1. Inspection and Palpation of the heart
Surface anatomy of the heart

4. 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

5. 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

6. 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

8. 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 )

9. AUSCULTATORY AREAS
Aortic valve :Aortic area (2nd right intercostal space )
Pulmonary valve:Pulmonary area (2nd left intercostal space )

10. 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

11. Inspection and palpation
Look for
Chest deformity
Surgical scars
Apex beat
Visible pulsations

12. CHEST DEFORMITIES Precordial bulge
Pectus excavatum :posterior displacement of the lower sternum
Pectus carinatum :Pigeon chest
Chest deformities may displace the heart

13. APEX BEAT
SITE
DIAMETER
AMPLITUDE
DURATION
THRILL
S3 AND S4

14. 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

15. 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

16. 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

17. 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

18. DISPLACEMENT OF THE HEART
B-Cardiac enlargement
IN LVH :Apex is displaced down and out
IN RVH:Apex is displaced outwards

19. SITE OF APEX INVISIBLE APEX Obesity Thick west wall Emphysema
Pericardial effusion
Weak dilated heart

20. DIAMETER OF APEX Normal :2.5cm with patient supine
3 cm in left lateral position
Increased diameter in left ventricular enlargement

21. 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

22. 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

23. 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

24. 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

25. EPIGASTRIC PULSATION RIGHT VENTRICULAR PULSATIONS OF ABDOMINAL AORTA
With hand flattened press index finger under the rib cage upwards to the left shoulder
PULSATIONS OF ABDOMINAL AORTA
LIVER PULSATION

26. 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

27. PULSATION IN RIGHT 2ND SPACE
Prominent pulsations :dilated or aneurysmal aorta

28. PULSATIONS TO RIGHT OF STERNUM
Aortic aneurysm
Enlarged right atrium

29. SUPRASTERNAL PULSATIONS
Hyperkinetic states
High aortic arch or aortic arch aneurysm
Aortic regurge
Coarcatation of aorta
Kinking of carotids due to atherosclerosis