Percussion

Thechestispercussedtoconfirmthecardiacborders,size,contourandpositioninthethorax.Relativecardiacdullness(心相對濁音界)Absolutecardiacdullness(心絕對濁音界)Methodofpercussionforheart

Patientshouldliesupineonanexaminingtableorsitonthechair,withthephysicianathisrightside.Usuallyweemployindirectpercussion(間接叩診法)forpercussingheartborders.

Manybeginners,inattemptngtooutlinethecardiacdullness,striketooforciblyandthusfailtoheartheslightchangeinthepercussionnotecausedbythethinlayerofoverlyinglung.Oneshouldusethelightestpercussionpossibleand,withexperience,relymoreandmoreuponthevibratorysense.PercussionwithfingerparalleltocardiacoutlinesPercussionwithfingeratrightangletocardiacoutline

Theorthopercussion(直指叩診法)methodofPleschiscarriedoutbyflexingtheleftmiddlefingertoarightangle,placingthepulpofthefingerontheareatobepercussed,andthenstrikingtheflexedfingeratthedistalendofthefirstphalanx.

Thismethodisrecommendedinthepercussionofabsolutecardiacdullness,andgiveexcellentresultscomparingwithordinarymethods.

Itisoutlinedbypercussinginthe5th,4th,3rdand2ndinterspaceontheleftsequentially,startingneartheaxillaandmovingmediallyuntilcardiacdullnessisencountered.Percussion

Thebeginnershouldmarkwithaskinpencilwherethenotechanges.Thedistancefrommidsternallinetotheleftbordershouldbemeasuredandrecorded,measurementshouldbemadealongastraightlineparalleledtothetransversediameterinthethorax.Heartborders

Rightborderoftheheartformedbysupvena(上腔靜脈),ascendingaorta(升主動脈),rightatrium(右心房)Leftborderoftheheartformedbyaortaarch(主動脈弓),pulmonaryarterialtrunk(肺動脈段),leftatriaappendage(左心房),LV(左心室)InferiorborderoftheheartformedbyRV(右心室),lesserextentLV

Normalheartdullness

right(cm)ICS,MSLleft(cm)

2-3Ⅱ2-32-3Ⅲ3.5-4.53-4Ⅳ5-6Ⅴ7-9NormallyfrommidsternallinetoMCLisabout8-10cmPhysiologicchangesintheareaofcardiacdullnessThepositionoftheheart,andwithittheareaofcardiacdullness,isinfluencedbythelevelofthediaphragm.

Indeepinspirationthediaphragmdescends,producingadecreaseincardiacdullness,whileinforcedexpirationthediaphragmrisesandproducesanincreaseinthecardiacdullness.

Inthelatermonthsofpregnancythediaphragmispushedupward,causingthehearttoliemorehorizontallyandclosertothechestwall,thusincreasingtheareaofcardiacdullness.Cardiacdullnessin

abdominaldistention

Avarietyofpathologicconditionssuchasascites,anovariancyst(卵巢囊腫),orperitonitis(腹膜炎)maycauseanelevationofthediaphragmwithanincreaseintheareaofcardiacdullness.Changesinpositionof

cardiacdullness

Aleft-sidedpleuraleffusion(胸腔積液)willpushthehearttotheright,andincreasethecardiacdullnesstotherightofsternum,theleftborderinsuchcasescanusuallynotbemadeout.Aright-sidedpleuraleffusionincreasethecardiacdullnessonleftside.

Inpneumothoraxtheheartisdisplacedtowardthenormalside,butinmassivecollapseofthelung(肺萎縮)theheartisdisplacedtowardtheaffectedside.

Pleuraladhesions(胸膜粘連)maypullthehearttotheaffectedsidewithresultingchangesincardiacdullnesssimilartothoseproducedbycollapseofthelung.Decreaseintheareaof

cardiacdullness

Adecreaseintherelativecardiacdullnessmayoccurinpulmonaryemphysema(肺氣腫).Theabsolutecardiacdullnessisusuallydecreasedinsuchcases,sincethelungisincreasedinsizeandcoversagreaterareaoftheheartthannormal.

Increaseintheareaof

cardiacdullnessAnincreaseintheareaofcardiacdullnessismoststrikinglyseeninpatientswithcardiacdisease.wecannotdetectbypercussionanappreciableincreaseofthecardiacdullnessinhypertrophyoftheheartunlessthereisanaccompanyingdilatation.CardiacenlargementEnlargementoftheleftventricleproducesanincreaseintherelativecardiacdullnesstotheleftandoftendownwardonthisside.Theheartsilhouettelookslikeashoe

Enlargementoftheleftventricleappearsinaorticinsufficiency,inaorticstenosis,inmitralinsufficiency,inlongstandinghypertensionandinchronicnephritis(慢性腎炎).Itiscalledaorticheart(主動脈型心).

Rightventricularenlargement,thecardiacdullnesswillextendedtoleftandupward.Iftherightventricularisseverelyenlarged,therightborderoftheheartwillextendtotheright.Itisseenincor

pulmonale,inmitral

stenosis,intricuspidinsufficiencyetc.

Boththeleftatriumandpulmonaryarteryenlarged,thepulmonaryarterywillbeexaggeratedtoleftward.Thecardiacsilhouetteislikeapearandcalledmitralheart(二尖瓣型心),itisfrequentlyseeninmitralvalvestenosis.Theheartsilhouetteislikeapear

Aorticdilation(主動脈擴(kuò)張),aneurysmofaorta(主動脈瘤),pericardialeffusion,allthosediseasesmaycausethebaseborderofheartenlargement,sothatthebaseborderoftheheartwillbewidened.

Congestiveheartfailure,severemyocarditis,Keshandisease(克山病),dilatedmyocardiopathy(擴(kuò)張性心肌病)maycausetheheartsilhouetteextendingbothtorightandleft(普大心).Pericardialeffusion

Thecardiacdullnessisincreasedinalldirectionsandassumestheformofatrianglewiththeapexatthelevelofthefirstorsecondintercostalspaceorageneralglobularenlargement.TheheartsilhouetteislikeaflaskTheheartsilhouetteislikeaglobeAdhesivepericarditisThedegreeofenlargementdependsontheextentoftheadhesiveprocess.Therelative,andespeciallytheabsolute,cardiacdullnessarebothmarkedlyincreasedtoleftandtotheright.Increaseintheabsolute

cardiacdullnessIncreaseintheabsolutecardiacdullnesswithoutdemonstrablecardiacenlargementoccurswhentheleftlungisretractedandalargerareaoftheventricleisexposed.

It