Palpation Feel for diagnosis Continuing Medical Implementation bridging

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

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

Palpation-Pulses • • • Rhythm, rate, regularity Contour Water hammer pulse-AR Brachial-radial delay AS Pulsus paradoxus – Tamponade – COPD • Pulsus alternans – LV dysfunction © Continuing Medical Implementation …. . . bridging the care gap

Carotid Examination • Carotid upstroke – brisk, normal or delayed – bisferiens or anacrotic – volume: normal, increased or decreased • Carotid auscultation – Bruit – Transmitted murmur – A 2 audible in neck? Presence excludes severe AS © Continuing Medical Implementation …. . . bridging the care gap

Palpation - Precordium Parasternal: – Palpable P 2 -pulmonary HTN • Thrill – VSD/HCM • RV lift – RVH – Severe MR © Continuing Medical Implementation …. . . bridging the care gap

Precordium-Palpation Parasternal • Lift: RVE or severe MR • Thrill: VSD, HOCM (IHSS) • Palpable P 2 (ULSB): pulmonary hypertension • Medial retraction LVE • Lateral retraction RVE © Continuing Medical Implementation …. . . bridging the care gap

Palpation - 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 location Normal Size: • No larger than 3 cm (about 2 finger breadths) © Continuing Medical Implementation …. . . bridging the care gap

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

Apex–Dynamic Abnormalities Sustained Apex: • correlates with pressure overload • ( > 2/3 systole-hangs out to S 2) • AS, LVH or LV systolic dysfunction Hyperdynamic Apex: • correlates with volume overload AR/MR • palpable S 4 (atrial kick) • palpable S 1 (MS) • palpable non-ejection click (MVP) © Continuing Medical Implementation …. . . bridging the care gap

Apex–Dynamic Abnormalities Atrial kick: • Palpable S 4 – Loss of LV compliance – LVH 2 o Hypertension – Aortic Stenosis – Hypertrophic Cardiomyopathy © Continuing Medical Implementation …. . . bridging the care gap

Non-invasive ejection fraction Palpable S 4/ apex not sustained • EF > 50% Palpable S 4/ Apex sustained • EF 40 -50% S 4 not palpable/ Apex sustained • EF < 40% TITLE: The apical impulse in coronary heart disease. AUTHORS: Ranganathan N; Juma Z; Sivaciyan V http: //130. 14. 32. 45/cgi-bin/VERSION_B/IGMclient? 12653+records+81 SOURCE: Clin Cardiol 1985 Jan; 8(1): 20 -33 © Continuing Medical Implementation …. . . bridging the care gap