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Examining
our Heart
Why
does a doctor thump on your chest? Why does he move
his stethoscope around in so many different positions?
One of the most important exams a physician performs
is the examination of the heart. The Bible says, "…the
life is in the blood…" (Leviticus 17:11).
Doctors
are trained to stand at the right side of a patient
as we begin our examination. We first simply look
at the chest area (inspection). We might look for
the apical impulse. This is usually in the fifth rib
space, 7-9 cm. from the middle of the breastbone.
Increased amplitude or intensity of this impulse can
be caused by thickening of the large pumping chamber
of the heart, often due to high blood pressure or
valve disease.
If
the location is shifted to the left, it can indicate
a dilation or increased size of the heart. A bulge
near the upper part of the breastbone can be caused
by an aneurysm or enlargement of the large blood vessel
that exits the heart (the aorta). If there is a prominent
pulsation noted in the lower portion of the heart,
this may simply be normal but occasionally can indicate
a displacement of the heart caused by emphysema.
If
we suspect a problem, we will often place our hand
on the chest wall (palpation) and feel for the point
of maximum impulse of the heartbeat. If it moves too
far to the left, it can indicate thickening in the
left ventricle and enlargement in the pumping chamber,
which can be caused by congestive heart failure and
other problems. Again, this can also be a clue to
the effects of high blood pressure or valve problems
in the heart. Sometimes we will take our fingers and
"thump" along the chest wall (percussion),
which can help us detect the overall size of the heart,
air in the lungs or collapse of the lungs, emphysema,
or fluid in the sac that surrounds the heart (pericardial
effusion).
Most
familiar to patients is when the physician takes the
stethoscope and begins listening to the heart. We
are evaluating several things as we listen through
the stethoscope. We can detect atrial fibrillation,
which is an irregular rhythm in the small chambers
in the top of the heart, and we can also detect clues
to malfunction of the heart's built-in pacemaker.
We can also detect premature or irregular beats in
the large pumping chamber of the heart.
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