the fact that the tumor appears early on the right of the sternum ; as it increases, it protrudes the inner part of the clavicle, or extends upwards into the neck. Its pulsation is diminished or suspended by pressure on the carotid or sub-clavian artery, while an aneu- rism of the aorta will not be affected by such pressure.
Key Takeaways
- Cardiac murmurs can indicate various heart conditions, including regurgitation and obstruction.
- Aneurisms of the thoracic aorta are common at different points along its course.
- Physical signs like bulging, pulsation, and loss of vocal resonance can help diagnose aneurisms.
Practical Tips
- Learn to identify the location and intensity of heart murmurs for accurate diagnosis.
- Use palpation and percussion techniques to detect changes in the precordial area indicative of pericarditis or hypertrophy.
- Be cautious when dealing with suspected aneurisms, as they can lead to severe complications like rupture.
Warnings & Risks
- Do not ignore persistent heart murmurs, as they may indicate serious conditions requiring immediate medical attention.
- Avoid applying excessive pressure during palpation of the aorta to prevent injury or misdiagnosis.
- Be aware that some physical signs can be similar between aneurisms and other conditions like tumors.
Modern Application
While the techniques described in this chapter are rooted in historical practices, they still provide valuable insights into diagnosing heart conditions. Modern medical imaging and technology have improved diagnostic accuracy but these foundational skills remain essential for recognizing early warning signs of cardiac issues. Understanding how to listen for and identify murmurs can be crucial in emergency situations where immediate action is needed.
Frequently Asked Questions
Q: What are the physical signs of an aortic regurgitant diastolic murmur?
A diastolic murmur from valve to right of apex may or may not increase downwards, depending on the proximity of heart to parietes, the position of lungs, etc. It can sometimes be heard in the left axilla and may decrease downwards due to emphysema or supine recumbency.
Q: How can you differentiate between aneurisms and intra-thoracic tumors?
Intra-thoracic tumors rarely pulsate, communicate a mere lifting pulsation, have a large area of dulness on percussion, and are usually not developed entirely in the tract of the aorta. Aneurisms may cause persistent swelling and oedema of the upper extremities, neck, and face.
Q: What should you do if you suspect an aneurism?
If you suspect an aneurism, carefully monitor for signs like bulging, pulsation, and loss of vocal resonance. However, avoid applying excessive pressure during palpation to prevent injury or misdiagnosis.