Common abnormalities

Inspection. Much can be learned by inspecting the pre-cordium. Chest deformities including pectus excavatum (posterior displacement of the lower sternum) can affect the rest of the examination. A midline sternotomy scar usually indicates previous coronary bypass surgery, or valve replacement. A left submammary scar is usually the result of a mitral valvotomy.

Pulsations are most readily identified by a combination of inspection (best for inward movements) and palpation (best for outward movements).

Displacement of the apex beat. The apex may be displaced laterally in subjects wilh chest deformity such as pectus excavatum (p. 131). It may also be displaced because of mediastinal shift secondary to a large pleural effusion, tension pneumothorax or pneumonectomy. In these situations the trachea may also be deviated.

In cardiac disease causing left ventricular dilatation, the apex beat is displaced interiorly and laterally and it i^ diffuse, felt over a wide area.

Character of the apical impulse. The character of the cardiac impulse is often more important than its precise position. Tlie so-called "tapping apex' which is found in mitral stenosis is actually a palpable first heart sound. In pure mitral stenosis (he apex is not displaced. Conditions which cause left ventricular pressure overload and consequent hypertrophy, such as hypertension and aortic stenosis, lead to a forceful and sustained apex beat which is usually not displaced. This apical "heave* or 'lift" is distinguishable from the diffuse impulse of left ventricular dilatation,

A double apical impulse is characteristic of hypertrophic cardiomyopathy.

Heaves arc palpable impulses from either the right or left ventricle which feel as though they are 'lifting' the examiner's hand from Ihe chest. A pulsation over the left parasternal area (right ventricular heave) is usually abnormal in adults and indicative of right ventricular hypertrophy, e.g. pulmonary hypertension.

Thrills are palpable murmurs. They feel rather like placing one's hand on a purring cat. The most commonly detected systolic thrill is that of aortic stenosis which may be palpable at the apex, the lelt or right sternal edge or over the carotid arteries in the neck. The thrill arising from a ventricular septal defect is usually best fell at the left sternal edge. Diastolic thrills are rare; the thrill of mitral stenosis is best felt at the apex with the patient rolled on to the left side; thrills arising from the base of the heart arc best felt with the patient leaning forward.

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