Boundaries of the heart during percussion: normal, causes of expansion, displacement

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Percussion is a diagnostic method that involves tapping individual parts of the body and analyzing the sound phenomena that arise during this. Based on the nature of the sound properties, the doctor determines the topography of internal organs, physical condition and partly their function.

Sounds can be divided into tones and noises. Pure tone is a relative concept. This is a vibration of one amplitude and frequency. Pure tones do not occur in nature. Noise is the sum of sounds with different properties, where the main tone cannot be distinguished. In the practice of diagnostic research, the doctor more often deals with noise, but in many cases sounds are usually called tones, especially if it is possible to identify the main four properties of sounds: 1st - strength; 2nd – height; 3rd – duration of sound and 4th – sound-likeness, from which the doctor builds a “picture of the disease”!

Percussion of the heart - a method for determining its boundaries

The anatomical position of any organ in the human body is determined genetically and follows certain rules. For example, the stomach in the vast majority of people is located on the left in the abdominal cavity, the kidneys are on the sides of the midline in the retroperitoneal space, and the heart occupies a position to the left of the midline of the body in the human chest cavity. The strictly occupied anatomical position of the internal organs is necessary for their full functioning.

During an examination of a patient, a doctor can presumably determine the location and boundaries of a particular organ, and he can do this with the help of his hands and hearing. Such examination methods are called percussion (tapping), palpation (palpation) and auscultation (listening with a stethoscope).

The boundaries of the heart are determined mainly using percussion, when the doctor uses his fingers to “tap” the front surface of the chest, and, focusing on the difference in sounds (voiceless, dull or voiced), determines the estimated location of the heart.

The percussion method often makes it possible to suspect a diagnosis even at the stage of examining the patient, before prescribing instrumental research methods, although the latter still play a leading role in the diagnosis of diseases of the cardiovascular system.

Percussion - determining the boundaries of the heart (video, lecture fragment)

Percussion – Soviet educational film

PERCUSSION

Ø Determination of the boundaries of relative dullness of the heart: right, left, upper.

Ø Determination of the boundaries of absolute dullness of the heart: right, left, upper.

Ø Determination of the heart configuration: drawing indicating dimensions: MD, MS, AO, Q, L, diameter.

To determine the boundaries of the heart, we use topographic finger-finger percussion: quiet to determine relative dullness, quiet to determine absolute dullness.

Determination of relative dullness of the heart (Fig. 23).

1. Since different heights of the diaphragm can affect cardiac percussion data, it is necessary to first determine it. To do this, a finger-pessimeter is placed in the 2nd intercostal space on the right along the midclavicular line parallel to the ribs, percussing downward to determine the lower border of the lungs, which is the height of the diaphragm. In a healthy normosthenic, the diaphragm along the midclavicular line is at the level of the 6th rib.

2. Next, the plessimeter finger is placed one rib above (normally the 4th intercostal space) parallel to the right border of the heart, and, going towards the heart, the transition of a clear sound to a dull sound is noted, which corresponds to the right border of the relative dullness of the heart. This border is formed by the right atrium or right ventricle.

3. To determine the left border of the relative dullness of the heart, the apex beat is first found as a guide during inspection or palpation. If the apical impulse is not detected, then percussion is performed in the 5th intercostal space, starting from the midaxillary line. The plessimeter finger is placed parallel to the left border and percussed towards the heart. This border is formed by the left ventricle.

The left border of the relative dullness of the heart almost always coincides with the apex beat. A discrepancy can be observed only in the presence of fluid in the pericardial cavity; the apical impulse will be inside percussion dullness, but, as a rule, it is not palpable in this case. When determining the left border of the heart by palpation by the apex beat and by percussion by determining the relative dullness of the heart, preference is given to palpation data with greater accuracy, naturally, if the apex beat is palpated.

4. To determine the upper limit of the relative dullness of the heart, a finger-pessimeter is placed along the left parasternal line parallel to the ribs, starting from the 1st intercostal space, and percussed downwards. As a reminder, the parasternal line runs midway between the edge of the sternum (sternal line) and the midclavicular line. This border is formed by the left atrial appendage.

Rice. 23. Percussion of the borders of relative dullness of the heart (ROTS)

MCL – midclavicular line; m/r – intercostal space

Right GOTS

1. Along the SCL to hepatic dullness (a) (normally the VI rib).

2. We place the plessimeter finger one intercostal space above (normally the IV intercostal space) parallel to the defined border. We percussion to the heart (normally 1 cm outward from the right edge of the sternum (b).

Left GOTS

3. Percussion along the 5th intercostal space from the anterior axillary line to the heart (normally 1-2 cm medially from the left midclavicular line (c) and coincides with the apical impulse).

Upper GOTS

4. Having stepped back 1 cm outward from the edge of the sternum (along the parasternal line), we percussion until cardiac dullness appears (d) (normally the third intercostal space).

Rice. 24. Percussion of the vascular bundle

Percussion of the vascular bundle is performed along the 2nd intercostal space on the right and left from the midclavicular line to the sternum (normally located along the edges of the sternum). The diameter is 5-6 cm (Fig. 24).

Definition of absolute dullness of the heart

1. To determine the right border of absolute dullness of the heart, a finger plessimeter is placed on the right border of relative dullness of the heart parallel to the right edge of the sternum and, using the quietest percussion, moved inward until a dull sound appears

2. To determine the left border of the absolute dullness of the heart, place the plessimeter finger parallel to the left border of the relative dullness of the heart, moving slightly outward from it, and move the plessimeter finger inward until a dull sound appears.

3. To determine the upper limit of absolute dullness of the heart, a finger-pessimeter is placed on the upper limit of relative dullness of the heart along the left parasternal line. Using the quietest percussion method, percussion is performed downward until a dull sound appears (Fig. 25).

Absolute dullness of the heart is that part of it that is not covered by the lungs, is directly adjacent to the chest and is formed by the right ventricle.

Rice. 25. Percussion of the boundaries of absolute dullness of the heart (GATS)

Determination of heart configuration

In addition to the right and left boundaries of the relative dullness of the heart, the relative dullness of the heart is determined on the right in the 3rd intercostal space, on the left in the 4th intercostal space. Percuss until a dull sound appears. The points obtained during percussion are connected along the right and left contours and thus reveal the configuration of the heart on the chest.

According to the configuration of the heart, a number of heart sizes are distinguished (Fig. 26):

1. MD - from the right contour of the heart in the 4th intercostal space to the anterior midline. Normally this size is 3-4 cm.

2. MS - from the left contour of the heart in the 5th intercostal space to the anterior midline. Normally this size is 8-9 cm.

3. The diameter of the heart is the sum of MD + MS. Normally this size is 11-13 cm.

4. L - long line (lonqitudinalis), from the right contour of the heart in the 3rd intercostal space to the left border of relative dullness in the 5th intercostal space. Normally, this size is 13-15 cm.

5. Q - oblique size (quercus), from the upper border to the right border of the relative dullness of the heart. Normally, this size is 9-11 cm.

6. AO - vascular bundle, from the right to the left contour of the heart in the 2nd intercostal space. Normally this size is 5-6 cm.

These heart sizes are typical for a normosthenic patient with a normal diaphragm position. Remember that a particular person’s size cannot fluctuate and, therefore, there can only be one number.

Rice. 26. Heart sizes

L – long (13-15 cm); MD+MS – diameter (11-13 cm);

Q – oblique size (9-11 cm); AO – vascular bundle (5-6 cm).

The following pathological configurations of the heart are distinguished (Fig. 27).

Mitral configuration of the heart No. 1 - expansion of the left atrium, right ventricle with mitral stenosis.

Mitral configuration No. 2 – the heart (with mitral valve insufficiency) enlarges upward, left and right, MD, Q, and possibly the diameter and length increase. The determining factor in the mitral configuration is the increase in the upper border of the heart due to the left atrium and the oblique size of the heart. In this regard, radiologists have the concept of a smoothed “waist” of the heart.

Rice. 27. Pathological configurations of the heart:

a – norm; b – mitral I; c – mitral II; d – aortic,

d – “bull’s heart”; e – trapezoidal

Aortic configuration of the heart - isolated dilatation of the left ventricle in aortic heart defects, hypertension. At the same time, the left border of the relative dullness of the heart, MS, L dimensions increases. Radiologists call such a heart a “sitting duck” or “boot” type, and the “waist” of the heart is not smoothed out.

“Bull's heart” is a sharp displacement of the boundaries of the heart in all directions, found in advanced cases of heart disease.

“Trapezoidal” configuration, or “roof with a chimney” - in the presence of fluid in the pericardial cavity. The “roof” refers to the enlarged contour of the heart, and the “smoke stack” is the intact vascular bundle.

· Shifting the borders of relative dullness of the heart to the right, increasing MD - with expansion of the right atrium or right ventricle.

· Shifting the borders of relative dullness of the heart to the left, increasing MS, L - with dilatation and hypertrophy of the left ventricle, sometimes with a pronounced enlargement of the right ventricle.

· Shifting the boundaries of relative dullness of the heart upward, increasing Q - with a significant increase in the left atrium.

· An increase in the transverse size of the relative dullness of the heart occurs with a hypersthenic body type, high standing of the diaphragm: during pregnancy, flatulence, ascites.

· A decrease in the transverse size of the relative dullness of the heart is observed with an asthenic body type, with prolapse of the diaphragm: with visceroptosis, pulmonary emphysema. Such a heart is called a hanging or drip heart.

· Expansion of dullness in the area of ​​the vascular bundle, an increase in AO occurs with expansion (aneurma) of the aorta, expansion of the pulmonary artery. An increase in AO may also be associated with non-cardiac causes - a mediastinal tumor.

SAMPLE recording from a healthy person.

Limits of relative dullness of the heart:

right - 1 cm outward from the right edge of the sternum in the 4th intercostal space,

left - 1.5 cm medially from the left midclavicular line at 5 m/r,

upper - in the 3rd intercostal space along the left parasternal line.

Limits of absolute dullness of the heart:

right - along the left edge of the sternum in the 4th intercostal space,

left - 2 cm medially from the left relative border of 5 m/r,

upper - in the 4th intercostal space along the left parasternal line.

Normal values ​​for the boundaries of cardiac dullness

Normally, the human heart has a cone shape, is directed obliquely downwards, and is located in the chest cavity on the left. On the sides and top the heart is slightly covered by small sections of the lungs, in front by the anterior surface of the chest, behind by the mediastinal organs, and below by the diaphragm. A small “open” area of ​​the anterior surface of the heart is projected onto the anterior chest wall, and just its borders (right, left and upper) can be determined by tapping.

boundaries of relative (a) and absolute (b) dullness of the heart

Percussion of the projection of the lungs, whose tissue has increased airiness, will be accompanied by a clear pulmonary sound, and tapping the area of ​​the heart, whose muscle is a denser tissue, will be accompanied by a dull sound. This is the basis for determining the boundaries of the heart, or cardiac dullness - during percussion, the doctor moves his fingers from the edge of the anterior chest wall to the center, and when the clear sound changes to a dull sound, he marks the border of dullness.

The boundaries of relative and absolute dullness of the heart are distinguished:

1. The boundaries of relative dullness of the heart are located along the periphery of the projection of the heart and indicate the edges of the organ, which are slightly covered by the lungs, and therefore the sound will be less dull (dull).
2. The absolute border marks the central area of ​​the projection of the heart and is formed by an open area of ​​the anterior surface of the organ, and therefore the percussion sound is more dull (dull).

Approximate values ​​of the limits of relative cardiac dullness are normal:

• The right border is determined by moving the fingers along the fourth intercostal space from the right to the left, and is usually marked in the 4th intercostal space along the edge of the sternum on the right.
• The left border is determined by moving the fingers along the fifth intercostal space on the left to the sternum and marking along the 5th intercostal space 1.5-2 cm inward from the midclavicular line on the left.
• The upper border is determined by moving the fingers from top to bottom along the intercostal spaces to the left of the sternum and is marked along the third intercostal space to the left of the sternum.

The right border corresponds to the right ventricle, the left border corresponds to the left ventricle, and the upper border corresponds to the left atrium. The projection of the right atrium cannot be determined using percussion due to the anatomical location of the heart (not strictly vertical, but obliquely).

In children, the boundaries of the heart change as they grow, and reach the values ​​of an adult after 12 years.

Normal values ​​in childhood are:

Lecture on medicine on the topic: Cardiac percussion

LECTURE No. 9

PERCUSSION OF THE HEART

Percussion or percussion of the heart involves determining the size, shape, position of the heart and vascular bundle. The physical basis of cardiac percussion is the same as described earlier.

The heart is mostly located in the left half of the chest and can be schematically represented as an obliquely located cone, the apex of which corresponds to the apex of the heart. It is directed down and to the left. The base of the heart faces upward. It is believed that only one third of the anterior surface of the heart lies in the right half of the chest, counting from the linea mediana anterior. Two thirds of it are located in the left half of the chest. The heart is, as it were, fixed from above by large vessels (aorta, pulmonary artery, superior vena cava). The right ventricle of the heart lies on the left dome of the diaphragm. The right, upper and left borders of the heart are identified, which are determined by percussion. The lower border of the heart is not determined! The semilunar space of Traube is located below the heart. In the projection of this space there is a gas bubble of the stomach, which gives a tympanic sound to percussion.

When percussed, the heart, as a muscular airless organ with blood contained in it, gives a dull sound. Therefore, over the area of ​​the anterior chest wall to the left of the sternum, to which the heart is directly adjacent, a dull sound occurs upon percussion, called the zone of absolute dullness of the heart. The lungs surrounding the heart on both sides and above contain sound and, when percussed, give a clear pulmonary sound. The heart on the right and left is partially covered by the lungs. Therefore, when percussion occurs over this part of the heart, a dull percussion sound occurs. Dullness obtained at the border separating the airy lung tissue from the airless tissue of the heart is called relative, or deep, dullness of the heart.

Cardiac percussion can be performed in both a vertical and horizontal position of the patient. However, it must be taken into account that the size of cardiac dullness in a horizontal position of the patient is slightly larger than in a vertical position. This is due to the mobility of the heart and the displacement of the diaphragm when the body position changes. Typically, cardiac percussion is performed with the patient standing or sitting with arms down, with normal quiet breathing. In seriously ill patients, percussion can be performed in a horizontal position of the patient's body. When performing percussion, the doctor should take a position that allows him to comfortably place a finger-pessimeter and apply percussion blows. When percussing the heart, mediated finger-on-finger percussion is usually used. Percussion according to Sokolsky is most often used. When determining the boundaries of absolute dullness of the heart, the quietest threshold percussion according to Goldscheider (Goldscheider) with finger placement according to Plesch is often used. Some clinicians, especially in pediatric practice, use percussion according to Obraztsov or Yanovsky.

When tapping the heart, the pessimeter finger should fit snugly to the surface of the chest parallel to the expected border of the heart. Percussion blows should be of medium strength and directed strictly in the sagittal direction. Typically, percussion is carried out in the direction from a clear pulmonary sound to a dull one,

those.
from the lungs to the heart, although some clinicians prefer to tap from dull to clear. In all cases, the boundary is marked along the edge of the finger facing towards the clear pulmonary sound,
i.e. to the side facing the lungs.

When percussing the borders of the heart, first the right, then the left, then the upper borders are determined

his.

Determination of the boundaries of relative cardiac dullness

Right contour of relative cardiac dullness

and the vascular bundle in the direction from top to bottom is formed by the superior vena cava to the upper edge of the 3rd rib, then down - by the right atrium.
The left contour of the relative dullness of the heart
is formed by the left part of the aortic arch, then by the pulmonary trunk, at the level of the 3rd rib by the left atrial appendage, further down by a narrow strip of the left ventricle. Thus, the expansion of each of the boundaries of the relative dullness of the heart reflects an increase in certain chambers of the heart: the right border - the expansion of the right atrium, the left border - the left ventricle, the upper border - the left atrium. An increase in the size of the right ventricle cannot be detected when assessing the boundaries of relative dullness of the heart, since it forms the anterior surface of the heart.

When determining the boundaries of relative dullness, the heart is percussed along the intercostal spaces to avoid lateral propagation of vibrations along the ribs. The percussion blow should be of medium strength. It is necessary to ensure that the pessimeter finger is pressed tightly against the chest wall, thereby achieving a deeper distribution of vibration.

Determination of the right border of relative dullness of the heart begins with determining the upper border of relative hepatic dullness (or the lower border of the right lung), i.e. height of the right dome of the diaphragm. Percussion is carried out along the right mid-clavicular line from the 3rd intercostal space down until a dull percussion sound appears. The upper limit of relative hepatic dullness (or the lower limit of the right lung) is normally located at the level of the 5th rib. Then the plessimeter finger is turned at a right angle (parallel to the expected border of the heart), placed 1 rib above the found edge of the lung

and begin to percussion along the intercostal space towards the right edge of the sternum.
Carefully monitor the nature of the resulting percussion sound, i.e., the transition from a clear pulmonary sound to a dull one. At the border of a dull percussion sound, a mark is made along the edge of the finger facing the clear pulmonary sound. This mark corresponds to the right border of the relative dullness of the heart. In a healthy person, it is located 1 - 1.5 cm outward from the right edge of the sternum in the 4th intercostal space
and is formed by the right atrium.

Before proceeding with percussion determination of the left border of the relative dullness of the heart, the location of the apex beat, which is formed by the left ventricle of the heart, should be palpated. In the case when percussion is performed on a woman with a developed mammary gland, the doctor asks her to lift and hold the mammary gland with her left hand. If the apical impulse cannot be detected, percussion is carried out along the 5th intercostal space, and then along the 6th intercostal space, starting from the anterior axillary line, moving the finger towards the heart. The plessimeter finger is placed across the intercostal space, i.e. parallel to the expected border of relative dullness of the heart. They try to apply a percussion blow strictly in the sagittal direction. If dullness of percussion sound is detected, a mark is placed along the outer edge of the finger facing the clear pulmonary sound. This mark corresponds to the left border of the relative dullness of the heart and is formed by the left ventricle of the heart. In a healthy person, it is located 1–2 cm medially from the left midclavicular line in the 5th intercostal space

and coincides with the apical impulse.

When determining the upper limit of the relative dullness of the heart, the plessimeter finger is placed 1 - 1.5 cm away from the left sternal line (from the left edge of the sternum) parallel to the ribs. Percussion begins in the 1st intercostal space and moves the finger – plessimeter – down until the sound becomes dull. A mark is made along the upper edge of the finger in the direction of a clear percussion sound. In a healthy person, this border runs along the 3rd rib

and is formed by the left atrial appendage.

The lower border of the heart is not determined by percussion, since the heart here comes into contact with the diaphragm and liver.

Having determined the boundaries of the relative dullness of the heart, measure the diameter of the heart

measuring tape.
The diameter of the heart is defined as the sum of perpendiculars to the anterior midline from the most distant points of the right and left borders of the heart. Normally, the distance from the right border of the relative dullness of the heart to the anterior midline is 3–4 cm, from the left border of the relative dullness of the heart to the anterior midline is 8–9 cm. Accordingly, the diameter of the relative dullness of the heart is 11–13 cm.
In practice, it is determined and long heart

.
The length of the heart is the distance from the right cardiovascular angle (the intersection of the border of cardiac dullness with the lower edge of the 3rd rib) to the apex of the heart (the left border of relative dullness of the heart). Normally, in a healthy person, the length of the heart is 13–15 cm.
width and height were previously determined

. The width of the heart is the sum of perpendiculars to the length of the heart from the most distant point of the upper left contour (the place of transition of the vascular bundle to the left border of the heart) and from the hepatic cardiac angle. The height of the heart consists of 2 segments: 1 – from the highest point of the upper border to the base of the xiphoid process and 2 – from the base of the xiphoid process to the lower contour of the heart. Since the lower contour cannot be determined, the second component is taken equal to 1/3 of the first.

The boundaries of the heart can change both due to a number of physiological circumstances and due to some pathological conditions. The area of ​​absolute dullness of the heart will increase with scarring, wrinkling or inflammatory compaction of the anterior edges of the lungs, with exudative pleurisy, and large tumors of the posterior mediastinum. An increase in the size of the relative dullness of the heart also occurs with a high position of the diaphragm in hypersthenics, patients with flatulence and ascites, and in pregnant women. In this case, the heart takes a horizontal position and is closer to the anterior chest wall. An increase in the size of the relative dullness of the heart, associated with an increase in the size of the heart itself, most often occurs with expansion (dilatation) of the chambers of the heart. It depends only to a small extent on the increase in thickness (hypertrophy) of the myocardium. Hypertrophy of the heart muscle alone usually cannot cause an increase in the size of the relative dullness of the heart, since such a slight increase in the size of the heart cannot be reliably determined using percussion.

As the chambers (cavities) of the heart expand, the boundaries of cardiac dullness shift in different directions. The shift of relative dullness of the heart to the right is caused by expansion of the right atrium. To a lesser extent, this is due to dilation of the right ventricle of the heart, displacing the right atrium to the right. Such an increase in the size of the relative dullness of the heart to the right can occur with stenosis (narrowing) of the opening of the tricuspid valve, tricuspid valve insufficiency, stenosis of the pulmonary artery, with late stages of mitral valve stenosis, leading to hypertension in the pulmonary circulation, as well as with other conditions leading to pulmonary tipertension.

A shift of the borders of relative dullness of the heart to the left occurs with dilatation and hypertrophy of the left ventricle of the heart. This occurs in patients with aortic heart defects, in the initial stages of mitral valve insufficiency, general atherosclerosis, in patients with hypertension and other diseases leading to arterial hypertension in the systemic circulation. With a significant increase in the size of the right ventricle of the heart, a shift in the boundaries of the relative dullness of the heart to the left may also be noted due to the pushing of the left ventricle to the left and posteriorly.

An upward shift of the border of relative dullness of the heart is usually caused by a significant expansion of the left atrium. This can occur with narrowing (stenosis) of the mitral valve opening, as well as with mitral valve insufficiency. An increase in the boundaries of relative dullness of the heart in both directions is detected with lesions of the heart muscle - myocardiosclerosis, acute and chronic myocarditis.

An increase in the boundaries of the heart in all directions is observed with a simultaneous increase in the left and right ventricles of the heart and the left atrium. This can happen with combined valvular heart defects, when several heart valves are affected and there are signs of cardiac decompensation. This change in the boundaries of the heart is called “bull’s heart” (cor bovinum).

An increase in the relative dullness of the heart in all directions can also occur with the accumulation of fluid in the pericardial cavity. In this case, the shape of cardiac dullness takes the form of a truncated triangle or trapezoid, with the base facing down.

A decrease in the size of the relative dullness of the heart often occurs with prolapse of the diaphragm, enteroptosis, pulmonary emphysema, and pneumothorax. In these cases, the heart not only moves downwards, but also takes on a more vertical position, called a hanging or drip heart.

The accumulation of fluid or air in one of the pleural cavities leads to a shift in the boundaries of cardiac dullness towards the healthy side. With the development of atelectasis or with shrinkage of the lung, with pleuropericardial adhesions, the boundaries of cardiac dullness shift to the affected side.

Determination of the configuration of cardiac dullness

, or the contour of the heart, is carried out by percussing strictly along the intercostal spaces, starting from the second intercostal space on the right and left and moving sequentially to the 5th - 6th intercostal spaces. The plessimeter finger is placed perpendicular to the intercostal spaces or parallel to the expected border of the heart. The mark of the found dullness is marked along the edge of the finger towards the clear pulmonary sound. Then the resulting points are connected with solid lines and the right and left contours of cardiac dullness are obtained.

The boundaries of the contour of cardiac dullness in relation to the anterior midline of the body are located in a healthy average-sized normosthenic as follows. The right border of the contour of cardiac dullness in the 2nd and 3rd intercostal spaces is spaced from the anterior midline by 3 cm, in the 4th intercostal space - by 4 cm. The left border of the contour of cardiac dullness in the 2nd intercostal space is spaced from the anterior midline by 3 cm, in the 3rd intercostal space - by 4 cm, in the 4th and 5th intercostal spaces - by 9 cm.

Depending on the disease the patient has, mitral and aortic configurations of the heart are distinguished. Before characterizing these concepts, it is necessary to introduce the term “heart waist”. The waist of the heart is the angle between the vascular bundle on the left and the left contour of the heart formed by its left ventricle. Normally, this angle is 140 - 150o.

The mitral configuration of the heart occurs with mitral heart defects - mitral valve insufficiency and advanced stage of mitral valve stenosis. It is characterized by enlargement of the left atrium of the heart. With a mitral configuration of the heart, the heart's waist flattens or even bulges due to a sharp increase in the left atrium.

The aortic configuration of the heart occurs in patients with aortic heart defects - aortic valve insufficiency and stenosis of the aortic mouth, as well as in severe hypertension. It is characterized by significant isolated enlargement of the left ventricle. At the same time, the waist of the heart becomes emphasized, the angle forming it approaches a straight line. The configuration of cardiac dullness is compared with the shape of a boot or the pose of a sitting duck.

After determining the boundaries of relative dullness of the heart, they begin to determine the boundaries of absolute dullness of the heart.

, i.e.
to the area of ​​the heart not covered by the lungs. It is formed by the right ventricle of the heart
. The term "absolute dullness" is misleading to novice researchers, since they are looking for truly absolute dullness, such as is detected, for example, in the hip. The heart, even where it is not covered by the lungs, produces not an absolutely dull sound, but a dull sound with an admixture of tympanitis. This is due to the fact that it is surrounded by air-containing lungs, and is bordered below by the gas-containing stomach and large intestine. When percussing this area, an absolutely dull percussion sound is determined. When determining the extent of absolute dullness of the heart, the same principles are used as when determining the boundaries of relative dullness of the heart, but they use quiet or even the quietest percussion according to Goldscheider with finger placement according to Plesch.

There are 2 ways to determine the boundaries of absolute cardiac dullness. In the first method, determining the boundaries of absolute dullness of the heart, having determined the boundaries of relative dullness, they continue to percussion, but with quiet percussion, with weak blows without bouncing of the percussion finger, further towards the center until an absolutely dull percussion sound appears. The pessimeter finger should be pressed against the chest with considerable force. This achieves a greater spread of vibrations deeper in the direction of the percussion blow and less in the lateral directions.

First, the left, then the right, then the upper limit of absolute cardiac dullness are determined. The mark of the found border is made along the outer edge of the finger, from the dull sound towards the dull percussion sound. Normally, the right border of absolute cardiac dullness on the right goes along the left edge of the sternum

.
The left border of absolute cardiac dullness is usually 1–1.5 cm inward from the left border of relative cardiac dullness.
The upper border of absolute cardiac dullness is normally
located along the lower edge of the cartilage of the 4th rib on the left.
The second method of determining the boundaries of absolute cardiac dullness can be used more often with greater success than the simpler first method. It gives reliable results in all cases where the use of the first method causes questionable results. With this method, percussion is carried out starting from the zone of absolute dullness of the heart, usually from the 4th intercostal space at the left edge of the sternum. The finger-plessimeter is installed at this point according to the Pleshu method. Goldscheider's quietest or threshold percussion is used, when the result of a percussion blow is assessed not only by ear, but also by tactile vibration that occurs. The plessimeter finger is placed in such a way that the percussion blow is distributed strictly in the sagittal direction. The plessimeter finger is gradually moved in the direction of the points (borders) of relative dullness of the heart. The first addition of a pulmonary admixture to the percussion sound will indicate a transition from the region of absolute dullness to the region of relative dullness of the heart. The resulting dull sound is marked in the direction of the dull sound (from the dull sound).

If necessary, the boundaries of absolute dullness of the heart can be determined using Obraztsov’s tactile percussion, when to determine the boundaries of organs that do not contain air, they use not only hearing, but also the touch of greater or lesser resistance, greater or lesser density of the underlying tissues.

When working, it is advisable to determine the boundaries of cardiac dullness not only in 3 places (right, left and upper borders), but to systematically tap out all the dullness and draw its outline on the patient’s skin using a demographer.

Expansion of the boundaries of absolute dullness of the heart from the indicated boundaries in a healthy person indicates an enlargement of the right ventricle of the heart. However, it will also increase with the accumulation of fluid in the pericardial cavity. In this case, the boundaries of relative and absolute dullness of the heart may coincide. In addition, an increase in the size of absolute dullness of the heart can also occur with extracardiac pathology, for example, with shrinkage of the lungs covering the heart.

A decrease in the size of absolute dullness of the heart under physiological conditions is observed with deep inspiration. A pathological decrease in the size of absolute dullness of the heart is observed in patients with pulmonary emphysema. They experience a decrease in the size of the absolute dullness of the heart until it completely disappears and is replaced by a box sound. In patients with an attack of bronchial asthma, with pneumothorax, with pneumopericardium, with subcutaneous emphysema in the heart area, with a low diaphragm, a decrease in the size of absolute dullness of the heart also occurs.

Determination of the boundaries of the vascular bundle

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Percussion determination of the boundaries of the vascular bundle, the main part of which is the aorta, is carried out at the level of the manubrium of the sternum in the 2nd intercostal space to the right and left of its edges. The pessimeter finger is placed in the 2nd intercostal space along the midclavicular line parallel to the expected dullness. When percussing, use quiet percussion. The pessimeter finger is gradually moved 0.5 - 1 cm towards the right edge of the manubrium of the sternum until a dull sound appears. At the site of the found dullness, a mark is made along the outer edge of the finger in the direction of the clear pulmonary sound. Then percussion is performed on the left in the same way and the left edge of the vascular bundle is found. The distance between the boundaries of the found dullness is measured with a centimeter tape. Normally, the width of the vascular bundle is 4–5 cm.
Usually, dullness of the percussion sound from the vascular bundle is obtained only on the sternum itself. When the aorta dilates, the dullness of the percussion sound extends beyond the contour of the sternum. With the expansion of the ascending aorta, the dullness of the percussion sound extends beyond the right edge of the sternum into the 2nd intercostal space. When the descending aorta expands, the dullness of the percussion sound extends beyond the left contour of the sternum. Lengthening the aorta results in dullness of percussion sound on both sides of the sternum. In the case of dilatation of the pulmonary artery, dullness of percussion sound is detected to the left of the sternum in the 2nd intercostal space or below this level.

Reasons for deviations from the norm

Focusing on the boundaries of relative cardiac dullness, which gives an idea of ​​the true boundaries of the heart, one can suspect an enlargement of one or another cardiac cavity due to any diseases:

• A shift to the right (expansion) of the right border accompanies myocardial hypertrophy (enlargement) or dilatation (expansion) of the cavity of the right ventricle, expansion of the upper border - hypertrophy or dilatation of the left atrium, and displacement of the left - the corresponding pathology of the left ventricle. The most common expansion of the left border of cardiac dullness occurs, and the most common disease that leads to the borders of the heart expanding to the left is arterial hypertension and the resulting hypertrophy of the left chambers of the heart.
• With a uniform expansion of the boundaries of cardiac dullness to the right and left, we are talking about simultaneous hypertrophy of the right and left ventricles.

Diseases such as congenital heart defects (in children), previous myocardial infarction (post-infarction cardiosclerosis), myocarditis (inflammation of the heart muscle), dishormonal cardiomyopathy (for example, due to pathology of the thyroid gland or adrenal glands), long-term arterial hypertension. Therefore, an increase in the boundaries of cardiac dullness may lead the doctor to think about the presence of any of the listed diseases.

In addition to an increase in the boundaries of the heart caused by myocardial pathology, in some cases there is a shift in the boundaries of dullness caused by the pathology of the pericardium (heart lining) and neighboring organs - the mediastinum, pulmonary tissue or liver:

• Pericarditis, an inflammatory process of the pericardial layers, accompanied by the accumulation of fluid in the pericardial cavity, sometimes in a fairly large volume (more than a liter), often leads to a uniform expansion of the boundaries of cardiac dullness.
• Unilateral expansion of the borders of the heart towards the affected side is accompanied by pulmonary atelectasis (collapse of a non-ventilated area of ​​lung tissue), and towards the healthy side – accumulation of fluid or air in the pleural cavity (hydrothorax, pneumothorax).
• Displacement of the right border of the heart to the left side is rare, but still observed in severe liver damage (cirrhosis), accompanied by a significant increase in liver volume and its upward displacement.

The aortic configuration is formed in all conditions accompanied by hypertrophy of the left ventricle and its overload (aortic defects, arterial hypertension of any origin). Signs of an aortic configuration are: a shift of the boundaries of relative cardiac dullness to the left in the IV-V intercostal spaces due to hypertrophy or dilatation of the left ventricle, the waist of the heart at the level of the III rib is emphasized and well defined, the angle between the vascular bundle and the left ventricle is approaching a straight line. Radiographically, the heart resembles a “boot” or “sitting duck” shape.

Among other pathological configurations, a peculiar configuration can be noted in effusion pericarditis - it resembles the shape of a trapezoid. With it, due to the accumulation of exudate or transudate in the pericardial cavity in a vertical position, mainly the lower parts of the relative cardiac dullness on the left and right expand. In the supine position, these boundaries decrease.

Determination of the boundaries of absolute cardiac dullness

When percussing an area of ​​the heart not covered by the lungs, a dull sound is heard - this is an area of ​​absolute cardiac dullness formed by the right ventricle. Percussion is carried out with the quietest percussion from the border of relative cardiac dullness inwards to an absolutely dull sound. The right one is determined in the 4th intercostal space to the right of the sternum, the left - in the 5th intercostal space to the left of the sternum, and the upper one - from top to bottom along the left edge of the sternum or retreating from it outward by 1 cm.

1. The right border of absolute cardiac dullness runs in the 4th intercostal space along the left edge of the sternum.

2. The left border is located at the level of the 5th intercostal space - 2-3 cm medially from the midclavicular line (or 1-1.5 cm medially from the border of relative cardiac dullness), the upper one is on the 4th rib.

Changing the boundaries of relative cardiac dullness in pathological conditions

1. Shifting the borders of relative dullness of the heart to the right is caused by expansion of the right ventricle (increased pressure in the a. pulmonalis with mitral defects, chronic diseases of the bronchopulmonary system, pulmonary embolism).

2. A shift of the border of relative dullness of the heart to the left at the level of the IV-V intercostal spaces occurs with expansion of the left ventricle (mitral valve insufficiency, aortic defects, arterial hypertension of any origin, coronary artery disease). It should be remembered that a sharply enlarged and hypertrophied right ventricle, pushing the left one, can sometimes shift the border of the relative dullness of the heart to the left.

3. When the diaphragm is high, the heart takes a horizontal position, which leads to an increase in its transverse size; when the diaphragm is low, on the contrary, its transverse size decreases.

4. The accumulation of fluid or air in one of the pleural cavities leads to a displacement of the borders of the heart to the healthy side, with atelectasis or shrinkage of the lungs, pleuropericardial adhesions - to the diseased side.

An increase in the boundaries of absolute cardiac dullness is observed:

1. with dilatation of the right ventricle,

2. with wrinkling and atelectasis of the lungs,

3. after pneumonectomy,

4. with a tumor of the mediastinum,

5. when exhaling deeply,

6. with exudative pleurisy or hydrothorax on the left and compaction of the edges of the left lung,

7. with exudative pericarditis,

8. with sharp hypertrophy of the right ventricle.

A decrease in the boundaries of absolute cardiac dullness is observed:

1. with a deep breath,

2. with a low aperture,

3. for pulmonary emphysema,

4. during an attack of bronchial asthma,

5. for pneumothorax,

6. with pneumopericardium.

Expansion of the vascular bundle is observed in atherosclerosis, syphilis, as well as aneurysms of the ascending part and aortic arch.

Auscultation of the heart

Auscultation of the heart is based on the fact that when the heart contracts and vibrates its main structures (valves, contractile myocardium, large vessels), sounds arise, which in ordinary medical practice are called heart sounds.

Auscultation of the heart is the most important method for diagnosing many diseases, especially congenital and acquired heart defects. To master this method, the doctor must have a good ear for music, as well as a clear understanding and knowledge of the basic patterns of intracardiac hemodynamics, the genesis of sound phenomena in the heart, the sequence and general rules of auscultation of the heart, the projection of the valves onto the chest and the points of their best auscultation.

Auscultation rules. It is carried out in a calm, comfortable environment, noise and extraneous sounds should be excluded.

1. Auscultation of the heart is carried out with the patient standing and lying down, and, if necessary, on the left, right side, after physical activity.

2. The stethoscope should fit tightly to the point being listened to.

3. Listening to the heart is most often done with a stethoscope, which makes it possible to isolate all sounds obtained during auscultation at a certain point. Direct auscultation can be used much less frequently.

4. Listening should be carried out in different phases of breathing. It is imperative to listen to the heart during the breath-holding phase, during inhalation and exhalation, in order to exclude the influence of respiratory sounds on the auscultatory picture of the heart.

5. Heart valves are auscultated in descending order of frequency of their damage. It must be remembered that the places of the anatomical projection of the valves on the chest do not coincide with the points of their auscultation (Fig. 36). In particular:

• The mitral valve is projected at the site of attachment of the third rib to the sternum on the left, and its listening point is the apex of the heart.

• The aortic valve is projected onto the middle of the sternum at the level of attachment of the 3 ribs to the sternum, but is heard in the 2nd intercostal space at the right edge of the sternum.

• The projection of the pulmonary artery valve and the point of listening to it coincide and is located in the second intercostal space at the left edge of the sternum.

• The tricuspid valve is projected in the middle of the distance between the place of attachment of the third rib to the sternum on the left and the 5th rib on the right, and the point of its best auscultation is at the base of the xiphoid process.

Rice. 36. Points of projection and auscultation of heart valves: 1- mitral; 2- aortic valves; 3- pulmonary valve; 4- tricuspid valve.

The first place to listen is the mitral valve, at the apex of the heart. Then the aortic valve - 2nd intercostal space on the right at the edge of the sternum. Then the pulmonary valve - 2nd intercostal space on the left at the edge of the sternum and the tricuspid valve (right atrioventricular) - the base of the xiphoid process of the sternum. 5th point - Botkin-Erb point is located in the third intercostal space on the left at the edge of the sternum. This is an additional listening point for the aortic valve. The Botkin-Erb point has been proposed especially for the early detection of aortic valve insufficiency.

6. If any noise is heard at the main points, then the entire region of the heart should be listened to.

Heart sounds

In healthy people, two tones are heard. The first sound occurs at the beginning of systole, which is why it is called systolic. The second sound occurs at the beginning of diastole, which is why it is called diastolic.

The first tone consists of 3 components: valve, muscle and vascular. The sequence of formation of these components becomes clear during the phase analysis of left ventricular systole. As is known, it consists of phases of asynchronous, isometric tension and the expulsion phase. During the phase of asynchronous contraction, only individual muscle fibers enter a tonic state, therefore the possible influence of this phase on the formation of the first tone is insignificant. Of greatest importance is the subsequent isometric tension phase, when virtually the entire contractile myocardium comes into tone. In this case, the pressure in the ventricles increases sharply, and a pressure gradient (difference) between the ventricles and atria occurs. Since the pressure in the ventricles is higher, the atrioventricular valves close and the most important component of the first sound, the valve sound, appears. At the same time, the muscle component is partially formed during this phase. The next moment, the expulsion phase begins, in which the muscular component is finally formed (as a result of contraction of the left and right ventricles), as well as the vascular component of the first tone (oscillation of the initial parts of the aorta and pulmonary artery during the ejection of blood from the ventricles). The “period of closed valves,” which is observed in the phase of isometric tension, is of utmost importance in the formation of a full-fledged I current. In this case, the atrioventricular valves are already closed, and the semilunar valves of the aorta and pulmonary trunk have not yet opened. The resulting closed system leads to a significant increase in intraventricular pressure, an increase in the potential energy of the ventricles, which is then realized in a loud, strong first tone. In the absence of a “closed valve period,” the first tone weakens.

Can changes in the boundaries of the heart manifest clinically?

If the doctor reveals expanded or displaced borders of cardiac dullness during examination, he should find out in more detail from the patient whether he has some symptoms specific to diseases of the heart or neighboring organs.

Thus, heart pathology is characterized by shortness of breath when walking, at rest or in a horizontal position, as well as swelling localized in the lower extremities and face, chest pain, and cardiac arrhythmias.

Pulmonary diseases are manifested by cough and shortness of breath, and the skin becomes bluish in color (cyanosis).

Liver diseases may be accompanied by jaundice, abdominal enlargement, stool disorders and edema.

In any case, expansion or displacement of the borders of the heart is not normal, and the doctor should pay attention to the clinical symptoms if he detects this phenomenon in the patient for the purpose of further examination.

Measuring the size of the heart.

According to M.G. Kurlov

: the length of the heart is the distance from the right atriovasal angle to the leftmost point of the heart contour.
The diameter of the heart is the sum of two distances: the right and left borders of the heart from the midline of the body. According to Ya.V.
Plavinsky: the patient’s height is divided by 10 and 3 cm is subtracted for the length and 4 cm for the diameter of the heart.
The limit of absolute dullness of the heart.
The boundaries of absolute dullness of the heart and the part of the right ventricle not covered by the lungs are determined by quiet percussion. The upper limit is examined along the same line as the upper limit of the relative dullness of the heart. It is good to use threshold percussion here, when the pulmonary sound is barely audible in the zone of relative dullness of the heart and completely disappears as soon as the pessimeter finger takes a position in the zone of absolute dullness. A mark is made along the outer edge of the finger. Under normal conditions, the upper limit of absolute cardiac dullness passes along the fourth rib. The right tranche of absolute cardiac dullness is determined along the same line along which the right border of relative cardiac dullness was examined. The pessimeter finger is placed vertically in the fourth intercostal space and, using the minimal percussion method, is moved inward until the pulmonary sound disappears. A mark is made along the outer edge of the pessimeter finger. In normal conditions, it coincides with the left edge of the sternum.

Measurement of the width of the vascular bundle.

The vascular bundle is located above the base of the heart behind the sternum. It is formed by the superior vena cava, aorta and pulmonary artery. The width of the vascular bundle is slightly greater than the width of the sternum. Minimal percussion is used. The pessimeter finger is placed on the right along the midclavicular line in the 2nd intercostal space, and percussion is directed towards the sternum. A mark is made along the outer edge of the finger. The same study is carried out in the 2nd intercostal space on the left, then in the 1st intercostal space on the left and right. Under normal conditions, the width of the vascular bundle is 5-6 cm. Fluctuations are possible from 4-4.5 to 6.5-7 cm depending on the gender, constitution and height of the patient. An increase in the width of the vascular bundle can occur with an aneurysm of the aorta, its ascending section and arch, with tumors of the anterior mediastinum, mediastinitis, compaction of the lungs in the study area, enlarged lymph nodes

When might treatment be needed?

Directly expanded or displaced borders of the heart cannot be treated. First, you should identify the cause that led to an enlargement of the parts of the heart or displacement of the heart due to diseases of neighboring organs, and only then prescribe the necessary treatment.

In these cases, surgical correction of heart defects, coronary artery bypass surgery or stenting of coronary vessels may be necessary to prevent recurrent myocardial infarction, as well as drug therapy - diuretics, antihypertensives, rhythm-slowing and other drugs to prevent the progression of enlargement of the heart.