© continuing medical implementation …...bridging the care gap palpation feel for diagnosis

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

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

© Continuing Medical Implementation …...bridging the care gap

PalpationPalpation

Feel for diagnosis

Page 2: © Continuing Medical Implementation …...bridging the care gap Palpation 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

Page 3: © Continuing Medical Implementation …...bridging the care gap Palpation Feel for diagnosis

© Continuing Medical Implementation …...bridging the care gap

Palpation-PulsesPalpation-Pulses

• Rhythm, rate, regularity• Contour• Water hammer pulse-AR• Brachial-radial delay AS• Pulsus paradoxus

– Tamponade– COPD

• Pulsus alternans– LV dysfunction

Page 4: © Continuing Medical Implementation …...bridging the care gap Palpation Feel for diagnosis

© Continuing Medical Implementation …...bridging the care gap

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

Page 5: © Continuing Medical Implementation …...bridging the care gap Palpation Feel for diagnosis

© Continuing Medical Implementation …...bridging the care gap

Palpation - Precordium Palpation - Precordium

Parasternal:– Palpable P2-pulmonary HTN

• Thrill– VSD/HCM

• RV lift– RVH– Severe MR

Page 6: © Continuing Medical Implementation …...bridging the care gap Palpation Feel for diagnosis

© Continuing Medical Implementation …...bridging the care gap

Precordium-PalpationPrecordium-Palpation

Parasternal

• Lift: RVE or severe MR

• Thrill: VSD, HOCM (IHSS)

• Palpable P2 (ULSB): pulmonary hypertension

• Medial retraction LVE

• Lateral retraction RVE

Page 7: © Continuing Medical Implementation …...bridging the care gap Palpation Feel for diagnosis

© Continuing Medical Implementation …...bridging the care gap

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)

Page 8: © Continuing Medical Implementation …...bridging the care gap Palpation Feel for diagnosis

© Continuing Medical Implementation …...bridging the care gap

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

Page 9: © Continuing Medical Implementation …...bridging the care gap Palpation Feel for diagnosis

© Continuing Medical Implementation …...bridging the care gap

Sustained Apex: • correlates with pressure overload• ( > 2/3 systole-hangs out to S2)• AS, LVH or LV systolic 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

Page 10: © Continuing Medical Implementation …...bridging the care gap Palpation Feel for diagnosis

© Continuing Medical Implementation …...bridging the care gap

Apex–Dynamic AbnormalitiesApex–Dynamic Abnormalities

Atrial kick:

• Palpable S4– Loss of LV compliance– LVH 2o Hypertension– Aortic Stenosis– Hypertrophic Cardiomyopathy

Page 11: © Continuing Medical Implementation …...bridging the care gap Palpation Feel for diagnosis

© Continuing Medical Implementation …...bridging the care gap

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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