carotids can only be observed in healthy persons; this pulsation is synchronous with the apex beat. In pathological conditions, mainly in aortic valve incompetence, pronounced pulsation of the carotid arteries can be observed (“carotid shudder”). Synchronously with pulsation of the carotid arteries, the head of the patient may rhythmically move. This is de Mussel's sign. Pulsation of arteries, e.g. subclavian, brachial, radial and other arteries can also be observed.
Even arterioles may pulsate (the so-called capillary pulse). In order to reveal the capillary pulse, the finger nail should be slightly pressed in order to form a small white spot: the margin between the red and blanched part will be seen to ebb and flow with each pulse beat. Similar pulsation can be seen on hyperaemic skin, e.g. of the forehead, after rubbing it. The name "capillary pulse" is not quite correct because it mostly depends on pulse variations in the arterioles. Capillary pulse can be found in patients with aortic valve failure and sometimes in thyrotoxic goitre.
During inspection of the veins the physician can observe their overfilling and dilation. This picture is found in general venous congestion and also in local disorders of blood outflow from the veins. The general venous congestion is caused by affection of the right heart and also by diseases that increase intrathoracic pressure and interfere with the outflow of venous blood through the venae cavae. The neck veins are dilated and become swollen. Local congestion is caused by compression of the vein from the outside (tumour, scars, etc.), or by its thrombosis. Local venous stasis is characterized by dilation of collaterals, while edema is formed at the site where blood outflows through the corresponding vein. In conditions of difficult outflow of blood through the superior vena cava, there are dilated veins of the head, neck, upper extremities, and the anterior surface of the trunk. In conditions of difficult blood outflow through the inferior vena cava, the veins of the lower extremities and lateral surfaces of the abdominal wall are dilated. The blood flow in this case is directed into the system of the superior vena cava, i.e. upwards. If the blood outflow through the portal vein is difficult, the collaterals, connecting the system of the portal vein with the vena cava, become arranged round the umbilicus to form the caput Medusae and the blood is directed through the dilated superficial veins to the system of the superior and inferior vena cava. In order to determine the direction of the blood flow in dilated veins, a length of a thick vein is pressed by the finger (after the blood is displaced from it). As the vein becomes filled, the direction of the blood flow can easily be determined: when it is directed downward, the vein portion lying above the compressed site is filled, it is directed upward when the part below this point is filled.
Jugular veins can be seen pulsating on the neck. Blood flow in the jugular vein is slowed down during atrial systole and accelerated during ventricular systole. The neck veins somewhat swell when the blood flow
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slows down, and collapse when the blood flow is accelerated. It follows that the veins collapse during systolic dilation of the arteries. This is the so-called negative venous pulse. It is hardly noticeable in healthy persons and becomes more evident when the veins are filled with blood due to congestion. Pulsation of the jugular veins caused by pulsation of the carotid arteries can be mistaken for the venous pulse. It should therefore be remembered that pulsation of the carotid artery can be seen medially of the sternocleidomastoid muscle, while pulsation of the vein laterally of this muscle. Moreover, if the vein is pressed by a finger along its course, the transmitted vibrations of the peripheral portion of the vein become more visible, whereas pulsation of this portion discontinues in genuine venous pulse. Distinct pulsation of the neck vessels in the presence of a slow pulse on the radial artery is caused by venous and not by arterial pulsation. The positive venous pulse presents in a failure of the three-cuspidate valve because of the backward wave of a blood from a right ventricle in a dextral auricle at a ventricular systole detains outflow a blood from veins in auricles, and veins swell simultaneously with appearance of arterial pulse wave.
Palpation of the heart
Palpation of the heart helps to reveal more accurately the apex beat, the presence of the cardiac beat, to find other pulsations, or detect “cat's purr“ symptom.
Palpation of the apex beat
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 distal 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 localization are outlined by locating the extreme left and lower point 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. If the apex beat is palpable, its properties are determined: localization; area; height; resistance.
Localization of the apex beat. A normal apex beat is found in the fifth interspace, 1—1.5 cm toward the sternum from the left midclavicular line. When the patient lies on his left side, the beat is displaced 3-4 cm to the left, and - 1.5 cm to the right when the patient lies on the right side. 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
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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 -1.5 cm toward the sternum from the right midclavicular line.
The position of the apex beat depends also on the diaphragm. Increased Pressure in the abdominal cavity (in pregnancy, ascites, meteorism, tumours) displaces the apex beat upward and to the left because the heart is not only lifted but also turned to the left to assume a horizontal position. If the diaphragm is low (after childbirth, wasting, visceroptosis), the apex beat is displaced downward and slightly to the right to assume the more vertical position.
Area (width) of the apex beat. The width of an apex beat is defined after a finding its localization. The 3-rd finger of the right arm is placed at the point of localisation of the apex beat, and 2-nd finger is displaced further the extreme right point of the pulsating area. The distance between two marks corresponds to width of the apex beat. Normal width of the apex beat is 1-2 sm. Considering that the apex beat in norm is localized in one intercostal space, and distance between two ribs equally 1 sm it is possible to calculate the area of an apex beat, having multiplied its width by 1 sm. In norm the area of the apex beat 1-2 см2. If the area is smaller than 1 см2, the apex beat is restricted. If the area exceeds more than 2 см2, the apex beat is considered diffused.
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).
The most frequent and important diagnostic cause of diffuse apex beat is enlargement of the heart, especially of the left ventricle. The width of the apex beat may increase also due to a closer contact of the heart apex to the chest wall in patients with thin thoracic wall, wide interspaces, sclerotic affection of the lower border of the left lung, displacement of the heart anteriorly by a growing tumour of the mediastinum, etc. The area of the apex beat decreases in patients with developed or edematous subcutaneous fat tissue, narrow interspaces, emphysema of the lungs, and low diaphragm.
Height of the apex beat is the amplitude of vibration of the chest wall at the apex beat area.
For definition height of the apex beat the 3-rd finger is displaced perpendicularly to the chest wall at the point of a maximal pulsation. If the
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finger feels a pressing of mild tissues of the distal phalanx, it is moderate height of the apex beat. In case of distal phalanx deflection synchronously with a pulsation it is a high apex beat. At a weak sensation of a pulsation without pressing of mild tissues of a phalanx it is a low apex beat.
Normally it is moderate height of the apex beat. At a pathology, and sometimes and in norm, apex beat can become high or low. This property of the apex beat usually varies with the width. Moreover, the height of the apex beat depends on the contractile strength of the heart. When a person is excited, performs exercises, or has fever, or thyrotoxicosis, the height of the apex beat increases due to the increased contractions of the heart.
Resistance of the apex beat is estimated by resistance that is felt by palpating finger at attempt to prevent pulsations of the apex beat. For this purpose a physician presses with 3-th finger of the right arm perpendicularly to the chest wall in a place of a maximal pulsation. Normal resistance of the apex beat is moderate. If expressed resistance at attempt to prevent pulsations with a pressing of palpating finger it is a resistant apex beat.
Like the former two properties, the resistance of the apex beat depends on thickness of the chest wall and the distance from the heart apex to the examining fingers; but it depends mostly on the strength of contractions of the left ventricle and density of the heart muscle. Density of the left ventricular muscle considerably increases with its hypertrophy to cause resistant apex beat. Hypertrophy of the left ventricle is characterized by diffuse, high, and resistant apex beat. In pronounced hypertrophy of the left ventricle attended by its dilation, the apex of the heart becomes tapered and can be felt by the palpating fingers as a dense and firm dome.
Extra-apical pulsations
Aortic pulsation is not palpable in healthy subjects (except in asthenic persons with wide costal interspaces). Palpation can be used to detect pulsation of the aorta during its distension. If the ascending part of the aorta is dilated, pulsation can be felt to the right of the sternum, and if the aortic arch is dilated, the pulsation can be felt in the region of the sternal manubrium. Aneurysm or pronounced dilation of the aortic arch is characterized by pulsation in the jugular fossa (retrosternal pulsation). Thinning and usuras of the ribs or the sternum can be caused by the pressure of the dilated aorta.
Epigastric pulsation, i.e. visible protrusion and retraction of the epigastric area, is synchronous with the heart work, and may depend not only on hypertrophy of the right ventricle, but on the pulsation of the abdominal aorta and the liver. Epigastric pulsation due to hypertrophy of the right ventricle is usually felt under the xiphoid process and becomes especially vivid during deep inspiration, whereas pulsation caused by the abdominal aorta is slightly lower and becomes less marked during deep inspiration.
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Intact abdominal aorta can pulsate in asthenic patients with a flaccid abdominal wall.
Pulsation of the liver can be detected by palpation. True and transmitted pulsations of the liver are distinguished. The true liver pulsation is the so-called positive venous pulsation; it may be seen in patients with tricuspid valve incompetence. During systole, the blood flows back from the right atrium to the inferior vena cava and hepatic veins. The liver therefore swells rhythmically with each heart contraction. The transmitted liver pulsation depends on the impulses transmitted by the contracting heart. Each systolic contraction displaces the entire mass of the liver in one direction.
The symptom of a cat's purr, i.e. low vibrating murmur, resembles purring of a cat. It is of great value in the diagnosis of heart diseases. This sign depends on the same causes that are responsible for the murmur arising in stenosed valve orifices. In order to determine the thrill, the palpating hand should be placed flat on the points where the heart is normally auscultated. Cat's purr palpated over the heart apex during diastolic contraction is characteristic of mitral stenosis, and thrills felt over the aorta during systole indicate stenosed aortic orifice.
Palpation of the arterial pulse
Palpation of the arterial pulse is the main method of examination of pulse. As a rule, pulse is studied first on the radial artery, since it is superficial and runs immediately under the skin and can thus be readily felt between the styloid process of the radial bone and the tendon of the internal radial muscle. The patient's hand is grasped by the examiner so that the thumb of the right hand is placed on the dorsal side of the arm (near the radiocarpal joint) while the other fingers remain on the frontal side of the arm. As soon as the artery is found, it is pressed against the underlying bone. The pulse wave is felt by the examining fingers as a dilation of the artery. The pulse may be different on different arms, and therefore it should first be palpated simultaneously on both radial arteries.
Palpation of arterial wall allows define the following properties of pulse: -similarity (uniformity) of pulse on both arms;
-rhythm of pulse, frequency (pulse rate),
-condition of the vascular wall,
-filling (volume) of pulse,
-strain (pressure) of pulse,
-size of pulse,
-deficiency of pulse.
Palpation of pulse begins with research of pulse on both arms. In norm pulse is identical on both arms. If pulse is identical on both arms following researches of its characteristics is performed on one hand. At presence of
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