© continuing medical implementation …...bridging the care gap palpation feel for diagnosis
TRANSCRIPT
© Continuing Medical Implementation …...bridging the care gap
PalpationPalpation
Feel for diagnosis
© Continuing Medical Implementation …...bridging the care gap
PalpationPalpation
• By the time you put stethoscope to chest you should know what you are going to hear
• If you don’t hear what you expect,explain it
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Palpation-PulsesPalpation-Pulses
• Rhythm, rate, regularity• Contour• Water hammer pulse-AR• Brachial-radial delay AS• Pulsus paradoxus
– Tamponade– COPD
• Pulsus alternans– LV dysfunction
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Carotid ExaminationCarotid Examination
• Carotid upstroke
– brisk, normal or delayed
– bisferiens or anacrotic
– volume: normal, increased or decreased
• Carotid auscultation
– Bruit
– Transmitted murmur
– A2 audible in neck? Presence excludes severe AS
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Palpation - Precordium Palpation - Precordium
Parasternal:– Palpable P2-pulmonary HTN
• Thrill– VSD/HCM
• RV lift– RVH– Severe MR
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Precordium-PalpationPrecordium-Palpation
Parasternal
• Lift: RVE or severe MR
• Thrill: VSD, HOCM (IHSS)
• Palpable P2 (ULSB): pulmonary hypertension
• Medial retraction LVE
• Lateral retraction RVE
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Palpation - ApexPalpation - Apex
Apex: • Palpable in 1 of 5 adults age 40• Best felt with fingertips or finger pads
Normal Location:• No more than 10 cm from mid-sternal line in the
supine position • Left decubitus position not reliable for apical locationNormal Size:• No larger than 3 cm (about 2 finger breadths)
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Apex-Dynamic QualitiesApex-Dynamic Qualities
• LV impulse outward movement like a ping pong ball were protruding between the ribs
• Apex moves outward for the first third of systole and falls away rapidly
• Lasts for no more than 2/3 of systole
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Sustained Apex: • correlates with pressure overload• ( > 2/3 systole-hangs out to S2)• AS, LVH or LV systolic dysfunctionHyperdynamic Apex:• correlates with volume overload AR/MR• palpable S4 (atrial kick)• palpable S1 (MS)• palpable non-ejection click (MVP)
Apex–Dynamic AbnormalitiesApex–Dynamic Abnormalities
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Apex–Dynamic AbnormalitiesApex–Dynamic Abnormalities
Atrial kick:
• Palpable S4– Loss of LV compliance– LVH 2o Hypertension– Aortic Stenosis– Hypertrophic Cardiomyopathy
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Non-invasive ejection fraction
Non-invasive ejection fraction
Palpable S4/ apex not sustained
• EF > 50%
Palpable S4/ Apex sustained
• EF 40-50%
S4 not palpable/ Apex sustained
• EF < 40%
TITLE: The apical impulse in coronary heart disease.
AUTHORS: Ranganathan N; Juma Z; Sivaciyan V
SOURCE: Clin Cardiol 1985 Jan;8(1):20-33
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