PercussionPercussion

The chest is percussed to confirm the cardiThe chest is percussed to confirm the cardiac borders, size, contour and position in thac borders, size, contour and position in the thorax. e thorax.

Relative cardiac dullness(Relative cardiac dullness( 心相对浊音界心相对浊音界 ))

Absolute cardiac dullness(Absolute cardiac dullness( 心绝对浊音界心绝对浊音界))

Method of percussion for heartMethod of percussion for heart

Patient should lie supine on an examinPatient should lie supine on an examining table or sit on the chair, with the phing table or sit on the chair, with the physician at his right side. Usually we emysician at his right side. Usually we employ indirect percussion(ploy indirect percussion( 间接叩诊法间接叩诊法 ) ) for percussing heart borders. for percussing heart borders.

Many beginners, in attemptng to outlinMany beginners, in attemptng to outline the cardiac dullness, strike too forcible the cardiac dullness, strike too forcibly and thus fail to hear the slight change y and thus fail to hear the slight change in the percussion note caused by the thiin the percussion note caused by the thin layer of overlying lung.n layer of overlying lung.

One should use the lightest percussion One should use the lightest percussion possible and, with experience, rely possible and, with experience, rely more and more upon the vibratory more and more upon the vibratory sense.sense.

Percussion with finger parallelPercussion with finger parallel to cardiac outlinesto cardiac outlines

Percussion with finger at right Percussion with finger at right

angle to cardiac outlineangle to cardiac outline

The orthopercussion(The orthopercussion( 直指叩直指叩诊法诊法 ) method of Plesch is car) method of Plesch is carried out by flexing the left midried out by flexing the left middle finger to a right angle, pladle finger to a right angle, placing the pulp of the finger on tcing the pulp of the finger on the area to be percussed, and thhe area to be percussed, and then striking the flexed finger at en striking the flexed finger at the distal end of the first phalathe distal end of the first phalanx.nx.

This method is recommended in the This method is recommended in the percussion of absolute cardiac dullness, percussion of absolute cardiac dullness, and give excellent results comparing and give excellent results comparing with ordinary methods.with ordinary methods.

It is outlined by percussing in the 5th, 4It is outlined by percussing in the 5th, 4th, 3rd and 2nd interspace on the left seth, 3rd and 2nd interspace on the left sequentially, starting near the axilla and quentially, starting near the axilla and moving medially until cardiac dullness moving medially until cardiac dullness is encountered. is encountered.

PercussionPercussionPercussionPercussion

The beginner should mark with a skin The beginner should mark with a skin pencil where the note changes. The distpencil where the note changes. The distance from midsternal line to the left boance from midsternal line to the left border should be measured and recorded, rder should be measured and recorded, measurement should be made along a smeasurement should be made along a straight line paralleled to the transverse traight line paralleled to the transverse diameter in the thoraxdiameter in the thorax. .

Heart bordersHeart borders

Right border of the heartRight border of the heart

formed byformed by

sup vena(sup vena(上腔静脉上腔静脉 ), ascendin), ascending aorta(g aorta(升主动脉升主动脉 ), right atrium(), right atrium(右右心房心房 ))

Left border of the heartLeft border of the heart

formed byformed by

aorta arch(aorta arch(主动脉弓主动脉弓 ), pulmonary ), pulmonary arterial trunk(arterial trunk( 肺动脉段肺动脉段 ), left atria ap), left atria appendage(pendage(左心房左心房 ), LV(), LV(左心室左心室 ))

Inferior border of the heartInferior border of the heart

formed byformed by

RV(RV( 右心室右心室 ), lesser extent LV), lesser extent LV

Normal heart dullnessNormal heart dullness

rightright(cm)(cm) ICS,MSL left ICS,MSL left(cm)(cm)

2-3 2-3Ⅱ2-3 2-3Ⅱ 2-3 3.5-4.5Ⅲ2-3 3.5-4.5Ⅲ 3-4 5-6Ⅳ3-4 5-6Ⅳ Ⅴ Ⅴ 7-97-9

Normally from midsternal line to MCL is about 8-10cmNormally from midsternal line to MCL is about 8-10cm

Physiologic changes in the area Physiologic changes in the area of cardiac dullnessof cardiac dullnessPhysiologic changes in the area Physiologic changes in the area of cardiac dullnessof cardiac dullness

The position of the heart, and with it The position of the heart, and with it the area of cardiac dullness, is the area of cardiac dullness, is influenced by the level of the influenced by the level of the diaphragm.diaphragm.

In deep inspiration the diaphragm In deep inspiration the diaphragm descends, producing a decrease in descends, producing a decrease in cardiac dullness, while in forced cardiac dullness, while in forced expiration the diaphragm rises and expiration the diaphragm rises and produces an increase in the cardiac produces an increase in the cardiac dullness.dullness.

In the later months of pregnancy the diIn the later months of pregnancy the diaphragm is pushed upward, causing the aphragm is pushed upward, causing the heart to lie more horizontally and closeheart to lie more horizontally and closer to the chest wall, thus increasing the ar to the chest wall, thus increasing the area of cardiac dullness.rea of cardiac dullness.

Cardiac dullness in Cardiac dullness in abdominal distentionabdominal distentionCardiac dullness in Cardiac dullness in abdominal distentionabdominal distention

A variety of pathologic conditions such A variety of pathologic conditions such as ascites, an ovarian cyst(as ascites, an ovarian cyst( 卵巢囊肿卵巢囊肿 ), ), or peritonitis(or peritonitis( 腹膜炎腹膜炎 ) may cause an e) may cause an elevation of the diaphragm with an increlevation of the diaphragm with an increase in the area of cardiac dullness.ase in the area of cardiac dullness.

Changes in position of Changes in position of cardiac dullnesscardiac dullnessChanges in position of Changes in position of cardiac dullnesscardiac dullness

A left-sided pleural effusion(A left-sided pleural effusion( 胸腔积液胸腔积液) will push the heart to the right, and inc) will push the heart to the right, and increase the cardiac dullness to the right of rease the cardiac dullness to the right of sternum, the left border in such cases casternum, the left border in such cases can usually not be made out. A right-sided n usually not be made out. A right-sided pleural effusion increase the cardiac dullpleural effusion increase the cardiac dullness on left side.ness on left side.

In pneumothorax the heart is displaced In pneumothorax the heart is displaced toward the normal side, but in massive toward the normal side, but in massive collapse of the lung(collapse of the lung( 肺萎缩肺萎缩 ) the heart ) the heart is displaced toward the affected side.is displaced toward the affected side.

Pleural adhesions(Pleural adhesions( 胸膜粘连胸膜粘连 ) may pul) may pull the heart to the affected side with resl the heart to the affected side with resulting changes in cardiac dullness similulting changes in cardiac dullness similar to those produced by collapse of the ar to those produced by collapse of the lung. lung.

Decrease in the area ofDecrease in the area of cardiac dullness cardiac dullnessDecrease in the area ofDecrease in the area of cardiac dullness cardiac dullness

A decrease in the relative cardiac dullnA decrease in the relative cardiac dullness may occur in pulmonary emphysemess may occur in pulmonary emphysema(a(肺气肿肺气肿 ). The absolute cardiac dulln). The absolute cardiac dullness is usually decreased in such cases, sess is usually decreased in such cases, since the lung is increased in size and coince the lung is increased in size and covers a greater area of the heart than norvers a greater area of the heart than normal.mal.

Increase in the area ofIncrease in the area of cardiac dullness cardiac dullnessIncrease in the area ofIncrease in the area of cardiac dullness cardiac dullness

An increase in the area of cardiac An increase in the area of cardiac dullness is most strikingly seen in dullness is most strikingly seen in patients with cardiac disease. we cannot patients with cardiac disease. we cannot detect by percussion an appreciable detect by percussion an appreciable increase of the cardiac dullness in increase of the cardiac dullness in hypertrophy of the heart unless there is hypertrophy of the heart unless there is an accompanying dilatation.an accompanying dilatation.

Cardiac enlargementCardiac enlargementCardiac enlargementCardiac enlargement

Enlargement of the left ventricle Enlargement of the left ventricle produces an increase in the relative produces an increase in the relative cardiac dullness to the left and often cardiac dullness to the left and often downward on this side.downward on this side.

The heart silhouette looks like a shoeThe heart silhouette looks like a shoe

Enlargement of the left ventricle appeaEnlargement of the left ventricle appears in aortic insufficiency, in aortic stenrs in aortic insufficiency, in aortic stenosis, in mitral insufficiency, in longstanosis, in mitral insufficiency, in longstanding hypertension and in chronic nephrding hypertension and in chronic nephritis(itis( 慢性肾炎慢性肾炎 ). It is called aortic heart). It is called aortic heart((主动脉型心主动脉型心 ).).

Right ventricular enlargement, the cardRight ventricular enlargement, the cardiac dullness will extended to left and uiac dullness will extended to left and upward. If the right ventricular is severelpward. If the right ventricular is severely enlarged, the right border of the heart y enlarged, the right border of the heart will extend to the right. It is seen in cor will extend to the right. It is seen in cor pulmonale, in mitral stenosis, in tricusppulmonale, in mitral stenosis, in tricuspid insufficiency etc.id insufficiency etc.

Both the left atrium and pulmonary artBoth the left atrium and pulmonary artery enlarged, the pulmonary artery will ery enlarged, the pulmonary artery will be exaggerated to leftward. The cardiac be exaggerated to leftward. The cardiac silhouette is like a pear and called mitrsilhouette is like a pear and called mitral heart(al heart(二尖瓣型心二尖瓣型心 ), it is frequently ), it is frequently seen in mitral valve stenosis.seen in mitral valve stenosis.

The heart silhouette is like a pearThe heart silhouette is like a pear

Aortic dilation(Aortic dilation( 主动脉扩张主动脉扩张 ), aneurys), aneurysm of aorta(m of aorta( 主动脉瘤主动脉瘤 ), pericardial eff), pericardial effusion, all those diseases may cause the usion, all those diseases may cause the base border of heart enlargement, so thbase border of heart enlargement, so that the base border of the heart will be wat the base border of the heart will be widened. idened.

Congestive heart failure, severe myocarCongestive heart failure, severe myocarditis, Keshan disease(ditis, Keshan disease( 克山病克山病 ), dilated ), dilated myocardiopathy(myocardiopathy( 扩张性心肌病扩张性心肌病 ) may c) may cause the heart silhouette extending both tause the heart silhouette extending both to right and left(o right and left(普大心普大心 ). ).

Pericardial effusionPericardial effusionPericardial effusionPericardial effusion

The cardiac dullness is increased in all The cardiac dullness is increased in all directions and assumes the form of a tridirections and assumes the form of a triangle with the apex at the level of the fiangle with the apex at the level of the first or second intercostal space or a genrst or second intercostal space or a general globular enlargement. eral globular enlargement.

The heart silhouette is like a flaskThe heart silhouette is like a flask

The heart silhouette is like a globeThe heart silhouette is like a globe

Adhesive pericarditisAdhesive pericarditisAdhesive pericarditisAdhesive pericarditis

The degree of enlargement depends on The degree of enlargement depends on the extent of the adhesive process. The the extent of the adhesive process. The relative, and especially the absolute, relative, and especially the absolute, cardiac dullness are both markedly cardiac dullness are both markedly increased to left and to the right.increased to left and to the right.

Increase in the absolute Increase in the absolute cardiac dullnesscardiac dullnessIncrease in the absolute Increase in the absolute cardiac dullnesscardiac dullness

Increase in the absolute cardiac Increase in the absolute cardiac dullness without demonstrable cardiac dullness without demonstrable cardiac enlargement occurs when the left lung enlargement occurs when the left lung is retracted and a larger area of the is retracted and a larger area of the ventricle is exposed. ventricle is exposed.

It also occurs in mediastinal tumors whIt also occurs in mediastinal tumors when the heart is pushed up against the chen the heart is pushed up against the chest wall and a large area of the ventriclest wall and a large area of the ventricle comes into direct contact with the ante comes into direct contact with the anterior surface of the chest.erior surface of the chest.

复习复习复习复习

心界叩诊的顺序心界叩诊的顺序正常心浊音界的组成正常心浊音界的组成心脏浊音界改变及临床意义心脏浊音界改变及临床意义

重要名词重要名词重要名词重要名词

主动脉型心主动脉型心 ((靴形心靴形心 ))普大型心普大型心二尖瓣型心二尖瓣型心 ((梨形心梨形心 ))烧瓶形心烧瓶形心球形心球形心

单选题单选题单选题单选题

心浊音界改变的论述心浊音界改变的论述 ,,正确的是正确的是A. A. 一侧大量胸水积液可使心界移向患一侧大量胸水积液可使心界移向患侧侧

B. B. 一侧大量气胸可使心界移向患侧一侧大量气胸可使心界移向患侧C. C. 肺气肿时心界变大肺气肿时心界变大D. D. 一侧肺不张可使心界移向患侧一侧肺不张可使心界移向患侧E. E. 以上均不是以上均不是

心脏叩诊浊音界向左下扩大、心腰加深，心脏叩诊浊音界向左下扩大、心腰加深，见于见于

A. A. 二尖瓣狭窄二尖瓣狭窄B. B. 高血压性心脏病高血压性心脏病C. C. 三尖瓣狭窄三尖瓣狭窄D. D. 心肌病心肌病E. E. 克山病克山病

心脏叩诊左心房和肺动脉段增大心脏叩诊左心房和肺动脉段增大 ,,使使心腰部饱满或膨出可见于心腰部饱满或膨出可见于

A. A. 主动脉瓣关闭不全主动脉瓣关闭不全B. B. 二尖瓣狭窄二尖瓣狭窄C. C. 二尖瓣关闭不全二尖瓣关闭不全D. D. 心包积液心包积液E. E. 房间隔缺损房间隔缺损

心包积液的特征为心包积液的特征为A. A. 心浊音界向左下增大心浊音界向左下增大B. B. 心浊音界向右增大心浊音界向右增大C. C. 梨形心梨形心D. D. 心界向两侧扩大心界向两侧扩大 ,,同时浊音界可随同时浊音界可随体位而改变体位而改变

E. E. 以上均不是以上均不是

标准配伍型题标准配伍型题标准配伍型题标准配伍型题

A. A. 靴形心靴形心B. B. 胸骨右缘第胸骨右缘第 1,21,2 肋间浊音界增宽肋间浊音界增宽C. C. 普大型心普大型心D. D. 梨形心梨形心E. E. 三角形烧瓶样心三角形烧瓶样心扩张性心肌病扩张性心肌病 ? ? 二尖瓣狭窄二尖瓣狭窄 ??

高血压性心脏病高血压性心脏病 ? ? 心包积液心包积液 ??