1. © Continuing Medical Implementation …...bridging the care gap Palpation Feel for diagnosis

2. © Continuing Medical Implementation …...bridging the care gap Palpation By the time you put stethoscope to chest you should know what you are going to hear If you don’t hear what you expect,explain it

3. © Continuing Medical Implementation …...bridging the care gap Palpation-Pulses Rhythm, rate, regularity Contour Water hammer pulse-AR Brachial-radial delay AS Pulsus paradoxus –Tamponade –COPD Pulsus alternans –LV dysfunction

4. © Continuing Medical Implementation …...bridging the care gap Carotid Examination Carotid upstroke –brisk, normal or delayed –bisferiens or anacrotic –volume: normal, increased or decreased Carotid auscultation –Bruit –Transmitted murmur –A 2 audible in neck? Presence excludes severe AS

5. © Continuing Medical Implementation …...bridging the care gap Palpation - Precordium Parasternal: –Palpable P 2 -pulmonary HTN Thrill –VSD/HCM RV lift –RVH –Severe MR

6. © Continuing Medical Implementation …...bridging the care gap Precordium-Palpation Parasternal Lift: RVE or severe MR Thrill: VSD, HOCM (IHSS) Palpable P2 (ULSB): pulmonary hypertension Medial retraction LVE Lateral retraction RVE

7. © Continuing Medical Implementation …...bridging the care gap Palpation - Apex Apex: Palpable in 1 of 5 adults age 40 Best felt with fingertips or finger pads Normal Location: No more than 10 cm from mid-sternal line in the supine position Left decubitus position not reliable for apical location Normal Size: No larger than 3 cm (about 2 finger breadths)

8. © Continuing Medical Implementation …...bridging the care gap Apex-Dynamic Qualities LV impulse outward movement like a ping pong ball were protruding between the ribs Apex moves outward for the first third of systole and falls away rapidly Lasts for no more than 2/3 of systole

9. © Continuing Medical Implementation …...bridging the care gap Sustained Apex: correlates with pressure overload ( > 2/3 systole-hangs out to S2) AS, LVH or LV systolic dysfunction Hyperdynamic Apex: correlates with volume overload AR/MR palpable S4 (atrial kick) palpable S1 (MS) palpable non-ejection click (MVP) Apex–Dynamic Abnormalities

10. © Continuing Medical Implementation …...bridging the care gap Apex–Dynamic Abnormalities Atrial kick: Palpable S4 –Loss of LV compliance –LVH 2 o Hypertension –Aortic Stenosis –Hypertrophic Cardiomyopathy

11. © Continuing Medical Implementation …...bridging the care gap Non-invasive ejection fraction Palpable S4/ apex not sustained EF > 50% Palpable S4/ Apex sustained EF 40-50% S4 not palpable/ Apex sustained EF < 40% TITLE: The apical impulse in coronary heart disease. AUTHORS: Ranganathan N; Juma Z; Sivaciyan V SOURCE: Clin Cardiol 1985 Jan;8(1):20-33 http://130.14.32.45/cgi-bin/VERSION_B/IGM- client?12653+records+81