Acquiaintance of students with the tasks of internal diseases clinics. The general method of examination of a patient by a doctor. The scheme of case history. The sequence of inquiry and physical examination of a patient. General inspection of a patient.
Inquiry and inspection of patients with cardiovascular system pathology.
Physical method of examination of cardiovascular system. Percussion and auscultation of a heart. Heart sounds and murmurs. Laboratory and instrumental methods of investigation of cardiovascular system.
Main cardilogical syndromes
Sequence of interviewing.
The Case History consist of such components as: the identifying data, the main complaints, the history of present illness, the past medical history, the review of systems. The outlined compounds of a case history, being used in the correct order, help to obtain the organized set of data about patient’s condition and disease.
Identifying Data and their diagnostic value
Identifying Data include at least age, sex, race, place of birth, present address, marital status, occupation (profession).
Patient¢s complaints and their detalization
You should collect main patient’s complaints, when possible, in patient’s own words, and then describe their characteristics. The principal symptoms should be described in terms of their location, quality, quantity or severity, timing (i.e., onset, duration, and frequency), setting, factors that have aggravated or relived these symptoms, and associated manifestations. Then find out and analyze the general complaints. For example, weakness, high body temperature, etc.
The chief complaint represents the specific reason for the child’s visit to the clinic, office, or hospital. The chief complaint may be viewed as the theme, with the present illness as the setting of this problem. Six guidelines determine appropriate recording of the chief complaint: (1) it consists of a brief statement, (2) it is restricted to one or two symptoms, (3) it refers to a concrete complaint, (4) it is recorded in the child’s or parent’s own words, (5) it avoids the use of diagnostic terms or translations, and (6) it states the duration of the symptoms.
The doctor elicits the chief complaint by asking open-ended neutral questions such as, “Tell me what seems to be the matter?”, “How may I help you?” or “What brings you here?” Labeling-type questions such as, “How are you sick?” should be avoided, since it is possible that the reason for the visit is not because of illness. For example, the visit may be for a routine health assessment, or the chief complaint may be of a nonphysical nature.
Examples of properly recorded chief complaints for a variety of situations may be: (1) ambulatory clinic – “My child has had a runny nose and sore throat for 4 days, but today it is worse”, (2) hospital admission – “I need to have my tonsils fixed”, sore throat and repeated earaches for 5 years, and (3) health center – “We are here for a routine checkup”, last visit 1 year ago.
If the visit is for examination, one can ask, “Before we begin, is there anything of particular concern that you would like to discuss?”. This type of statement encourages the parent (or child) to bring up an issue that may not surface during routine interviewing.
Occasionally it is difficult to isolate one symptom or problem as the chief complaint because the parent may identify many. In this situation it is important to be as specific as possible when asking questions. For example, asking informants to state which one problem or symptom caused them to seek help now may help them to focus on the most immediate concern.
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Example of patients complaints description: In case, if you have been visited by a patient with chronic pyelonephritis, its possible, that the result of the examination would be the following: The patient R. complains of a constant dull pain in the lumbar region (noniradiating); it remits after taking Baralginum, No-spa and it increases after taking spicy or salty food; constant rise of body temperature up to 37,80C, chill, frequent urination (up to 10 times a day). Besides, the patient complains of general weakness, insomnia, depression of working ability.
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Patient’s present illness history
The history of present illness is a clear, chronological narrative account of the problems which the patient is seeking care for. It should include the onset of the problem, the setting in which they was developed, their manifestations, treatment, their impact upon the patient’s life, and meaning to the patient. Relevant data from the patient’s chart, such as laboratory reports, also belong in the present illness.
The history of the present illness is a narrative of the chief complaint from its earliest onset through its progression to the present. Its four major components are (1) details of onset, (2) complete interval history, (3) present status, and (4) reason for seeking help now. The focus of the present illness is on all those factors that are relevant to the main problem, even if they have disappeared or changed during the onset, interval, and present.
Analyzing a symptom. Since pain is often the most characteristic symptom denoting onset of a physical problem, it is used as a prototype for analysis of a symptom. The doctor should assess pain for (1) type, (2) location, (3) severity, (4) duration, and (5) influencing factors. The type or character of pain should be as specific as possible.
By type pain may be sharp, throbbing, dull, aching, stabbing, and so on. Whatever words they use should be recorded in quotes.
The location of the pain also must be specific. “Stomach pains” is too general description. Sometimes it is necessary to ask to “point with one finger to where it hurts”. The doctor can also determine if the pain radiates by asking, “Does the pain stay there or move? Show me where it goes with your finger“.
The severity of pain is best determined by finding out how it affects the patient’s usual behavior. It is preferable to record pain in terms of interference with activity.
Duration of pain should include the duration, onset, and frequency of attacks. Influencing factors are anything that causes a change in the type, location, severity, or duration of the pain. These include (1) precipitating factors (those that cause or increase the pain), (2) relieving factors (those that lessen the pain, such as medications), (3) temporal events (times when the pain is relieved or increased), (4) positional events (standing, sitting, lying down, and so on), and (5) associated events (meals, stress, coughing, and so on).
A standard method of analyzing a symptom is listed in the following outline. These three categories – onset, characteristics, and course since onset – comprise the essential data for the present illness. Although the analysis of a symptom has concentrated on discussion of physical complaints, the same process of description and investigation can be used for emotional or psychosocial problems.
Past history:
The general state of health:
Previous diseases including viral hepatitis, sexual-transmitted diseases, infectious diseases within the last month, AIDS-risk factors
2. Immunizations: tetanus, diphtheria, polio etc.
3. Adult illness, operations, injuries, allergies.
4. Current medications, including home remedies, nonprescription drugs, and medicines borrowed from family or friends. When patient seems likely to be taking one or more medications, survey one 24-hour period in detail.
5. Diet.
6. Sleep Patterns. Including times that the person goes to bed and awakens, difficulties in failing asleep or staying asleep, and daytime naps.
7. Habits, including exercise and the usage of coffee, alcohol, other drugs, and tobacco.
8. The Family History:
The age and health, or age and cause of death of each immediate family member (i.e., parents, siblings, and children). Data on grandparents or grandchildren may also be useful.
The occurrence in the family of any of the following conditions: diabetes, tuberculosis, heart disease, high blood pressure, kidney disease, cancer, arthitis, anemia, headaches, mental illness, or symptoms like those of the patient.
Social History: assessment of the home and job environment, professional hazards.
Review of Systems: the relevant items are limited, but expand as the patient’s age increases.
Systems ‘reviewing:
Carrying out the reviewing of systems you should pay attention to the following:
1. General state of health: weight, recent weight change, weakness, fatigue, fever.
2. Skin: Rashes, lumps, itching, dryness, color changes, changes in hair or nails.
3. Head: Headache, head injury.
4. Eyes: Vision, glasses or contact lenses, last eye examination, pain, redness, excessive tearing, double vision, glaucoma, cataracts.
5. Ears: Hearing, tinnitus, vertigo, earaches, infection, discharge.
6. Nose and sinuses. Frequent colds, nasal stuffiness, hay fever, noseblends, sinus trouble.
7. Mouth and throat. Condition of teeth, last dental examination, sore tongue, frequent sore throats.
8. Neck: Lumps ieck swollen glands, pain in the neck.
9. Breasts: Lumps, pain, nipple discharge, self-examination
10. Respiratory system: Cough, sputum (color, quantity), hemoptysis, wheezing, asthma, bronchitis, emphysema, pneumonia, tuberculosis, pleurisy, tuberculin test; last chest x-ray film.
11. Cardiovascular system: high blood pressure, rheumatic fever, heart murmurs; dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema; chest pain, palpitations; past electrocardiogram or other heart tests
12. Gastrointestinal system: Appetite, nausea, vomiting, vomiting of blood, indigestion, frequency of bowel movements, change in bowel habits, rectal bleeding or black tarry stools, constipation, diarrhea; abdominal pain, food intolerance, meteorism, hemorrhoids; jaundice, liver or gallbladder trouble, hepatitis.
13. Urinary: Frequency of urination, polyuria, nocturia, dysuria, hematuria, urgency, hesitancy, incontinence; urinary infections, stones.
14. Genito-reproductive:
Male: Discharges, history of venereal disease and its treatment, hernias, testicular pain; sexual difficulties.
Female: Age at menarche; regularity, frequency, and duration of periods; amount of bleeding, bleeding between periods or after intercourse, last menstrual period; dysmenorrhea; age of menopause, menopausal symptoms, post-menopausal bleeding. Discharge, venereal disease and its treatment; Number of pregnancies, number of abortions (spontaneous and induced);complications of pregnancy; sexual difficulties.
15. Musculoskeletal system: Joint pains or stiffness, arthritis, backache..Muscle pain.
16. Periferal vessels: Intermittent claudication, cramps, varicose veins, thrombophlebitis.
17. Nervous system: Fainting, blackouts, paralysis, local weakness, tremors, memory.
18. Endocrine system: Thyroid trouble, heat or cold intolerance, excessive sweating, diabetes, excessive thirst, hunger, urination.
19. Hematologic: Anemia, easy bruising or bleeding, past transfusions and possible reactions and antibiotics.
THE GENERAL EXAMINATION
Sequence for performing a physical examination
With experience, you will develop your own style and sequence of physical examination. A regular routine helps to reduce the chance of you missing things out.
The sequence of examination is:
Inspection
Palpation
Percussion
Auscultation.
Anatomical, physiological and clinical peculiarities of different stages of consciousness disorders and their diagnostic value
Patient’s consciousness may be clear or deranged. Depending on the degree of disorder, the following psychic states are differentiated.
1. Stupor. The patient cannot orient himself to the surroundings, he gives delayed answers. The state is characteristic of contusion and in some cases poisoning.
2. Sopor. This is an unusually deep sleep from which the patient recovers only for short periods of time when called loudly, or roused by an external stimulus. The reflexes are preserved. The state can be observed in some infectious diseases and at the initial stage of acute uraemia.
3. Coma. The comatose state is the full loss of consciousness with complete absence o’f response to external stimuli, with the absence of reflexes, and deranged vital functions. The causes of coma are quite varied but the loss of consciousness in coma of any aetiology is connected with the cerebral cortex dysfunction caused by some factors, among which the most important are disordered cerebral circulation and anoxia. Oedema of the brain and its membranes, increased intracranial pressure, effect of toxic substances on the brain tissue, metabolic and hormone disorders, and also upset acid-base equilibrium are also very important for the onset of coma. Coma may occur suddenly or develop gradually, through various stages of consciousness disorders. The period that precedes the onset of a complete coma is called the precomatose state. The following forms of coma are most common.
Alcoholic coma. The face is cyanotic, the pupils are dilated, the respiration shallow, the pulse low and accelerated, the arterial pressure is low; the patient has alcohol on his breath.
Apoplexic coma (due to cerebral haemorrhage). The face is red, breathing is slow, deep, noisy, the pulse is full and rare.
Hypoglycaemic coma can develop during insulin therapy for diabetes.
Diabetic {hyperglycaemic) coma occurs ion-treated diabetes mellitus.
Hepatic coma develops in acute and subacute dystrophy and necrosis of the liver parenchyma, and at the final stage of liver cirrhosis.
Vraemic coma develops in acute toxic and terminal stages of various chronic diseases of the kidneys.
Epileptic coma. The face is cyanotic, there are clonic and tonic convulsions, the tongue is bitten. Uncontrolled urination and defaecation. The pulse is frequent, the eye-balls are moved aside, the pupils are dilated, breathing is hoarse.
4. Irritative disorders of consciousness may also develop. These are characterized by excitation of the central nervous system in the form of hallucinations, delirium (delirium furibundum due to alcoholism; in pneumonia, especially in alcoholics; quiet delirium in typhus, etc.).
General inspection can also give information on other psychic disorders that may occur in the patient (depression, apathy).
Patient’s posture, bearing and gait
Posture of a patient can be active, passive, or forced.
The patient is active if the disease is relatively mild or at the initial stage of a grave disease. The patient readily changes his posture depending on circumstances. But it should be remembered that excessively sensitive or alert patients would often lie in bed without prescription of the physician.
Forced posture is often assumed by the patient to relieve or remove pain, cough, dyspnoea. For example, the sitting position relieves ortho-pnoea: dyspnoea becomes less aggravating in cases with circulatory insufficiency.
Patient with emphysema bending over in Tri-Pod Position
The relief that the patient feels is associated with the decreased volume of circulating blood in the sitting position (some blood remains in the lower limbs and the cerebral circulation is thus improved). Patients with dry pleurisy, lung abscess, or bronchiectasis prefer to lie on the affected side. Pain relief in dry pleurisy can be explained by the limited movement of the pleural layers when the patient lies on the affected side. If a patient with lung abscess or bronchiectasis lies on the healthy side, coughing intensifies because the intracavitary contents penetrate the bronchial tree. And quite the reverse, the patient cannot lie on the affected side if the ribs are fractured because pain intensifies if the affected side is pressed against the bed. The patient may sit inclining slightly forward if fluid is accumulated in the pericardium.
The patient with cerebrospinal meningitis would usually lie on his side with his head thrown back and the thighs and legs flexed on the abdomen. Patients with angina pectoris and intermittent claudication prefer to stand upright. The patient is also erect (standing or sitting) during attacks of bronchial asthma. He would lean against the edge of the table or the chair back, with the upper part of the body slightly inclined forward. Auxiliary respiratory muscles are more active in this posture. The supine posture is characteristic of strong pain in the abdomen (acute appendicitis, perforated ulcer of the stomach or duodenum). The prone position (lying with the face down) is characteristic of patients with tumours of the pancreas and gastric ulcer (if the posterior wall of the stomach is affected). Pressure of the pancreas on the solar plexus is lessened in this posture. In rheumatic arthritis patient gains a forced supine posture; patient may be in prone position if his spine is affected.
Some patients change their posture frequently because previous posture doesn’t relieve their pain.
Passive posture is observed with unconscious patients or, in rare cases, with extreme asthenia. The patient is motionless, his head and the limbs.
The posture or attitude of the patient is often indicative of his general tone, the degree of muscle development, and sometimes of his occupation and habits. Most patients with grave diseases or with psychic depression are often stooped. Active posture, erect bearing, easy gait, and free and unconstrained movements indicate the normal condition of the body. Some gaits are specific for certain diseases of the nervous system (hemiplegia, sciatica, etc.). Surgical diseases of the bones and joints, rheumatism, or deranged blood circulation in the lower extremities change the gait and bearing and make walking difficult. The so-called waddling gait is characteristic of osteomalacia or congenital dislocation of the femur.
Anthropometric examination of a patient. The types of body built (constitution), their characteristic and classification
The concept of habitus includes the body-build, i.e. constitution, height, and body weight.
The methods and techniques used to assess the morphological conditions of man are called anthropometry (Gk anthropos man and metron measure).
The height of the patient is measured by a simple device which is actually a vertical plank graduated in centimetres along which a horizontal piece slides. The patient stands upright on the platform, his heels, buttocks and shoulder blades touching the vertical plank.
The head should be held in a position in which the auditory meatus is level with the lateral edge of the eye. The horizontal piece is then lowered to touch the head and the patient’s height is read off the plank.
The patient is weighed on medical scales. His weight is determined up on admittance and not less than once a week during his stay at the hospital. The patient should be weighed in his underwear in the morning before breakfast, after urination and emptying the bowels. A normal weight is found by subtracting 100 from the height (in cm). This is only a tentative method since normal weight varies with age and for many other factors. The patient usually loses weight in many diseases, especially those associated with malignant newgrowths, tuberculosis, acute infections, and gastrointestinal diseases. Fat tissue is lost first, then the patient loses weight at the expense of muscular tissues. Patients with oedema gain weight due to retention of moisture in the tissues.
The girth of the chest is measured by a tape passed under the angles of the shoulder blades on the back and across the 4th rib of the chest. The girth should be measured with quiet breathing and hanging hands freely at the patient’s sides. The measurements are taken at the height of inspiration and expiration.
Constitution (L constituero to set up) is the combination of functional and morphological bodily features that are based on the inherited and acquired properties, and that account for the body response to endo- and exogenic factors. The classification dy M. Chernorutsky differentiates between the following three main constitutional types: asthenic, hypersthenic, and normosthenic.
The asthenic constitution is characterized by a considerable predominance of the longitudinal over the transverse dimensions of the body by the dominance of the limbs over the trunk, of the chest over the abdomen. The heart and the parenchymatous organs are relatively small, the lungs are elongated, the intestine is short, the mesenterium long, and the diaphragm is low. Arterial pressure is lower than in hypersthenics; the vital capacity of the lungs is greater, the secretion and peristalsis of the stomach, and also the absorptive power of the stomach and intestine are decreased; the haemoglobin and red blood cells counts, the level of cholesterol, calcium, uric acid, and sugar in the blood are also decreased. Adrenal and sexual functions are often decreased along with thyroid and pituitary hyperf unction.
The hypersihenic constitution is characterized by the relative predominance of the transverse over the longitudinal dimensions of the body (compared with the normosthenic constitution). The trunk is relatively long, the limbs are short, the abdomen is large, the diaphragm stands high. All internal organs except the lungs are larger than those in asthenics. The intestine is longer, the walls are thicker, and the capacity of the intestine is larger. The arterial pressure is higher; haemoglobin and red blood cell count and the content of cholesterol are also higher; hypermobility and hypersecretion of the stomach are more normal. The secretory and the absorptive function of the intestine are high. Thyroid hypofunction is common, while the function of the sex and adrenal glands is slightly increased.
Normosthenic constitution is characterized by a well proportioned make-up of the body and is intermediate between the asthenic and hypersthenic constitutions.
The posture or attitude of the patient is often indicative of his general tone, the degree of muscle development, and sometimes of his occupation and habits. Most patients with grave diseases or with psychic depression are often stooped. Erect posture, easy gait, and free and unconstrained movements indicate the normal condition of the body. Some gaits are specific for certain diseases of the nervous system (hemiplegia, sciatica, etc.) Surgical diseases of the bones and joints, rheumatism, or deranged blood circulation in the lower extremities change the gait and make walking difficult. The so-called waddling gait is characteristic of osteomalacia or u’enital dislocation of the femur.
During the general inspection, the physician should pay attention to the open parts of the patient’s body, the head, the face and the neck.
Changes in the size and shape of the head can give diagnostic clues. Excessive growth of the skull occurs in hydrocephalus. An abnormally small is typical of microcephalus, which is also marked by mental underdevelopment. A square head, flattened on top, with prominent frontal nbers, can indicate congenital syphilis or rickets in past history. The position of the head is also important in diagnosing cervical myositis or spondylarthritis. Involuntary movements of the head (tremor) are characteristic of parkinsonism. Rhythmical movements of the head in synchronism with the cardiac pulse are characteristic of aortic incompetence (Musset‘s sign). The presence of scars on the head may suggest the cause of persistent headache. It is necessary to find out whether the patient has vertigo tigo which is typical particularly for Meniere’s syndrome, or epileptiform attacks.
Countenance. The facial expression can indicate the mental composure and various psychic and somatic conditions. It also depends on age and sex and can therefore give diagnostic clues when diagnosing some endocrine disorders (woman-like expression in men and masculine features in women). The following changes in the face are diagnostically essential:
2. Corvisart’s facies is characteristic of cardiac insufficiency. The face is oedematous, pale yellowish, with a cyanotic hue. The mouth is always half open, the lips are cyanotic, the eyes are dull and the eyelids sticky.
3. Facies febrilis is characterized by hyperaemic skin, sparkling eyes and excited expression. There are special features of facies febrilis characteristic of some infectious diseases: feverish redness in acute lobar pneumonia (more pronounced on the side of the affected lung); general hyperaemia of the puffy face is characteristic of louse-borne typhus, the sclera is injected (“rabbit eye” according to F. Yankovsky); slightly icteric yellow colour is characteristic of typhoid fever. Tuberculosis patients with fever have “burning” eyes on an exhausted and pale face with blush localized on the cheeks. An immobile face is characteristic of septic fever; the face is pale, sometimes slightly yellowish.
4. Face and its expression are altered in various endocrine disorders;
(a) a face with enlarged promient parts (such as nose, chin, and cheek bones) and enlarged hands are characteristic of acromegalia (hands become enlarged in some pregnancies);
(b) myxoedematous face indicates thyroid hypofunction; the face may be uniformly puffy with oedematous mucosa, narrowed eye slits, the face features smoothed down, the hair is absent on the outward portions of the eyebrow; the presence of a blush on a pale face resembles the appearance of a doll;
(c) facies basedovica this is the face of a patient with thyroid hyperfunction; the face is lively with widened eye slits and abnormally sparkling eyes; the eyes are protruded and the face looks as if frightened;
d) an intense red, moon-like glittering face with a beard and mustaches in women is characteristic of the Itsenko-Cushing disease.
5. Facies leontina with nodular thickening of the skin under the eyes and over the brows, with flattened nose is observed in leprosy.
6. Parkinson’s mask (or facies) is an amimic face characteristic of encephalitis patients.
8. Risus sardonicus with a semblance of a grin occurs in tetanus patients: the mouns widens as in laughter, while the skin folds on the forehead express grief.
9. Facies hippocratica (first described by Hippocrates) is associated with collapse in grave diseases of the abdominal organs (diffuse peritonitis,perforated ulcer of the stomach or duodenum, rupture of the gall bladder).
10. Asymetric movements of facial muscles indicate a history ofcerebral haemorrhage or facial neuritis.
11. Face in sclerodermia is amimic, moth os narrowed, skin is stretched:
Inspection of the eyes and eyelids can reveal some essential diagnostic signs. Oedema of the eyelids, especially of the lower eyelids, is the first indication of acute nephritis; it is also observed in anaemia, frequent attacks of cough, and deranged sleep; oedema of the eyelids can also occur in the morning in healthy persons as well.
The colour of the eyelids is important. The eyelids are dark in diffuse toxic goitre and
The shape of the pupils, their symmetry, response to light, accommodation and convergence, and also their “pulsation” are of great diagnostic significance in certain diseases. Abnormally contracted pupil (miosis) is observed in uraemia, tumours and intracranial haemorrhages, and inmor-phine poisoning. Enlargement of the pupil (mydriasis) occurs in comatose states (except uraemic coma) and cerebral haemorrhages, and also in atropine poisoning. Anisocoria (unequal size of the pupils) occurs in some affections of the nervous system. Squinting results from paralysis of the ocular muscles due to lead poisoning, botulism, diphtheria, affections of the brain and its membranes (syphilis, tuberculosis, meningitis, cerebral haemorrhage).
Sclera: The normal sclera is white and surrounds the iris and pupil. In the setting of liver or blood disorders that cause hyperbilirubinemia, the sclera may appear yellow, referred to as icterus. This can be easily confused with a muddy-brown discoloration common among older African Americans that is a variant of normal.
Icteric Sclera
Muddy Brown Sclera
Conjunctiva: The sclera is covered by a thin transparent membrane known as the conjunctiva, which reflects back onto the underside of the eyelids. Normally, it’s invisible except for the fine blood vessels that run through it. When infected or otherwise inflamed, this layer can appear quite red, a condition known as conjunctivitis. Alternatively, the conjunctiva can appear pale if patient is very anemic. By gently applying pressure and pulling down and away on the skin below the lower lid, you can examine the conjunctival reflection, which is the best place to identify this finding.
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Pale Conjunctiva, due to severe anemia.
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1.
2. Conjunctivitis
Blood can also accumulate underneath the conjunctiva when one of the small blood vessels within it ruptures. This may be the result of relatively minor trauma (cough, sneeze, or direct blow), a bleeding disorder or idiopathic. The resulting collection of blood is called a subconjunctival hemorrhage. While dramatic, it is generally self limited and does not affect vision.
3. Subconjunctival Hemorrhage
Herpes labialis
Skin eruption (roseola)
Skin eruption (erythema)
Boldness (general and local)
The size of the nose may attract attention providing some diagnostic signs, e.g. it has an abnormal size in acromegaly, or its shape deviates from the normal in rhinoscleroma. The nose may be sunken as a result of syphilis in the past history (saddle nose). Soft tissues of the nose are disfigured in lupus.
When inspecting the mouth attention should be paid to its shape (symmetry of the angles, permanently open mouth), the colour of the lips, eruption on the lips (cold sores, herpes labialis), and the presence of fissures. The oral mucosa should also be inspected (for the presence of aphthae, I pigmentation, Filatov-Koplik spots, thrush, contagious aphthae of the fooi and mouth disease, haemorrhage). Marked changes in the gums can be I observed in some diseases (such as pyorrhoea, acute leukaemia, diabetes I mellitus, and scurvy) and poisoning (with lead or mercury). The teeth I should be examined for the absence of defective shape, size, or position! The absence of many teeth is very important in the aetiology of somcl alimentary diseases. Caries is the source of infection and can affect somc other organs.
Disordered movement of the tongue may indicate nervous affections, grave infections and poisoning. Marked enlargement of the tongue is characteristic of myxoedema and acromegaly; less frequently it occurs in glossitis. Some diseases are characterized by the following abnormalities of the tongue: (1) the tongue is clear, red, and moist in ulcer; (2) crimson-red in scarlet fever; (3) dry, with a brown coat and grooves in grave poisoning and infections; (4) coated in the centre and at the root, but clear at the tip and margins in typhoid fever; (5) smooth tongue without papillae (as if polished) is characteristic of Addison-Biermer disease. The glassy tongue is characteristic of gastric cancer, pellagra, sprue, and ariboflavinosis; (6) local thickening of the epithelium is characteristicof smokers (leucoplakia). Local pathological processes, such as ulcers of various aetiology, scars, traces left from tongue biting during epileptic fits, ets, are also suggestive of certain diseases.
Coated tongue
Skin depigmentation (vitiligo)
During inspection of the neck attention should be paid to pulsation of the carotid artery (aortic incompetence, thyrotoxicosis), swelling andpulsation of the external yugular veins (tricuspid valve insufficiency), enlarged lymph nodes (tuberculosis, lympholeukaemia, lymphogranulomatosis and cancer metastases), diffuse or local enlargement of thethyroid gland (thyrotoxicosis, simple goiter, malignant tumour).
Lymph Nodes: The major lymph node groups are located along the anterior and posterior aspects of the neck and on the underside of the jaw. If the nodes are quite big, you may be able to see them bulging under the skin, particularly if the enlargement is asymmetric (i.e. it will be more obvious if one side is larger then the other). To palpate, use the pads of all four fingertips as these are the most sensitive parts of your hands. Examine both sides of the head simultaneously, walking your fingers down the area in question while applying steady, gentle pressure. The major groups of lymph nodes as well as the structures that they drain, are listed below. The description of drainage pathways are rough approximations as there is frequently a fair amount of variability and overlap. Nodes are generally examined in the following order:
Palpating Anterior Cervical Lymph Nodes
1. Anterior Cervical (both superficial and deep): Nodes that lie both on top of and beneath the sternocleidomastoid muscles (SCM) on either side of the neck, from the angle of the jaw to the top of the clavicle. This muscle allows the head to turn to the right and left. The right SCM turns the head to the left and vice versa. They can be easily identified by asking the patient to turn their head into your hand while you provide resistance. Drainage: The internal structures of the throat as well as part of the posterior pharynx, tonsils, and thyroid gland.
2. Posterior Cervical: Extend in a line posterior to the SCMs but in front of the trapezius, from the level of the mastoid bone to the clavicle. Drainage: The skin on the back of the head. Also frequently enlarged during upper respiratory infections (e.g. mononucleosis).
3. Tonsillar: Located just below the angle of the mandible. Drainage: The tonsilar and posterior pharyngeal regions.
4. Sub-Mandibular: Along the underside of the jaw on either side. Drainage: The structures in the floor of the mouth.
5. Sub-Mental: Just below the chin. Drainage: The teeth and intra-oral cavity.
6. Supra-clavicular: In the hollow above the clavicle, just lateral to where it joins the sternum. Drainage: Part of the throacic cavity, abdomen.
A number of other lymph node groups exist. However, palpation of these areas is limited to those situations when a problem is identified in that specific region (e.g. the pre-auricular nodes, located in front of the ears, may become inflamed during infections of the external canal of the ear).
Lymph nodes are part of the immune system. As such, they are most readily palpable when fighting infections. Infections can either originate from the organs that they drain or primarily within the lymph node itself, referred to as lymphadenitis. Infected lymph nodes tend to be:
- Firm, tender, enlarged and warm. Inflammation can spread to the overlying skin, causing it to appear reddened.
If an infection remains untreated, the center of the node may become necrotic, resulting in the accumulation of fluid and debris within the structure. This is known as an abscess and feels a bit like a tensely filled balloon or grape (a.k.a. fluctuance). Knowledge of which nodes drain specific areas will help you search efficiently. Following infection, lymph nodes occasionally remain permanently enlarged, though they should be non-tender, small (less the
Malignancies may also involve the lymph nodes, either primarily (e.g. lymphoma) or as a site of metastasis. In either case, these nodes are generally:
Lymph nodes of the head and neck
- Firm, non-tender, matted (i.e. stuck to each other), fixed (i.e. not freely mobile but rather stuck down to underlying tissue), and increase in size over time.
The location of the lymph node may help to determine the site of malignancy. Diffuse, bilateral involvement suggests a systemic malignancy (e.g. lymphoma) while those limited to a specific anatomic region are more likely associated with a local problem. Enlargement of nodes located only on the right side of the neck in the anterior cervical chain, for example, would be consistent with a squamous cell carcinoma, frequently associated with an intra-oral primary cancer.
Cervical Adenopathy: Massive right side cervical adenopathy secondary to metastatic squamous cell cancer originating from this patient’s oropharynx.
Cervical Adenopathy: Right anterior cervical adenopathy secondary to metastatic cancer
1. Changes of skin properties (colour, moisture, turgor) in different pathological conditions.
The colour, elasticity, and moisture of the skin, eruptions and scars are important. The colour of the skin depends on the blood filling of cutaneous vessels, the amount and quality of pigment, and on the thickness and translucency of the skin. Pallid skin is connected with insufficiency of blood circulation in the skin vessels due to their spasms of various aetiology or acute bleeding, accumulation of blood in dilated vessels of the abdominal cavity in collapse, and in anaemia. In certain forms of anaemia, the skin is specifically pallid: with a characteristic yellowish tint in Addison-Biermer anaemia, with a greenish tint in chlorosis, earth-like in malignant anaemia, brown or ash-coloured in malaria, “cafe au lait” in subacute septic endocarditis. Pallid skin can also be due to its low translucency and considerable thickness; this is only apparent anaemia, and can be observed in healthy subjects.
Red colour of the skin can be transient in fever or excess exposure to heat: persistent redness of the skin can occur in subjects who are permanently exposed to high temperatures, and also in erythraemia. Cyanotic itch can be due to hypoxia in chronic pulmonary diseases etc. Yellowish colour of the skin and mucosa can be due to upset secretion of bilirubin by the liver or due to increased haemolysis. Dark red or brown skin is characteristic of adrenal insufficiency. Hyperpigmentation of the breast nipples and the areola in women, pigmented patches on the face and the white line on the abdomen are signs of pregnancy. When silver preparations are taken for a long time, the skiri becomes grey on the open parts of the body (argyria). Foci of depigmentation of the skin (vitiligo) also occur.
The skin can be wrinkled due to the loss of elasticity in old age, in prolonged debilitating diseases and in excessive loss of water.
Elasticity and turgor of the skin can be determined by pressing a fold of skin (usually on the abdomen or the extensor surface of the arm) between the thumb and the forefinger. The fold disappears quickly oormal skin when the pressure is released while in cases with decreased turgor, the fold persists for a long period of time.
Moist skin and excess perspiration are observed in drop of temperature in patients recovering from fever and also in some diseases such as tuberculosis, diffuse toxic goitre, malaria, suppuration, etc. Dry skin can be due to a great loss of water, e.g. in diarrhoea or persistent vomiting (toxicosis of pregnancy, organic pylorostenosis).
Eruptions on the skin vary in shape, size, colour, persistence, and spread. The diagnostic value of eruptions is great in some infections such as measles, German measles, chicken- and smallpox, typhus, etc.
Erruption due to medication allergy.
Roseola is a rash-like eruption of 2-
Desquamation of the skin is of great diagnostic value. It occurs in debilitating diseases and many skin diseases. Scars on the skin, e.g. on the abdomen and the hips, remain after pregnancy (striae gravidarum), in Itsenko-Cushing disease, and in extensive oedema. Indented stellar scars, tightly connected with underlying tissues, are characteristic of syphilitic affections. Postoperative scars indicate surgical operations in past history.
a. Clubbing: Bulbous appearance of the distal phalanges of all fingers along with concurrent loss of the normal angle between the nail base and adjacent skin. This is most commonly associated with conditions that cause chronic hypoxemia (e.g. severe emphysema), though it is also associated with a number of other conditions. However, in general it is neither commoor particularly sensitive for hypoxia, as most hypoxic patients do not have clubbing.
b. Cyanosis: A bluish discoloration visible at the nail bases in select patient with severe hypoxemia or hypoperfusion. As with clubbing, it is not at all sensitive for either of these conditions.
Subcutaneous fat, it’s development and distribution
Subcutaneous fat can be normal or to various degrees excessive or deficient. The fat can be distributed uniformly or deposited in only certain pans of the body. Its thickness is assessed by palpation. Excessive accumulation of subcutaneous fat (adiposis) can be due to either exogenic (overfeeding, hypodynamia, alcoholism, etc.) or endogenic factors (dysfunction of sex glands, the thyroid, or pituitary gland). Insufficient accumulation of subcutaneous fat may result from constitutional factors (asthenic type), malnutrition, or alimentary dysfunction. Excessive wasting is referred to as cachexia, and may occur in prolonged, intoxication, chronic infections (tuberculosis), malignant newgrowths, diseases of-the pituitary, thyroid and pancreas, and in some psychological disorders as well. Weighing the patient gives additional information about his diet and is an objective means in following up on the patient’s weight changes during the treatment of obesity or cachexia.
Checking the degree of subcutaneous fat development can be performed by making a skin fold in patient’s interscapular region between the tumb and the forefinger of physitian arm. Normal width of the fold is about 2 sm, dereases in malnutrition and is more sick in obesity.
Obecity
Edema, their localisation, methods of determination
Oedema can be caused by penetration of fluid through the capillary walls and its accumulation in tissues. Accumulated fluid may, be congestive (transudation) or inflammatory (exudation). Local oedema is a result of some local disorders in the blood or lymph circulation; it is usually associated with thrombosis of the veins, that is, compression of the veins by tumours or enlarged lymph nodes. General oedema associated with diseases of the heart, kidneys or other organs is characterized by general distribution of oedema throughout the entire body (anasarca) or by symmetrical localization in limited regions of the body. These phenomena can be due to the patient lying on one side. If oedema is generalized and considerable, transudate may accumulate in the body’s cavities: in the abdomen (ascites), pleural cavity (hydrothorax) and in the pericardium (hydropericardium). Examination reveals swollen glossy skin.
Note divit left (pitting) after application of pressure.
Edema in this case is due to lymphatic obstruction.
The specific relief features of the oedema-affected parts of the body disappear due to the levelling of all irregularities on the body surface. Stretched and tense skin appears transparent in oedema, and is especially apparent on loose subcutaneous tissues (the eyelids, the scrotum, etc.). In addition to observation, oedema can also be revealed by palpation. When pressed by the finger, the oedematous skin overlying bones (external surface of the leg, malleolus, loin, etc.) remains depressed for 1-2 minutes after the pressure is released. The mechanism of the development of oedema and methods to reveal this condition will be discussed in detail in the special section of this textbook.
Allergic edema of lips (Quinke’s edema)
Joint deformation in artritis
Examination of cardiovascular system
Patient’s complaints typical for heart diseases
The most typical complaints are the pain in the heart area, dyspnea, palpitation etc.
Dyspnea is the subjective feeling of air hunger or shortness of breath or digressing feeling of air deficit. Dyspnoea is a sign of the developing circulatory insufficiency, the degree of dyspnoea being a measure of this insufficiency. When questioning the patient, it is therefore necessary to find the conditions under which dyspnoea develops. At the initial stages of heart failure, dyspnoea develops only during exercise, such as ascending the– stairs or a hill, or during fast walk. Further, it arises at mildly increased physical activity. During talkind, after meals or during normal walk. .In advanced heart failure, dyspnoea is observed even at rest. Cardiac dyspnoea is caused by some factors which stimulate the respiratory centre.
It is necessary to distinguish attacks of cardiac asthma. In the time of attack the patient complaints on acute air hunger, rising of gurgling rales during breathing, expectoration of foamy sputum with impurity of blood. The patients quite often complain on palpitation. Sometimes the feeling of heart intermissions can occur, caused by infringement of its rhythm.
Attacks of asphyxia, which are known as cardiac asthma, should be differentiated from dyspnoea. An attack of cardiac asthma usually arises suddenly, at rest, or soon after a physical or emotional stress, sometimes during night sleep. It may develop in the presence of dyspnoea. In paroxysmal attacks of cardiac asthma, the patient would usually complain of acute lack of air; respiration becomes stertorous, the sputum is foamy with traces of blood.
The important attribute of heart failure is the pain in the heart area which is an important and informative sign.
It is necessary to find out its exact localization, reasons and conditions of its occurrence (physical or emotional overload, its occurrence at rest, during motion or in dream), character (acute, dull pain, feeling of weight or compression behind sternum, slight dull pain in the top of the heart), duration, irradiation.
The character of pain is different in various diseases of the heart. The physician should determine (by questioning) the location of the pain, the cause or condition under which it develops (exercise, emotional stress, walking, attack Of pain at rest, during night sleep), the character of pain (acute, boring, piercing, a feeling of heaviness or retrosternal pressure, small boring pain in the region of the apex), duration and radiation of pain, conditions under which the pain abates. Pain often develops due to acute insufficiency of the coronary circulation, which results in myocardial ischaemia. This pain syndrome is called stenocardia or angina pectoris. In angina pectoris pain is retrosternal or slightly to the left of the sternum; it most commonly radiates to the region under the left scapula, the neck, and the left arm. The pain is usually associated with exercise, emotional stress, and is abated by nitroglycerin. Angina pectoris pain occurs mostly in patients with coronary atherosclerosis but it may arise in inflammatory diseases of the vessels, e.g. rheumatic vasculitis, syphilitic mesaortitis, periarteritis nodosa, and also in aortal heart diseases and grave anaemia.
Pain is especially intense in myocardial infarction and, unlike in angina pectoris, it persists for a few hours, and sometimes for several days, it does not abate after vasodilatory preparations are given. Pain in dissecting aneurysm of the aorta is piercing (like in myocardial infarction). Unlike in myocardial infarction, pain radiates usually .to the spinal column, and moves gradually along the course of the aorta. Myocarditis is characterized by intermittent and pressing pain; it is dull, mild, and is intensified during exercise. Pain in pericarditis is located at the middle of the sternum or throughout the entire cardiac region; the pain is stabbing or shooting, and is intensified during movements, cough, even under the pressure of a stethoscope; the pain may persist for several days or arise in attacks. Permanent pain behind the manubrium sterni that does not depend on exercise or emotional stress (the so-called aortalgia) occurs in aortitis. Stabbing pain at the heart apex that arises at emotional stress or fatigue is sharacteristics of cardioneurosis. It should be remembered that pain in the cardiac region may arise due to affection of intercostals muscles, nerves, pleura, or the asjanced organs (diaphragmatic hernia, cholecystitis, ulcer, gastric cancer).
Patients with heart diseases often complain of cough which is due to congestion in the lesser circulation. The caygh is usually dry; sometimes a small amouln of sputum is coughed up. Dry caugh is also observed in aortal aneurism because of the stimulation of the vagus nerve. Haemoptysis in grave heart diseases is mostly due to congestion in the lesser circulation and rupture of fine bronchial vessels (e.g. during coughing)/ Haemoptysis mostly occurs in patients with mitral heart disease. It may occur in embolism of the pulmonary artery.
Oedema Venous congestion in the greater circulation occurs in severe heart diseases. The patients would complain of oedema, which first develops only in the evening and resolves during the nigit sleep. Oedema occurs mostly in the malleolus region and on the dorsal side of the foot; shins are then affected. In graver cases when fluid is accumulated at the abdominal cavity (ascites) he patient would complain of heaviness in the abdomen and its enlargement. Heaviness most commonly develops in the right hypochondrium due to congestion and enlargement of the liver. In rapidly developing congestion, pain is felt in this region dueto distention of the liver capsule. Patients may complain also of poor appetite, nausea, vomiting, and swelling of the abdomen. These symptoms are associated with disordered blood circulation in the abdominal organs. The renal function is upset for the same reason and diuresis decreases.
Patients often complain of palpitation. They feel accelerated and intensified heart contractions. Palpitation is determined by the increased excitability of the patient’s nerve apparatus that controls heart activity. Palpitation is a sign of affection of the heart muscle in cardiac diseases such as myocarditis, myocardial infarction, congenital heart diseases, etc. it may arise as a reflex in diseases of some other organs, in fever, anaemia, neurosis, hyperthyroidism, and after administration of some medicinal preparations (atropin sulphate, etc.). Palpitation may also occur in healthy persons under heavy physical load, during running, emotional stress, smoking or coffee abuse. Patients with serious heart diseases may feel palpitation constantly, or it may arise in attacks of paroxysmal tachycardia.
Some patients comptain of intermissions (escaped beats) which are due to disorders in the cardiac rrhythm. Intermissions are described by the patients as a feeling of sinking, stoppage of the heart. Questioning the patient is aimed at determining the circumstances under wich intermissions develop. They may arise at rest or during exercise, they may be intensified in special postures of the patient, etc.
Temperature: Cool hands occur most commonly as a result of exposure to a cold environment. However, this can also reflect vascular insufficiency, vasospasm, or hypovolemia.
General complaints. Patients with cardiovascular pathology often have dysfunction of .the central nervous system, which is manifested by weakness, rapid fatigue, decreased work capacity, increased excitability, and deranged sleep. Compaints of headache, nausea, noise in the ears or the head are not infrequent n essential hypertension patients. The headache, feeling of the noise in ears, vertigo in persons with hypertension are frequently observed.
Some heart disease’s (myocarditis, endocarditis, etc.) are attended by fevered (usually Subfebrile) temperature; sometimes high fever may occur. The patient should be asked about the time of the day when the temperature usually rises, how long it persists and if this rise is accomopained by chills, profuse sweating, etc.
History of present disease. The time of the onset of the disease and its first symptoms should be determined such as pain, palpitation, dyspnoea, elevation of the arterial pressure, the characteitand intensity of these symptoms, connection with infections and other diseases of the past, cooling, and physical overloads. The character of development of the primary symptoms is important. It is also necessary to find out if any treatment was given and its effect, if any. If there were exacerbations of the disease, their course and causes should be established.
Anamnesis. Special attention should be paid to various possible causes of the present heart disease. Information should be carefully collected concerning diseases of the past, especially such diseases as rheumatism, frequent tonsillitis, diphtheria, syphilis, which would normally provoke cardiovascular pathology. It is important to know the unfavourable living and working conditions, chronic exposure to cold and high humidity, nervous and psychic overstrain, hypodynamia, overeating, occupational hazards, smoking and alcohol abuse and ether harmful habits. It is also imprtant to ask the patient about cardiovascular diseases that occurred in his relatives, because familial predisposition to some, heart diseases is possible. It is necessary to inquire women about past pregnancies and labour, the onset of menopause because sometimes symptoms of cardiovascular pathology develop in them during this period.
Anamnesis:
-A complete history is essential regardless of the type of heart defect. The major categories to investigate include a history of:
– Poor weight gain, poor feeding habits, and fatigue during feeding
– Frequent respiratory infections and difficulties
– Cyanosis with or without clubbing of fingers
– Evidence of exercise intolerance in addition,
– a history of previous defects in a sibling,
– -In rheumatic fever a history of a previous streptococcal infection is of primary importance.
Examination of the heart involves the skills of inspection, palpation, percussion, and auscultation, although the latter is the most significant. Overall assessment of cardiac function involves a comprehensive evaluation of pulse, blood pressure, respiratory function, and general physical growth and development. The doctor must be familiar with the anatomy and physiology of the normal heart in order to properly evaluate the findings.
The apex is located at the left midclavicular line and fifth intercostal space or mitral area. The heart of the infant is more horizontally positioned; therefore, the apex is higher (third to fourth intercostal space) and to the left of the midclclvicular line. The apical impulse, or point of maximum impulse, is normally located at the apex.
Data of general inspection
During examination of a patient you should pay attention to his general condition, posture, motor acivity, gait, skin color, facial expressions. Labored breathing, wheezing, cough are typical for heart decompensation.
The general appearance of the patient, his posture in bed, colour of the skin and visible mucosa, the presence of abcense of edema, the shapes of the terminal finger phalanges (clubbing fingers) and the belly should be assessed.
You should notice the patient’s forced posture – for example, preference for sitting up in the left-sided heart failure. Patients with expressed dyspnea usually lay in bed with high head end, at heavy dyspnea the patient is sitting with the lowered downwards legs (opthopnea). At exudative pericarditis patients prefer to sit, a little having bent forward. At heart dilatation they more often lay on the right side, as in postion on the left side the unpleasant sensations can occur.
Observe facial expressions at rest, during conversation about specific topics, during the physical examination, and in interaction with others. For the heart diseases anxiety, depression, sweading expressions are typical.
In elevation of intrathoracic pressure swelling of neck veins is visible;
The colour of the skin is important for diagnosis of some heart diseases. A skin pallor, cyanosis or yellowness may often be revealed in the patients with heart diseases.
Cyanosis. In heart diseases cyanosis is expressed on distant from heart sites (fingers of hands and legs, tip of the nose, lips, ear bowls).
Acrocyanosis
In the case if decompensation the central cyanosis can occur. Mitral stenosis can be diagnosed by the violet-red colour of the patient’s cheeks, mildly cyanotic colour of the lips, nose, and extremities, rhe skin and visible mucosa of patients with aortal heart diseases are usually pale. Cyanosis in combination with pallor (pallid cyanosis) is characteristic of stenosis of the orifice of the pulmonary trunk or thrombosis of the pulmonary artery. Icteric colour of the sclera and skin is characteristic of grave circulatory insufficiency. The skin of patients with persisting septic endocarditis has a peculiar colour resembling that of coffee with milk.
Cyanosis in mitral stenosis
Central and peripheral cyanosis in heart diseases
Venous insufficiency is characterized by a dark bluish/purple discoloration. Over time, long standing stasis of blood leads to the deposition of hemosiderin, giving the skin a dark, speckled appearance. If the leg is placed in a dependent position, the bluish/purple discoloration may darken dramatically, further suggestive of venous insufficiency. This occurs as a result of gravity working against an already ineffective blood return system. Patients with severe arterial insufficiency, on the other hand, may have relatively pale skin as a result of under perfusion. When their legs are placed in a dependent position, gravity enhances arterial inflow and the skin may become more red as maximally dilated arterioles attempt to bring blood to otherwise starved tissues. In cases of severe ischemia, the affected areas (usually involving the most distal aspect of the foot), can appear whitish or mottled, giving the leg a marbleized appearance. Dead tissue turns black (a.k.a. gangrene)
In rheumatic fever patients sometimes develop rash (erytema annulare)
Oedema frequently attends heart diseases. In gross heart lesions venous congestion in pulmonay ciculation as well as overload of right ventricle develop. They result in venous congestion in systemic ciculation and occurence of edema. Cardiac edema appear only to the evening at first and resolve for night and placed in the area of condilus, crues and back party of feets. In heavier cases the fluid accumulates in abdominal cavity and the patients complain on feeling of weight in the abdomen. If the patient stays out of bed, oedema is localized mainly in the malleolus, the dorsal side of the feet, and the shins, where a pressure of fingers leaves slowly levelling impresions. If the patient lies in bed, oedema is localized in the sacrolumbal region.
Determination of edema
If congestion in portal system develops the pain in the right hypochondrium occurs. At a bed mode edema are located on the back side of patient’s trunk. At severe heart disease with decompensation of heart failure hydrotorax, ascites or hydropericardiunm develop.
Ascites
If oedema is significant, it may extend onto the entire body while the ascitic fluid accumulates in various cavities of the body, such as the pleural cavity (hydrothorax), abdominal cavity (ascites), or in the pericardium (hydropericardium). Generalized oedema is called anasarca. The oedematous skin, especially the skin of the extremities, is pallid, smooth, and tense. In persistent oedema, the skin becomes rigid, its elasticity is lost, and the skin acquires a brown tinge due to diapedesis of erythrocytes from the congested vessels. Linear rhexes may develop in the subcutaneous fat of i he abdomen in pronounced oedema, which resemble the scars of pregnancy. In order to assess objectively the degree of oedema, the patient should be weighed regularly and the amount of liquid taken and excreted should foe strictly recorded.
Local oedema sometimes develops in cardiovascular pathology. When the superior vena cava is compressed, for example in exudative pericarditis or aneurysm of the aortal arch, the face, neck, and the shoulder girdle can foe affected by oedema (the collar of Stokes). In thrombophlebitis of the shin or thigh oedema of the affected extremity forms; ascites develops during thrombosis of the portal vein or the hepatic veins.
While edema is a relatively common finding in the lower extremity, it rarely occurs in the arms and hands. This is because the lower extremities are exposed to greater hydrostatic pressure due to their dependent position. Upper extremity edema, when present, usually occurs focally over an area of local inflammation (e.g. cellulitis). Diffuse arm edema can occur if drainage is compromised, as when the lymphatics are disrupted following axillary lymph node surgery for staging and treatment of breast cancer. Upper extremity venous obstruction can also cause edema, though blood clots in this region are much less common then in the lower extremity.
Edema is commonly associated with venous insufficiency, a blood return problem. This disorder tends to get worse when the legs are allowed to dangle for prolonged periods below the level of the heart (e.g. towards the end of the day if the patient has been standinag for long periods of time). The fluid builds up preferentially in the most distal aspects of the leg and progress up towards the knee as the process worsens. Arterial insufficiency, on the other hand, rarely causes edema, which makes perfect sense as the problem lies in the delivery of blood to the extremity, not the return from it. On occasion, the conditions may coexist.
It may be difficult to detect small amounts of fluid. Look around the malleoli, as fluid will cause a loss of the normally distinct appearing edges of the bone. Similarly, fluid will tend to “fill in” the spaces between the extensor tendons on the top of the foot, causing them to appear less defined. If you’re not sure whether fluid is present, push on the area for several seconds, release, and then gently rub your finger over that same spot, feeling for the presence of a “divot,” referred to as pitting. Much is said about pitting edema being associated with some disease states and non-pitting with others; however, the actual importance of this distinction is probably over stated. Also note the proximal extent of the edema and if it is present to the same degree in both legs. Edema may either be diffuse, involving all of the surrounding tissue symmetrically, as is frequently the case in disorders of low oncotic or elevated hydrostatic pressure. If, however, there is a local inflammatory process, as might occur with cellulitis, the area of edema can be quite focal. There is a very subjective scale for rating edema which ranges from “trace at the ankles” to “4+ to the level of the knees.” After examining many patients, you’ll develop a sense of what is a lot and what is not.
Edema: Fluid frequently collects in the feet and ankles due to the effects of gravity.
This is related to some perturbation in the Startling forces. Thinking in broad strokes, it’s usually the result of: Increased hydrostatic pressure: Transmitted back from the level of the heart (right heart failure), liver (portal hypertension), local venous insufficiency (e.g. venous valvular incomepetence with impaired flow of blood back to the heart from the legs), lymphatic obstruction (e.g. retroperitoneal adenopathy secondary to malignancy), or obesity (which may impair both venous and lymphatic drainage).
Realize that all “circulation” problems are not the same. Disorders of blood inflow (arterial) and outflow (venous) have different associated signs and symptoms based on their varying pathophysiology (see above).
For the control of edema of dynamics one should measure the patients’ body weigh systematically and keep up the volume of fluid patient had drunk per day as well as volume of excharged urina.
Take into account, that a healthy person in the absence of a body temperature elevation looses for about 0, 5-
Splinter hemmorrhages: Short, thin, brown, linear streaks in the nails of some patients (the minority) with endocarditis
Nail growth: Nail thickening and deformity often occurs with arterial insufficicency; also with fungal infections
Skin: Any obvious growths? Shiny, hairless appearance (seen with arterial insufficiency)? Dilated or varicose superficial veins? Ulceration of the skin can occur in the setting of either venous or arterial disease.
Capillary Refill: Push on the tip of the great toe or the nail bed until blanching occurs. Then release and note how long it takes for the red color to return, a reflection of blood inflow to the distal aspect of the lower extremity. Longer then 2-3 seconds is considered abnormal and consistent with arterial insufficiency. Refill may also be delayed in the setting of significant hypovolemia, as decreased blood volume available for perfusion is shunted away from the extremities to feed more vital organs.
Skin that is discolored from venous insufficiency blanches when pushed and it generally takes more then a few seconds for the bluish hue to return. Cellulitic areas, however, blanch and then very rapidly return to their bright red coloration. This can be helpful as it will occasionally be difficult to determine if infection and venous insufficiency are both present.
Tissue death (i.e. gangrene) of the fingers secondary to severe peripheral vascular disease
Inspection of heart region (precordium)
While examining the chest, any obvious bulging is noted, especially on the left side, which may indicate cardiac enlargement. This is best done by observing the patient sitting and looking at the anterior chest wall from an angle, comparing both sides of the rib cage to each other. Normally they should be symmetric. In patients with thin chest walls, the point of maximum impulse, or apical pulse, is sometimes apparent as a pulsation. Noting the location of the impulse may give some indication of the size and positioning of the heart, especially if it deviates from the expected apical site.
Since comprehensive evaluation of cardiac function is not limited to the heart, the doctor also considers other findings, such as presence of all pulses (especially the femoral pulses), distended neck veins, peripheral cyanosis, edema, blood pressure, and respiratory status.
You should inspect the precordium, assess the apical impulse, identify the jugular venous pulsations.
During the examination the patient should be lying with his upper body somewhat elevated. If you are examining the patient’s anterior chest, visualize the underlying cardiac chambers and great vessels: the right and left ventricles, the aorta, and the pulmonary artery. Try to detect any abnormal pulsations that they can produce.
You can see cardiovascular pulsations more easy when patients are thin. In contrast, a thick wall can obscure them, and lung tissue can intervene when age or emphysema increases the anteroposterior to detect pulsations. Observe for any pulsation on the aortic, pulmonary area or the right ventricular area (lower half of the sternum and the parasternal area, espesially on the left). Observe for diffuse lift or heave. You can revealed pulsation of aortic aneurism or pulsation of increased pressure or flow in the pulmonary artery; in patients with anemia, hyperthyroidism, fever, where cardiac output is increased, a brief right ventricular impulse may be revealed in epigastrium.
In at least half of adults the apical impulse may be revealed in the apical or left ventricular area (the 5th intercostal space or just medial to the midclavicular line), especially in thin persons. Normally the apical impulse is just medial to the midclavicular line in either the 5th or 4th interspase.
The apical impulse may be displaced upward and to the left by pregnansy or a high left diafragm. It may also be displaced by deformities of the chest wall and by heart disease. When cardiac output is increased, as in anemia, hyperthyroidism, fever, or pregnansy, the apical impulse can have an increased amplitude.
Normally the apical impulse is a light tap, seen in an area about
Look and feel carefully for any extra impulses, such as those that can coincide with S3 to S4.
A rare patients has dextrocardia – a heart situated in the right chest. The cardiac impulses will then be found on the right side.
The pulsation of the abdominal aorta may often be seen in a normal person. In addition, the pulsation of the enlarged right ventricle can sometimes been seen.
At left ventricular enlargement the apical impulse may be displaced to the left and downward. It’s square occupies
Cardiac hump-back can be seen during inspection of the precordium. This is bulging of the area over the heart. The degree of protrusion depending on the enlargement and hypertrophy of the heart (provided these defects develop in childhood when the chest is liable to changes). General protrusion of the cardiac region and levelling of the costal interspaces are observed in massive effusive pericarditis. The cardiac hump should be differentiated from deformation of the chest caused by changes in the bones, e.g. in rickets.
Palpation
Palpation of the heart helps reveal more accurately the apex beat, the presence of the cardiac beat, the visible pulsation, or detect cat’s purr symptom. Palpation is useful in determine the size of the heart by feeling for the point of maximum impulse, which ordinarily corresponds to the apex.
Apex beat palpation
Technique of palpation: In order to determine the apex beat, the palm of the right hand is placed on the patient’s chest. (The left mammary gland in women is first moved upward and to the right.) The base of the hand should be rested on the sternum, while the fingers should be directed toward the axillary region, between the 3rd and 4th ribs. The terminal phalanges of three fingers should be flexed to form a right angle to the surface of the chest, and moved slowly along the interspaces toward the sternum until the moderately pressing fingers feel the movement of the heart apex. If the apex beat is felt over a considerable area, its borders are outlined hy locating the extreme left and lower points of the protruding area, which is considered to be the point of the apex beat. The apex beat can be better detected if the patient slightly leans forward, or by palpation during a deep expiration: in this position the heart is pressed closer to the chest wall.
A normal apex beat is found in the fifth interspace, 1-
Properties of the apex beat: Stable displacement of the apex beat may depend on the changes in the heart itself or the adjacent organs. For example, if the left ventricle is enlarged, the apex beat is displaced to the left to the axillary line, and downwards to the 6th and 7th interspace. If the right ventricle is dilated, the apex beat may be displaced to the left as well because the left ventricle is moved to the left by the distended right ventricle. In cases with abnormal congenital heart position, e.g. in dextrocardia, the apex beat is felt in the fifth costal interspace, 1-
In the presence of effusion or gas in the right pleural cavity, the apex beat is displaced to the left accordingly. Pleuropericardial adhesions and sclerotic affection of the lungs due to growth of connective tissue in them displace the heart to the involved side. In patients with left-sided pleurisy with effusion and in accumulation of the fluid in the pericardial region, the apex beat disappears. In about one third of cases the apex is impalpable (covered by the rib).
Pathological changes:The apex is usually at a lower interspace and more lateral in a patient with cardiac enlargement. The apex is felt by placing the fingertips or the palmar aspect of the fingers and hand at the fifth intercostal space and left midclavicular line.
Stable displacement of the apex beat may depend on the changes in the heart itself or the adjacent organs. For example, if the left ventricle is enlarged, the apex beat is displaced to the left to the axillary line, and downwards to the 6th and 7th interspace. If the right ventricle is dilated, the apex beat may be displaced to the left as well because the left ventricle is moved to the left by the distended right ventricle. In cases with abnormal congenital heart position, e.g. in dextrocardia, the apex beat is felt in the fifth costal interspace, 1-
In the presence of effusion or gas in the right pleural cavity, the apex beat is displaced to the left accordingly. Pleuropericardial adhesions and sclerotic affection of the lungs due to growth of connective tissue in them displace the heart to the involved side. In patients with left-sided pleurisy with effusion and in accumulation of the fluid in the pericardial region, the apex beat disappears. In about one third of cases the apex is impalpable (covered by the rib).
While feeling for the point of maximum impulse, the doctor notes the presence of vibratory thrills and pericardial friction rubs. Thrills are palpable vibrations most commonly produced by the flow of blood from one chamber of the heart to another through a narrowed or abnormal opening, such as a stenotic valve or a septal defect. They are best felt with the ball of the hand (palmar surface at the base of the fingers) and during expiration. Thrills feel similar to the placing of one’s hand on a purring cat.
Pericardial friction rubs are scratchy, high-pitched grating sounds, similar to pleural friction rubs, except that they are not affected by changes in respiration. This is a useful clue in differentiating the two rubs, because the pleural rub will cease if the child holds his breath, but the pericardial rub will not. Both thrills and rubs are abnormal and must be reported for further evaluation.
Percussion.
Percussion is used mainly to determine the size, position and shape of the heart by outlining its borders and to check the vascular bundle width. Dullness is normally heard over the left area of the heart and partially over the right.
The relative and absolute heart dullness, the sequence of percussion of heart dullness borders, their normal indicies
The right contour of dullness of the heart and the vascular bundle is formed (from top to bottom) by the superior vena cava to the upper edge of the 3rd rib and by the right atrium at the bottom. The left contour is formed by the left part of the aortic arch at the top, then by the pulmonary trunk, by the auricle of the left atrium at the level of the 3rd rib and downward by a narrow strip of the left ventricle. The anterior surface of the heart is formed by the right ventricle. Being an airless organ, the heart gives a dull percussion sound. But since it is partly covered on its sides by the lungs, dullness is dual in its character, i.e. it is relative (deep) and absolute (superficial). The relative cardiac dullness is the projection of its anterior surface onto the chest. It corresponds to the true borders of the heart, while the absolute dullness corresponds to the anterior surface of the heart that is not covered by the lungs. Percussion can be done with the patient in both erect and lying position. It should, however, be remembered that the area of cardiac dullness in the vertical position is smaller than in the horizontal. This is due to mobility of the heart and the displacement of the diaphragm as the patient changes his posture.
Determining relative cardiac dullness. When determining the borders of relative cardiac dullness, interspaces should be percussed in order to avoid lateral distribution of vibrations along the ribs. The percussion stroke should be of medium strength. The pleximeter-inger should be tightly pressed against the chest so that the percussion vibration might penetrate deeper regions.
When determining the border of relative dullness, the remotest points of the cardiac contour are first found on the right, then on the left, and finally at the top. Since the border of cardiac dullness depends on the position of the diaphragm, the lower border of the right lung is first determined in the midclavicular line; its normal position is at the level of the 6th rib. The position of the lower border of the lung indicates the level of the diaphragm. The pleximeter-finger is then moved one interspace above the lower border of the right lung and placed parallel to the right border of the heart being determined (normally, in the 4th costal interspace). Percussion is continued by moving the pleximeter-finger gradually along the interspace toward the heart until the percussion sound dulls. The right border of the heart is marked by the outer edge of the finger directed toward a clear resonant sound. Its normal position is
The left border of the relative cardiac dullness is determined in the interspace, where the apex beat is present. The apex beat is therefore first determined by palpation, and the pleximeter-fmger is then placed laterally of this point, parallel to the sought border, and the interspace is percussed toward the sternum. If the apex beat cannot be determined, the heart should be percussed in the 5th interspace from the anterior axillary line toward the sternum. The left border of relative cardiac dullness is located 1-
The upper border of the relative cardiac dullness is determined
Once the area of relative cardiac dullness of the heart has been established, its transverse length is measured by a measuring tape, from the extreme points of the relative dullness to the anterior median line. The normal distance from the right border of relative cardiac dullness (usually in the 4th interspace) to the anterior median line is 3 or
The shape of the heart can be determined by percussion of the borders of the vascular bundle in the 2nd intercostal space on the right and left, and of relative cardiac dullness in the 4th or 3rd interspace on the right, and in the 5th, 4th, or 3rd interspace on the left. The pleximeter-finger is moved parallel to the borders of expected dullness and the elicited points of dullness are marked on the patient’s skin. The points are then connected by a line to mark the contours of the relative cardiac dullness. Normally, an obtuse angle is formed by the lines of the left heart contour between the vascular bundle and the left ventricle. The heart is of normal configuration in such cases. In pathological conditions, when the chambers of the heart are dilated, mitral and aortal configurations are distinguished.
Displacement of the left border of relative heart dullness proved by X-ray examination.
of the right border of relative heart dullness proved by X-ray examination.
Determining absolute (superficial) cardiac dullness. The anterior wall of the heart is not covered by the lungs and the area of absolute cardiac dullness corresponds to the area of the heart. Percussion of this area gives dullness. To determine absolute dullness of the heart, light percussion strokes are needed. The right border uf absolute cardiac dullness is first elicited. The pleximeter-finger is placed on the right border of relative (deep) cardiac dullness, parallel to the sternum, and then moved medially, to the left, to dullness. The border is marked by the outer edge of the finger directed toward resonance. Iormal subjects this border parses along the left edge of the sternum.
To outline the left border of absolute cardiac dullness, the pleximeter-finger is placed slightly outside the border of relative cardiac dullness, and then moved medially to dullness. The left border of absolute cardiac dullness is normally 1-
Border’s of relative cardiac dullness
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Border |
Location |
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Right |
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upper |
The upper edge of the IV rib (at the left parasternal line) |
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Left |
1- |
Border’s of absolute cardiac dullness
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Border |
Location |
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Right |
left sternal line (4th intercostal space) |
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upper |
The upper edge of the III rib (at the left parasternal line) |
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Left |
1- |
In pathological conditions borders of absolure heart dullness can change:
The width of vessel bundle, normal indicies and pathologiocal changes
The borders of the vascular bundle are determined by light percussion in the second intercostal space, to the right and left from the midclavicular line, toward the sternum. When the percussion sound dulls, a mark should be made by the outer edge of the finger. The right and left borders of vascular dullness are normally found along the edges of the sternum; the transverse length of dullness is 5—6 cm.
The square of heart dullness, normal indicies and pathologiocal changes
The heart transverse diameter is the sum of shortest distances between the left and right borders of the relative heart dullness to the medial line. It is about 11-
The area of cardiac dullness can be modified by extracardiac factors. At high position of the diaphragm, the heart assumes a horizontal position and its transverse dimensions thus increase. When the diaphragm is low, the heart assumes the vertical position and its transverse diameter is thus diminished. Accumulation of liquid or air in one pleural cavity displaces cardiac dullness toward the healthy side; in atelectasis and pneumosclerosis, or in the presence of pleuropericardial adhesion the borders of cardiac dullness are displaced to the affected side. The area of absolute cardiac dullness markedly diminishes or disappears in pulmonary emphysema, while it increases in pneumosclerosis. The area of absolute dullness is also enlarged in the anterior displacement of the heart (e.g. by a mediastinal tumour, due to accumulation of fluid in the pericardium, or in dilatation of the right ventricle). The borders of relative dullness are displaced in the presence of enlarged heart chambers. Displacement to the right is due to dilatation of the right atrium and the right ventricle. If the left atrium or the conus of the pulmonary trunk is enlarged, the area of relative dullness is displaced upwards. Dilatation of the left ventricle displaces the area of relative dullness to the left. It should be remembered that a markedly enlarged and hypertrophied right ventricle displaces the left ventricle and can also displace the border of relative dullness to the left. Aortic dilatation increases the dullness area in the second interspace.
Examination of a pulse
A pulse is a rhythmic fluctuations of arteries walls, caused by emission of blood into arterial bed and changes of blood pressure in it during systole and diastole. With each contraction the left ventricle ejects a volume of blood (a stroke volume) into the aorta and then into the arterial tree. A pressure wave moves rapidly through the arterial system where it can be felt as the arterial pulse. The spreading of a pulse wave depends on the ability of arteries walls to elastic extension and contraction.
Perypheric arterial pulse nay be assessed at carotic, axillary, cubital, radial, femoral, popliteal arteries, arteries of the foot and abdominal aorta.
Popliteal arteries. Move down to the level of the knee allowing it to remain slightly bent. Place your hands around the knee and push the tips of your fingers into the popliteal fossa in an effort to feel the popliteal pulse. Note whether it feels simply pulsatile (normal) or enlarged and aneurysmal (uncommon). This artery is covered by a lot of tissue and can be difficult to identify, so you may need to push pretty hard. Even then, it may not be palpable, which is not clinically important if you can still identify the more distal pulses (see below).
Pulses are assessed to identify the presence of arterial vascular disease. In general, the less prominent the pulses, the greater the chance that there is occlusive arterial disease. This is not a perfect correlation, however, as pulses may be palpable even when significant disease is present (e.g. may be affecting predominantly smaller, more distal blood vessels). A history of pain/cramps with activity suggestive of arterial insufficiency is also of great importance. The location of the blockage(s) will dictate the symptoms and findings. Aorto-iliac disease, for example, will cause symptoms in the hips/buttocks and a loss of the femoral pulse while disease affecting the more distal vessels will cause symptoms in the calves and feet
Properties of the pulse are assessed at the radial artery.
First the examiner should determine if the pulse can be equally felt on both arms. To that end both radial arteries should be palpated simultaneously he magnitude of pulse waves on both hands compared (normally it is the same). The pulse on one arm may happen to be lower (in unilateral structural abnormalities in peripheral course of the artery, its constriction, compression by a tumor etc.). Pulse may also be different when similar changes occur in in the brachial or subclavial artery, or due to compression of large arterial trunk by the aortic aneurism, mediastinal tumor, retrosternal goiter, or markedly enlarged left atrium.
Rrhythm. In healthy individuals cardiac contractions and pulse waves follow one another at regular intervals: the pulse is said to be rrhythmic or regular. Some pulse waves nat be missed or they may appear prematurely (in extrasystole) or pulse waves follow one another at irregular intervals ( fibrillation).
Pulse rate iormal conditions corresponds to the rate of cardiac contractions and is 60-80 per min.
If the pulse is arrhythmic the heart bets should be counted and compared with the pulse rate. During the frequent and irregular contractions of the heart, some systoles of the left ventricle can be so weak that the blood is not ejected into the aorta or the amount of blood is very small and the pulse wave does not reach the peripheral arteries. The difference between heart and pulse rate is called the pulse difficit while the pulse itself is called pulsus defcicens.
Pulse pressure is determined by the force that should be applied to the pulsating artery to compress it completely. This property depends on the magnitude of the systolic arterial pressure. If arterial pulse is normal, the artery can be compressed bya moderate pressure. A normal pulse is therefore of moderat tension. The higher the pressure, the more difficult is it to compress the artery (dull pulse or pulsus durus). If the arterial pressure is small, the artery is easy to compress and the pulse is called soft (pulsus mollis).
Volume of pulse. Pulse volume shows the artery filling with blood, which is turn depends on the amount of blood that is ejected during systole into the arterial system and which produses variations in the artery volume. Pulse volume depends on the stroke volume, on the total amount of circulating blood, and its diatribution in the body. If the stroke volume is normal and the artery is sufficiently filled with blood, the pulse is said to be full (pulsus plenus)/ In abnormal circulation and blood loss, pulse volume decreases (pulsus vacuus)/
Pulse size – implies filling and tension.
If the pulse pressure and filling are high the pulse is called large-volume pulse or pulsus magnus or pulsus
The pulse wave my be quite insignificant in shock, acute cardiac failure and massive loss of blood. This pulse is called thready (pulsus filiformis).
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Properties of pulse on radial artery: symmetry (synchronous or asynchronous), frequency (accelerated, slowed, the pulse rate), rhythm (rhythmic, arhythmic), tension (of moderate tension, dull, soft), feeling (full, empty), size (high, small, thready), character (quick, slow), pulse deficiency (indicate the number of missing waves per min). Presence of pulse on carotic, temporal, subclavial, femoral arteries, a.poplitea, a.dorsalis pedis, abdominal part of aorta, jugular veins.Quincke’s (capillary) pulse.
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Methods of blood pressure measuring; principles of definition of blood pressure by N.S.Korotkov:
Blood pressure in the arterial system varies with the cardiac cycle, reaching a systolic peak and diastolic trough, the levels of which are measured by sphygmomanometer. The difference between systolic and diastolic pressures is known as the pulse pressure.
The technique. The patient should be as comfortable and relaxed as possible, his arm free of clothing. Center the inflatable bagover the brachial artery on the inside of the arm. The lower border shoud be about
With the thumb or fingers of one hand resting on the brachial artery, rapidly inflate the cuff to about
Now place the bell of a stethoscope lightly over the brachial artery. Inflate the cuff again, to about
Continue to lower the pressure slowly until the sounds become muffled and then disappear. Then deflate the cuff rapidly to zero. The disappearance point, which is usually only a few mm Hg below the muffling point, marks the diastolic pressure.
Blood pressure should be taken in both arms at least once. Normally there may be a difference in pressure of
The normal and changed indicies of blood pressure:
Upper limit of normal blood pressure in adults have traditionaly been set on 140\90 mm of Hg. Even the lower of these two criteria would be suspiciously high, however, in a young adult. The indices of blood pressure above this limit should be interpreted as an arterial hypertension. But blood pressure readings on at least three separate visits should usually taken before making a diagnosis of hypertension.
Lower limits of normal blood pressure, sometimes estimated at 90\60 in adults, should always be interpreted in the light of past reading and the patient’s present clinical state.
Heart auscultation
Auscultation of a heart
Auscultation involves listening for heart sounds with the stethoscope, similar to the procedure used in assessing breath sounds.
The sites of projections of the valves on the anterior chest wall are very close to one another. The mitral valve projects to the left of the sternum, at the 3rd costosternal articulation, and the tricuspid valve, on the sternum midway between the 3rd left and 5th right costosternal articulations The valve of the pulmonary trunk is projected in the 2nd intercostal space, to the left of the sternum, the aortic valve is projected in the middle of the sternum, at the level of the 3rd costosternal articulation. Since all heart valves are projected on a small area of the chest, it is difficult to decide which of them is damaged if the valves are auscultated at sites of their actual projections.
Where to place your stethoscope
As with palpation of the heart, auscultation should proceed in a logical manner over 4 general areas on the anterior chest, beginning with the patient in the supine position. The 4 percordial areas are examined with diaphragm, including:
1. Aortic region (between the 2nd and 3rd intercostal spaces at the right sternal border) (RUSB – right upper sternal border).
2. Pulmonic region (between the 2nd and 3rd intercostal spaces at the left sternal border) (LUSB – left upper sternal border).
3. Tricuspid region (between the 3rd, 4th, 5th, and 6th intercostal spaces at the left sternal border) (LLSB – left lower sternal border).
4. Mitral region (near the apex of the heard between the 5th and 6th intercostal spaces in the mid-clavicular line) (apex of the heart).
The auscultatory areas are as follows: (1) the area of the apex beat for the mitral valve because the vibrations are well transmitted by the muscle of the left ventricle and the cardiac apex is at the nearest distance to the anterior chest wall during systole; (2) the lower part of the sternum near its junction with the xiphoid process (the right-ventricular area); for the tricuspid valve; (3) the valve of the pulmonary trunk is best heard at its anatomical projection onto the chest, i.e. in the second intercostal space, to the left of the sternum; (4) the aortal valve is best heard in the second intercostal space, to the right of the sternum where the aorta is the nearest to the anterior chest wall. Moreover, the heart sounds which are associated with the contractions of the aortic valve or which develop during its affections can be heard to the left of the sternum at the 3rd and 4th costosternal articulation (the so-called fifth listening post at the Botkin-Erb point).
The first sound is produced by several factors. One of them is the valve component, i.e. vibrations of the cusps of the atnoventicular valves during the isometric contraction phase, when the valves are closed. The second component is muscular, and is due to the myocardial isometnc contraction. The intensity of myocardial and valvular vibrations depends on the rate of ventricular contractions: the higher the rate of their contractions and the faster the intraventricular pressure grows, the greater is the intensity of these vibrations. The first heart sound will thus be more resonant. The third component of the first heart sound is the vascular one. This is due to vibrations of the nearest portions of the aorta and the pulmonary trunk caused by their distention with the blood during the ejection phase. The fourth component is atrial; it is generated by vibrations caused by atrial contractions. This fourth component gives rise to the first sound since the atrial systole precedes the ventricular systole. Vibrations caused therefore possible to find certain sites on the chest where sounds of eac valve can be better heard.
The first sound is produced during systole, after a long pause. It is best heard at the heart apex since the systolic tension of the left ventricle is more pronounced than that of the right ventricle. The first sound is longer and louder than the second heart sound. The second sound is generated during diastole, after a short pause, and is best heard at the heart base because it is produced by the closure of the semilunar cusps of the aortic and pulmonary trunk valves. As distinct from the first sound, the second sound is shorter and higher. The tone of the heart sounds may by the atrial systole are normally blended with vibrations caused by the ventricular systole, and are heard as one sound.
Perception of sounds generated in the heart depends on the distance from the valve to its projection on the chest wall and on sound conduction by the course of the blood flow It is change in pathology, and in order to differentiate between the first and second sounds it should be remembered that the first sound coincides in time with the apex beat (if the latter can be palpated) or with the pulse of the aorta and the carotid artery.
Intensity of the heart sounds may depend on conditions of the sound wave transmission, i.e. on the extracardiac causes. If subcutaneous fat or muscles of the chest are overdeveloped, or there are lung emphysema, liquid in the left pleural cavity, and some other affections that separate the heart from the anterior chest wall, the intensity of the heart sounds decreases. If conditions for sound transmission are improved (thin chest wall, the lung edges are sclerosed, the heart is pressed against the anterior chest wall by a growing tumour in the posterior mediastinum, etc.), the intensity of the heart sounds increases. The sounds can also be increased by the resonance in large empty cavities filled with air (a large cavern in the lung, large gastric air-bubble). The intensity of the heart sounds also depends on the composition of the blood flowing through the heart: if the blood viscosity decreases (in anaemia) the intensity increases.
The intensity of the heart sounds can decrease in decreased myocardial contractility in patients with myocarditis, myocardial dystrophy, cardiosclerosis, collapse, and accumulation of fluid in the pericardial cavity.
Both heart sounds can be increased due to the effect of the sympathetic nervous system on the heart. It occurs in physical and emotional strain, during exercise, and in patients with exophthalmic goitre. Changes in only one heart sound is very important diagnostically.
First heart sound diminishes in the mitral and aortic valve insufficiency. The cusps of the affected mitral valve fail to close completely the left atrioventricular orifice during systole. Part of the blood is thus regurgitated to the left atrium. The pressure of the blood against the ventricular walls and the cusps of the mitral valve is below normal, and the valvular and muscular components of the first heart sound markedly diminish. The period of closed valves is absent also during systole in the aortic valve insufficiency. It means that the valvular and muscle components of the first heart sound will also diminish significantly.
The second sound can be inaudible over the aorta if the aortic valve is much destroyer The second sound diminishes over the aorta in cases with marked hypotension; the second sound diminishes over the pulmonary trunk in cases with aortic valve incompetence (in very rare cases) and in decreased pressure in the lesser circulation.
Two other heart sounds – S3 and S4 – may be produced. S3 is the result of vibrations produced during ventricular filling. It is normally heard only in some children and young adults, but it is considered abnormal in older individuals. S4 is caused by the recoil of vibrations between the atria and ventricles following atrial contraction, at the end of diastole. It is rarely heard as a normal heart sound; usually it is considered indicative of further cardiac evaluation.
The third sound is caused by vibrations generated during quick passive filling of the ventricles with the blood from the atria during diastole of the heart; it arises in 0.15—1.12 s from the beginning of the second sound.
The fourth sound is heard at the end of ventricular diastole and is produced by atrial contractions during quick filling of the ventricles with blood.
The third and fourth sounds are low-pitch and soft and are therefore hardly heard iormal subjects. But they are clearly seen on a phonocardiogram. These sounds are better heard in immediate (direct) auscultation. The presence of the third and fourth sounds in the middle-aged usually indicates severe affection of the heart muscle.
A gallop rrhythm is auscultated in the case of increased intesity of III or IV sounds. The third heart sound results from vibration originating within the left ventricular walls, as this chamber active rapid expensil motion is a abruptly halted in early diastole. This sound is auscultated at direct above an apex of a heart, the best position when the ill lies. On PG adventitious III sound will be distant from beginning of the II sound on 0,12-0,15 sec. The occurence of pathological cardiac sound is conditioned by contraction of hypertrophic left atrium at loss of muscular component of ventriclularcontraction what cause by presence in ventriles of inflammatory-degenerative processes. On PCG it arises after 0,08-0,14 sec. from top of wave P on electrocardiogram, almost coincides with the end of the last one. In childrens and adolescents the IV sound is considered physiological. Presence of this sound in adult and elderly peoples is considered as a pathology, and in these cases it is called pathological IV sound.
Gallop rrhythm occurs at heavy lesions of cardiac muscle (inflammatory, degenerative, toxic), it is called as ” cry of a heart for help”.The gallop rrhythm is conditionally divides into protodiastolic (intensified III sound arises up though 0,12-0,2 sec. after second sound), mesodiastolic(at tachicardia descend coalescence of III and IV sounds and it is accepted at auscultation as a single sound) and presystolic (is conditioned by pathological IV cardiac sound). A gallop rhythm is better auscultated directly by ear (together with a note is accepted mild impetus transmitted from heart on thoracal cage in diastole phase) in the apical region at left lateral recumbent position of the patient, in III- IV intercostal spaes to the left.
Triple rrhythm (Rhithmus coeturnici) is a cardiac rhythm which is auscultated only in mitral stenosis and arises if there is presence of such an adventitious sound as mitral click (or sound of opening of mitral valve) together with slapping first and second sounds. Slapping I sound (intensified I sound) is conditioned by fast reduction of left ventricle which is insufficiently filled with blood in diastole phase and oscillations of sclerotic usps of mitral valve, which one in diastole were in more relaxing condition because of small filling by blood the left ventricle. On PCG the mitral click arises over 0,05-0,13 sec. after II sound and it creates the visibility of dualization of this sound, however as against true dualization is better auscultated on an apex of heart instead of for the basis. It causes by sudden effort of sclerotic valve cusps at transit of blood from the left atrium into the left ventricle. The interval teh II sound and mitral click becomes more short, if stenosis is expressed more strongly. Rhithmus coeturnici is auscultated above heart apex and is conducted upwards and toward the axillary fossa.
In the case of pendulum rhythm the large (diastolic) heart pause is so shortened, that becomes an equal to small (systolic) pause. The sound phenomenon, which one arises thus, reminds of even pendulum swinging. Such rhythm disturbance meets usually at heavy lesions of heart muscle . If pendulum rhythm is accompaning by sharp heart acceleration, this phenomenon is called as embriocardia.
An extra-pericardial-sound can occur in pericardial adhesion. It occures during diastole, 0.08-0.14s after the second sound, and is generated by the vibrating pericardium during the rapid dilatation of the ventricles at the beginning of diastole. The extra sound in adhesions in the pericardium can also arise during systole, between the first and the second heart sounds. This short and loud sound is also known as the systolic click. A place of best auscultation is teh bottom of breastbone.
