Home Hygiene Boundaries of the heart during percussion: normal, causes of expansion, displacement. Borders of the heart anatomy Right border

Hygiene

Boundaries of the heart during percussion: normal, causes of expansion, displacement. Borders of the heart anatomy Right border

Reasons for the decline
What does pressure 110 over 50 mean?
Is there any danger
What to do for quick help
Treatment

Low blood pressure is a common occurrence. Young people and children most often suffer from low blood pressure. Blood pressure of 110 over 50 is a reason to worry, what does this indicator mean and what to do in this case?

Blood pressure is a biological marker of a person's well-being. If it deviates from normal indicators it becomes clear that something is wrong with the body. Low blood pressure (hypotension) is no less dangerous than hypertension (high blood pressure).

Reasons for the decline

Nothing happens in the body just like that. And any change is influenced by certain factors. There are two groups of reasons that can affect the occurrence of hypotension:

Physiological (excessive physical activity, climate change, fatigue, etc.). They are isolated in nature, unless there is repeated exposure from the outside;
Pathological (stenosis aortic valve, vegetative-vascular dystonia). It is diseases and pathological conditions that provoke hypotension.
The development of hypotension is influenced by long bed rest. For example, after a major operation, a patient requires long-term rehabilitation. And during the entire period of rehabilitation, he got up only a few times. This will cause a forced reduction in pressure.
In some cases, pharmacological drugs can lower blood pressure.

The symptoms of hypotension can be easily differentiated:

body temperature decreases;
pallor of the skin is observed;
sweating increases;
patients complain about excessive tearfulness and irritability a sharp decline performance, apathy;
dizziness;
headache in the temporal zone;
floaters before eyes.

Such symptoms are alarm bells. To determine blood pressure readings, you need to use a tonometer. Electronic models will determine the pressure level in a matter of seconds. It should be noted that the considered level of blood pressure in adults almost never leads to the appearance of clinical symptoms. 100/50 - slight hypotension, which may be a variant of the norm.

What does pressure 110 over 50 mean?

Such indicators are not always a warning sign. There are situations in medicine when such indicators can be both normal and pathological.

If the child is under 10 years old, then the lower limit (50) is a normal physiological indicator. And here upper limit indicates the development of hypertension. Worth worrying if you small child such pressure;
If a teenager (12-16 years old) is examined, the situation is different. At this age, the upper limit corresponds to the norm. But the lower limit indicates the development of hypotension. It is worth paying attention to the teenager’s health condition and identifying the cause.

In old age, a pressure of 110/50 indicates the development of chronic hypotension. After all, most often older people have hypertension. What does it mean? Hypotension at this age indicates disturbances in the functioning of the cardiovascular system associated with a slower heartbeat.

A blood pressure of 110 over 50 during pregnancy may be normal. In this case, the woman’s well-being remains unchanged, she does not show any complaints, and remains cheerful. When hypotension during pregnancy is accompanied by deterioration of the condition, complaints, or loss of consciousness, it is necessary to immediately consult a specialist. There is a threat to the life of both mother and child.

Is there any danger

The state of hypotension carries a certain danger. Hypotension during pregnancy, in the elderly, and with heart disease can cause unpredictable symptoms. Symptoms manifest themselves individually, but hypotension does not go unnoticed for anyone. And this affects not only the emotional state.

Hypotension can provoke:

loss of consciousness: at best, you can get a bruise. At worst - a fracture or dislocation due to a fall, loss of the fetus during pregnancy;
insufficient functioning of the heart vessels, which affects its performance;
oxygen starvation of the body, which leads to insufficient functioning of all organs and systems;
development of sensitivity to changes in climatic conditions. This makes life very difficult for some patients;
in women there is a violation menstrual cycle, and men may suffer from decreased potency.

It should be noted that the blood pressure indicators under consideration do not lead to the development of the conditions indicated in the first two points of the list. Similar changes occur with more significant hypotension.

What to do for quick help

Considering the possibility of encountering a hypotensive attack, it is worth remembering a few rules:

If not urgent need should not be given to the patient medications(unless the hypotension is chronic and the person knows very well what medications are prescribed).
In case of severe condition (loss of consciousness, severe pallor, convulsions), you should immediately call an ambulance team.
In case of significant hypotension, accompanied by certain clinical symptoms, the use of over-the-counter medicines(Caffeine 1 tablet, Citramon 1 tablet).

Simple ways to help with mild degree hypotension:

Lay the person down, raise the legs higher than the body.
Thoroughly ventilate the room, loosen tight clothing on the victim.
Brew strong tea with sugar and give it to the victim to drink.
Advise the person to breathe slowly and deeply.

Treatment

Drug therapy for hypotension is carried out after consultation with a specialist. The patient is examined by a therapist, cardiologist and other doctors as necessary. After the tests, instrumental examination and after making a final diagnosis, therapy is prescribed.

Spend enough time on fresh air(walk, play sports);
Properly organize work and rest schedules;
Give up bad habits (smoking, alcohol);
Eat balanced and healthy. Limit spicy, salty foods. In the winter-spring period, enrich the body with vitamin complexes;
Be examined by a doctor every six months.

If you suspect hypotension, you should not think that it will go away on its own. It won’t work, and it will add another bag of problems. Timely visit to the therapist, implementation of medical recommendations and healthy image life - this is what can defeat hypotension.

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

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 of the vast majority of people is on the left side. 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. Strictly occupied anatomical position internal organs 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)

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 its boundaries (right, left and upper) can be determined by tapping.

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 a clear sound changes to a dull sound, he marks the border of dullness.

The boundaries of relative and absolute stupidity hearts:

Borders relative stupidity hearts are located along the periphery of the projection of the heart and mean the edges of the organ, which are slightly covered by the lungs, and therefore the sound will be less dull (dull).
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 on the right in left side, and are usually noted 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 anatomical location hearts (not strictly vertically, 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:

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 a displacement of the left - the corresponding pathology of the left ventricle. Most often there is an expansion of the left border of cardiac dullness, and the most frequent illness, leading to the fact that the boundaries of the heart are expanded to the left - this 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.

Dilation of the heart cavities or myocardial hypertrophy can be caused by 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 thyroid gland or adrenal glands), prolonged 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, lung tissue or liver:

Pericarditis often leads to a uniform expansion of the boundaries of cardiac dullness - inflammatory process pericardial sheets, accompanied by the accumulation of fluid in the pericardial cavity, sometimes in a fairly large volume (more than a liter).
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.

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 edema localized on the lower limbs and face, pain in chest, heart rhythm disturbances.

Pulmonary diseases are manifested by cough and shortness of breath, and skin covering acquires a bluish coloration (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.

Additional examination methods

Most likely, after detecting the expanded boundaries of cardiac dullness, the doctor will prescribe an additional examination - an ECG, chest x-ray, ultrasound of the heart (echocardioscopy), ultrasound of the internal organs and thyroid gland, and blood tests.

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 it may be necessary surgical correction heart defects, coronary artery bypass grafting or stenting coronary vessels to prevent recurrent myocardial infarction, as well as drug therapy– diuretics, antihypertensives, rhythm-lowering and other drugs to prevent the progression of enlargement of the heart.

Topography of the heart - educational lecture (video)

What to do if blood pressure does not decrease after taking the pills?

Hypertension is a real epidemic modern society. This disease affects approximately one third of all people over 50 years of age. The disease, once established in the body, cannot be cured complete cure. The only way to avoid dangerous complications- constant use of medications.

Any hypertensive patient eventually considers himself a “professor” in this area, as he is constantly faced with the problem of choice effective drug and dosages. But everyone has cases when blood pressure does not decrease when taking the usual pills.

Why? This is what our article is dedicated to.

A short excursion into physiology

Blood pressure (BP) is created by the pressure of blood on the walls of the arteries, which exceeds atmospheric pressure. This is one of the main markers of the vitality of the organism. A change in the indicator indicates, at a minimum, trouble, and at a maximum, a serious condition that threatens human life.

The indicator is described by two numbers:

Systolic - recorded in the vascular system at the moment of blood ejection. It is also called the top one. Characterizes, first of all, the work of the heart: with what frequency and force this organ contracts;
Diastolic is the residual pressure that is recorded at the moment of complete relaxation of the heart muscle. Depends on the elasticity of blood vessels, heart rate and volume of pumped blood.

The normal value of the indicator is known to everyone - 120/80 mm Hg. Art. But not everyone knows that doctors allow deviations of these values up to 140/90 mm Hg. Art. Only if the patient persistently exceeds these limits is it said that hypertension.

Basic antihypertensive drugs

We do not set a task to do full review tablets used to treat hypertension. This is a huge area of cardiology that is dealt with by specialists. But for a better understanding of the problem it may be useful general characteristics antihypertensive drugs.

First line

The most common and effective means with which to begin treatment:

ACE inhibitors (angiotensin-converting enzyme): Enap, Lisinopril, Captopril, Moex. Their main mechanism of action is dilation of peripheral blood vessels. The advantage is that they do not affect the activity of the heart (do not change heart rate and cardiac output), therefore they are prescribed without fear for heart failure;

Diuretics: “Hypothiazide”, “Indap”, “Veroshpiron”. Increase urine output, which leads to a decrease in circulating blood volume. Often used in combination with the first group;

β-blockers: Atenolol, Betakor, Bisoprolol, Nebilong. Acting on myocardial receptors, they reduce cardiac output. Prescribed for concomitant angina and arrhythmias;
Angiotensin II receptor inhibitors (Sartans): Lozap, Irbetan, Vazar. Relatively new drugs that provide a persistent hypotensive effect throughout the day. Does not cause typical side effects ACE inhibitors(no dry hacking cough);

Calcium channel antagonists: Verapamil, Diltiazem, Amlodipine. Cause typical side effects: facial redness, disturbance heart rate, headache pain.

Second line

Prescribed in the presence of severe side effects, individual intolerance to first-line drugs, or for financial reasons, when the patient cannot afford to take expensive modern drugs for life.

α-blockers: Prazosin, Phentolamine - are less selective, therefore they have many complications (risk of stroke, heart failure). The only positive aspect is the ability to lower cholesterol levels, which is important for all hypertensive patients. Rarely prescribed;
Rauwolfia alkaloids: “Reserpine”, “Raunatine”. They have many side effects, but are cheap, so they are still used by patients, often for self-medication;
Centrally acting α2-agonists: Clonidine, Methyldopa, Dopegit. Act on the central nervous system. Characteristic adverse reactions(drowsiness, lethargy, headaches). But for certain groups of patients they are simply irreplaceable: safe in pregnant women (Methyldopa), since they do not penetrate the placental barrier;

Direct acting vasodilators: Dibazol, Apressin. Due to the dilation of blood vessels, they cause a quick effect, but long-term use leads to insufficient oxygen supply to the brain. It is used more often in the form of one-time injections as an aid.

We have given only some of the names of the drugs; there are many more. All products are freely sold in pharmacies without a prescription. Doses and dosage regimens should be prescribed only by a cardiologist.

Reasons for the ineffectiveness of tablets

All reasons for the lack of effect of antihypertensive therapy can be divided into medical and subjective. The latter are associated with mistakes that patients make when treating hypertension. Let's look at them in more detail.

What depends on the patient

Treatment of hypertension is a complex, long-term process in which there are no details. If you take the doctor’s recommendations lightly, your blood pressure remains high after taking the pills:

Failure to comply with the dose and dosage regimen. A situation often arises: after a month of prescribed treatment, the patient’s well-being improves, and he decides to “save” a little - he begins to take either a reduced dose or reduce the frequency of administration. This is wrong because everything modern drugs for hypertension are depot medications. They are designed to prevent a surge in pressure, and not to fight a fait accompli. If the dosage is not observed, the active substance does not accumulate in the body and another tablet taken occasionally may not work;

Self-replacement of medication. For the same reason, hypertensive patients independently look for analogues of the prescribed pills. Often, out of ignorance, they buy products with a different mechanism of action, guided only by price. As a result, the pressure does not decrease, since each case of hypertension is individual and requires careful selection effective remedy treatment;
Alcohol and other bad habits. Not a single drug will help a patient who continues to ruin his health and stimulate the development of the disease harmful substances. Alcohol, nicotine, and drugs nullify any competent treatment of this disease;
Poor nutrition and lifestyle. In most cases, the doctor explains to the patient that half the success of fighting high blood pressure lies in changes in diet and lifestyle. It is necessary to exclude caffeine (coffee, strong tea), salt (sodium retains water and leads to an increase in circulating blood volume), stress and heavy physical labor. The latter factors “work” through the central nervous system, which gives the command to spasm blood vessels during the body’s response to stress. Traditional antihypertensive drugs cannot cope with this mechanism, so blood pressure does not decrease;

Accompanying illnesses. Obesity, diabetes, kidney pathology and others chronic diseases always aggravate hypertension. If a person does not engage in treatment concomitant pathology, then blood pressure will always increase even with specific therapy;
Concomitant use of medications that reduce the effect of antihypertensive drugs. Often the patient does not attach importance to this information and does not communicate it to the cardiologist. In the meantime, drugs such as Aspirin, Indomethacin, Voltaren, Diclofenac, Ortofen and even some drops for the common cold block most antihypertensive drugs.

Sometimes the reason for blood pressure resistance to drugs lies in a defect in the tonometer or non-compliance with the rules for measuring pressure. Devices require regular verification in specialized medical equipment laboratories. The procedure is carried out only while sitting, the feet are flat on the floor, and the arm is in a relaxed, bent state. The tonometer cuff is located strictly at the level of the heart.

What depends on the doctor

Medical errors leading to prescription ineffective drugs, are not uncommon. After all, it takes time to fully select the right medicine: the patient must go to the hospital, where, after a full examination, the doctor will individually select an antihypertensive drug under constant supervision and laboratory control.

You don't see this approach very often. And a quick appointment at the clinic does not facilitate the collection of a detailed medical history. As a result, the patient leaves with recommendations that most often “work” according to the experience of this cardiologist.

For a competent purpose antihypertensive drug The doctor is required to:

Collect a detailed medical history (time of onset of first health problems, information about concomitant diseases, what medications were prescribed for treatment, what kind of lifestyle the patient leads and even where he works). Such a conversation takes time, but half the success depends on it;
Conduct additional research. Often a person is unaware of the presence of a disease leading to a secondary increase in blood pressure. This can be not only heart disease, but also kidney, adrenal gland, thyroid and many others;
It is imperative to schedule a follow-up visit for the patient if inpatient examination is not possible. During the second meeting, which usually takes place after a week, it becomes clear how the drug works, whether it causes side effects or is well tolerated.

Medicines tend to be addictive. If today pills normalize blood pressure, then after a year they often become ineffective. The patient needs to visit a cardiologist regularly to adjust the prescribed treatment.

What to do if blood pressure does not decrease

Any hypertensive patient should know the algorithm of their actions if blood pressure does not drop after taking the usual pills. Not only his health, but often his life depends on this.

Continue to fight your blood pressure on your own if it does not exceed 180/100 mm Hg. Art. For large numbers, call ambulance, otherwise the risk of stroke and heart attack increases many times;
Emergency therapy drugs - Captopril and Nifedepine, which are available in tablets and sprays, act within 30 minutes. But the effect lasts only a few hours. If your blood pressure has risen to high levels, it is better to consult a doctor after taking these medications, as the crisis may recur;
Acupuncture. Experience Chinese medicine effective in some cases. We find the depression under the earlobe, first press on it, then draw along the skin to the middle of the collarbone. We do everything symmetrically on both sides several times;
Pressure due to stress requires additional sedatives. The lightest are tinctures of valerian, motherwort, and peony;
Thermal procedures for calf muscles(mustard plasters, hot baths, compress with apple cider vinegar for 10 minutes) lead to blood redistribution and a slight decrease in pressure. Contraindications - varicose veins veins

Get involved folk ways doesn't last long. If after such procedures the pressure does not decrease within an hour, seek qualified medical help.

When preparing the source text, we all use some kind of Code Convention. It is good when there is a document within the company that describes these agreements. If not, then we have to use some kind of well-known thing that seems to us standard. Although, of course, the concept of its standard is very relative. It’s better to have such a document within the company so that there are no disagreements within the team.

One of the questions that arises when creating such a document is the right border in the source text. Previously, it was customary to use the right border of 80 (or even 76) characters. But now monitors are wide. Maybe it’s possible not to limit it? Or should it still be limited? For example, just recently, in this article, this issue caused quite a bit of controversy. Below is my vision of this issue + survey.

Why was there such a limit - 80 characters? A little history. Of course, you will quickly remember that old monitors in text mode had this width. This limitation was especially important when monitors (along with the video system) did not yet have a graphics mode. And therefore, it was customary to try to fit the program text into 80, or even better, 78 or even 76 characters. It was customary to use less than 80 because on some not very high-quality monitors the right and left sides were either severely distorted or even hidden behind the casing. I came across many monitors where about half of the familiarity was lost on the left and right.

In addition to monitors, printers had this width. Of course, there were also wide printers. But the most affordable printers designed for A4 paper or a roll of the same (210mm) width accurately printed the same 80 characters on paper.

Moreover, the punched card also held 80 characters.

That is, 80 character line width was, de facto, an industry standard, which was introduced, in my assumption, by IBM.

We've sorted out the history.

Well, good God bless them with punch cards and printers. Since the beginning of the 2000s, I personally haven’t had to print the original text on paper very often, and punch cards have completely become a thing of the past.

The question may arise: what exactly is the problem that the source text goes abroad? Maybe so be it? The compiler doesn't really care what the length of the line is. And even if our screen is still 80 characters wide, and we need to look in the IDE to see what’s beyond the right border of the screen, we can place the cursor on this line and go to the end. Maybe this is the way out?

Not really. This is not an option. We write the source text so that people can read it, and not just the compiler :). If a programmer who reads the source text does not see something immediately, at one glance, then with a high probability he will miss something and will not understand. Or he will waste time.

But why can’t modern monitors move away from this standard? Indeed, the importance of 80 characters began to decline as we moved to graphical screens with relatively high resolution. If, with a resolution of 640x480 VGA adapter, it was difficult to fit more of the same 80 characters on the screen (8 pixels per character width) (although I saw relatively good readable fonts having 5 and 6 pixels per character in width). Then, even at a resolution of 1024x768, it was possible to either improve the quality of drawing characters or increase their number per line. Well, or just add some additional functions to the left and right of the source text - a project tree, a chat with another developer, and so on.

Eat another option- do not wrap the line yourself, but leave this work to the IDE when displaying automatically. That is, in reality it is one long line, but in the IDE it is displayed with a wrap. Maybe this is a way out? In principle, this is already less bad... For some reason, iOS developers I know ended up with this option. Probably because, due to the peculiarities of the Objective C language, wrapping to another line is not always obvious. That is, it is not always clear and understandable what exactly and where exactly needs to be transferred. Well, that’s probably why Apple made this option enabled by default in their IDE (which is called Xcode).

But again. We write source code for people. Is not it? And with such an automatic transfer mode, the structure of the function may be lost, and therefore the logic will be more difficult to understand. Therefore, this is also a bad option.

Third option. With modern widths of 1920 or more pixels, efficiently displaying a large number of characters is not a problem. Maybe we’ll leave the right border as such, but at the same time increase it from the old 80 to 160? or at least 120 characters?

Well, this option is even better than the previous one. But still. Of course, monitors are now wide. With an aspect ratio of 9:16 or 10x16 and a wide-side resolution of, say, 1920 or 2560 pixels, a lot of text can fit. Moreover, with high-quality font rendering.

And everything would be fine... But what if you have to merge (merge) several branches of the source text? For example, what would a three-point merge look like?

For example, KDiff3. Especially this one:

What will three copies of your original text, each 120 characters wide, now look like on your monitor, which is only 1920 pixels wide? You will either have to sacrifice the quality of font rendering, that is, reduce the size and strain your eyes. Or lose part of the logic that will be hidden behind the right border. The second option is not acceptable at all! Because the need for a three-point merge arose as a result of conflict. And I (or you), during the merge process, need to understand exactly the logic that another developer implemented in the left version of the source text, relative to the base (centered) and the right version of the source text, relative to the base. You need to see all the logic!

With a screen width of 1920 pixels, I get 80 characters with 8 pixels per character in width for all 3 versions of the source text. And that's not even counting the overhead of displaying line numbers, boundaries, and so on.

Therefore, I am abroad in 76 characters!

Some clinicians determine not the dome of the diaphragm, but the edge of the lung - using quiet percussion. You just need to take into account that the edge of the lung lies slightly below the level of the diaphragm: the dome of the diaphragm in a normosthenic is located on the V rib, and the edge of the lung is on the VI rib. In a hypersthenic person, both levels can coincide.

Right border heart depends on the position of the dome of the diaphragm, which, in turn, determines the type of constitution in healthy people - in hypersthenics, the dome of the diaphragm lies higher than in normosthenics, and lower in asthenics. When the diaphragm is positioned high, the heart receives horizontal position, which leads to some

Rice. 325. Percussion determination of the boundaries of relative cardiac dullness. The percussion is loud.

Stages of percussion.

The right border of relative cardiac dullness is determined, the finger is placed horizontally on the right in the second intercostal space on the midclavicular line, percussion is carried out down to dullness, which corresponds to the dome of the diaphragm (V rib), then, rising to the width of the rib from the dome of the diaphragm, the finger is placed vertically along the midclavicular lines and along the IV intercostal space are percussed to the edge of the sternum until dullness appears, which will correspond to the border of the heart. Normally, the border is located 1 cm to the right from the edge of the sternum.
The left border of relative cardiac dullness is determined: the finger is placed vertically in the 5th intercostal space at the level of the anterior axillary line, that is, to the left of the apical impulse; percussion is carried out along the intercostal space to the apical impulse; the dullness will correspond to the border of the heart. Normally, the border is 1 - 1.5 cm medially from the midclavicular line.
The upper limit of relative cardiac dullness is determined: the finger is placed horizontally in the second intercostal space 1.5 cm from the left edge of the sternum (between the sternal and parasternal lines); percussion is carried down until dullness appears, which corresponds to the upper border of the heart. Normally, the upper border of the heart is located on the third rib.

The right dome of the diaphragm (relative hepatic dullness) is determined by loud percussion from the third intercostal space along the midclavicular line (possibly parasternally, if a large increase in the borders of the heart is not expected). The plessimer finger is positioned horizontally, its movement after double strike should not exceed 0.5-1 cm, that is, both intercostal spaces and ribs are percussed in a row. This must also be taken into account, since percussion along the edge gives a somewhat dull (shortened) sound. Women should be asked to retract the right breast right hand up and to the right. The dome of the diaphragm in a normosthenic is located at the level of the 5th rib or 5th intercostal space. In an asthenic person it is lower by 1 - 1.5 cm, in a hypersthenic person it is higher.

After determining the dome of the diaphragm, it is necessary to rise to the first rib above, which usually corresponds to the fourth intercostal space, and, placing a finger vertically upward on the midclavicular line, percuss with loud percussion along the intercostal space towards the heart, moving 0.5-1 cm until dullness appears . A mark is made along the edge of the finger facing the pulmonary sound.

Considering the dependence of the right border of the heart on the type of constitution, in an asthenic patient it is necessary to additionally perform percussion in the 5th intercostal space, and in a hypersthenic patient - in the 3rd intercostal space.

In a normosthenic, the right border of relative cardiac dullness is 1 cm outward from the right edge of the sternum in the IV intercostal space, in an asthenic - at the edge of the sternum in the IV-V intercostal space, in a hypersthenic

1.5-2 cm to the right from the edge of the sternum in the IV-III intercostal space. The right border of the heart is formed by the right atrium.

Left border of the heart. Determination of the left border of relative cardiac dullness begins with visual and palpation determination of the localization of the apex beat, the outer edge of which approximately corresponds to the most distant point of the left contour of the heart. Loud percussion is used. It starts from the mid-axillary line and is carried out horizontally at the level of the apex impulse towards the apex of the heart until a dull sound is obtained. Often, especially in hypersthenics, the left border of relative and absolute cardiac dullness coincides, so the pulmonary sound immediately turns into dull.

Percussion of the left border has the following features. At the beginning of percussion, the plessimeter finger should be pressed tightly against the chest with its lateral surface (the finger should always be in the frontal plane), and the blow to it should be applied strictly sagittally, that is, cutting off orthopercussion should be used, and not percussion perpendicular to the bend of the chest wall (Fig. 326 ). The force of percussion in comparison with percussion of the right border should be less due to the proximity of the heart to the surface. The boundary mark should be made on the outside of the finger, on the side of the pulmonary sound.

The position of the left border of the heart, as well as the right, depends on the type of constitution, therefore in a hypersthenic it is necessary to additionally percussion in the IV intercostal space, and in an asthenic in the VI intercostal space.

In a normosthenic, the left border of relative cardiac dullness is 1-1.5 cm medially from the midclavicular line and coincides with the outer edge of the apex beat. In an asthenic person, it can be located up to 3 cm medially from the midclavicular line

nii, in hypersthenics - on the midclavicular line. The left border of the heart is formed by the left ventricle.

The upper limit of relative cardiac dullness is determined from the first intercostal space along a line located 1 cm from the left edge of the sternum (between the sternal and parasternal lines). The plessimeter finger is positioned horizontally so that the middle of the percussed phalanx falls on this line. Impact force is average.

The upper border of the heart is located on the third rib, it does not depend on the type of constitution, it is formed by the cone of the pulmonary artery and the appendage of the left atrium.

The configuration of the heart is determined by loud percussion. To do this, in addition to the most distant points already found (right, left and upper border of the heart), it is necessary to carry out percussion along other intercostal spaces: on the right - in II, III, V, on the left - in

III, IV, VI. The pessimeter finger should be located parallel to the expected border. By connecting all the obtained points of relative cardiac dullness, we get the idea

about the configuration of the heart.

The lower border of the heart is not determined by percussion due to the fusion of cardiac and hepatic dullness. It can be conventionally represented in the form of an oval, closing the lower ends of the right and left contours of the heart, and thus obtaining the full configuration of the heart, its projection onto the anterior chest wall.

The transverse size of the heart (diameter of the heart, Fig. 315) is determined by measuring with a centimeter tape the most distant points of the cardiac boundaries to the right and left of the midline and the sum of these two perpendiculars. For a normosthenic man on the right this distance is 3-4 cm, on the left - 8-9 cm, the sum is 9-12 cm. For asthenics and women this size is 0.5-1 cm smaller, for a hypersthenic man - 0.5-2 cm see more. Determining the diameter of the heart very clearly reflects the position of the heart in the chest, the position of its anatomical axis.

In a normosthenic, the anatomical axis is in an intermediate position at an angle of 45°. In an asthenic person, due to the low position of the diaphragm, the heart takes a more vertical position; its anatomical axis is located at an angle of 70°, and therefore the transverse dimensions of the heart are reduced. In a hypersthenic diaphragm,) lies high, because of this the heart takes a horizontal position at an angle of 30°, which helps to increase the transverse dimensions of the heart.

Having acquired certain skills in percussion of the borders of the heart, absolute cardiac dullness can be determined from fragments simultaneously following the determination of relative dullness. For example, having found the right border of relative cardiac dullness with loud percussion, making a mark without lifting the plessimeter finger, they percussion further, but with quiet percussion until a dull sound appears, which will correspond to the border of absolute cardiac dullness on the right. The same is done when examining the upper and left borders.

The right border of absolute cardiac dullness is located at the left edge of the sternum, the upper one is on the IV rib, the left one either coincides with the border of relative cardiac dullness or is located on

1.5 cm inward from it. Absolute cardiac dullness is formed adjacent to the anterior chest wall right ventricle.

Determination of the boundaries of relative cardiac dullness

First, the right, left and upper limits of the relative dullness of the heart are determined. Pre-

It is absolutely necessary to obtain an indirect idea of the level of the diaphragm, which affects the results of percussion determination of the size of the relative dullness of the heart. To do this, first determine the lower limit right lung along the midclavicular line, which is normally located at the level of the VI rib (Fig. 3.63).

The right border of relative dullness of the heart (Fig. 3.64), formed by the right atrium (RA), is found by percussing one rib above the found lower border of the lung (usually in the 4th intercostal space), moving a vertically positioned pessimeter finger strictly along the intercostal space (Fig. 3.65 ).

The left border of the relative dullness of the heart (Fig. 3.66), formed by the left ventricle (LV), is determined after preliminary palpation of the apical impulse, usually in the 5th intercostal space, moving from the anterior axillary line towards the heart (Fig. 3.67).

The upper limit of the relative dullness of the heart (Fig. 3.68 and 3.69), formed by the left atrial appendage and the trunk of the pulmonary artery, is determined by percussing from top to bottom, 1 cm outward (3) from the left sternal line (but not along the left parasternal line!) .

1) The right border of the relative dullness of the heart in

normally located along the right edge of the sternum or on 1

cm outside of it.

2) The left border is 1-2 cm inward from the left

howl of the midclavicular line and coincides with the upper

3) The upper limit is normally located at the level

Fig.3.64. Definitions of the right border of relative cardiac dullness:

RA - right atrium; LV - left ventricle; RV - right ventricle; LP - left

atrium; 1 - midclavicular line.

Fig. 3.65. Determination of the right border of relative dullness of the heart.

Fig. 3.66. Scheme for determining the left border of relative dullness of the heart. The designations are the same as in Fig. 3.64.

Fig.3.68. Scheme for determining the upper limit of relative cardiac dullness.

The designations are the same as in Fig. 3.64: 1 - midclavicular line; 2 - left erudinal line;

3 - line along which the upper limit is determined.

Fig.3.70. The location of the right (1), left (2) and upper (3) boundaries of the relative dullness of the heart is normal (diagram), 4 - the boundaries of the vascular bundle.

Fig.3.71. Determination of heart diameter:

1 - right border of the heart; 2 - left border of the heart; 3 - anterior midline .

Measuring the diameter of the heart. To measure the diameter of the heart, determine the distance from the right and left borders of the relative dullness of the heart to the anterior midline (Fig. 3.71). Normally, they are 3-4 cm and 8-9 cm, respectively, and the diameter of the heart is cm.

Determining the boundaries of the vascular bundle. The vascular bundle, which includes the aorta, superior vena cava and pulmonary artery (Fig. 3.72), is quite difficult to determine by percussion. Percussion is performed with quiet percussion, moving a vertically positioned finger-pessimeter along the 2nd intercostal space on the right (Fig. 3.73a) and on the left (Fig. 3.73b) towards the sternum. Normally, the boundaries of the vascular bundle are

Fig.Z.72. Determination of the boundaries of the vascular bundle. 1 - midclavicular line .

fall with the right and left edges of the sternum, its width does not exceed cm.

Determining the configuration of the heart. To determine the configuration of the heart, the boundaries of the right and left contours of the relative dullness of the heart are additionally identified, percussing on the right in the third intercostal space, and on the left in the third and fourth intercostal spaces (Fig. 3.74).

By connecting all the points corresponding to the boundaries of relative dullness, we get an idea of the configuration of the heart (Fig. 3.75). Normally, along the left contour of the heart between vascular bundle and the left ventricle is clearly defined by an obtuse angle, the so-called waist of the heart (3).

Fig.3.73. Determination of the boundaries of the vascular bundle on the right (a) and on the left (b).

Fig.3.74. Scheme for determining the configuration of the heart .

Fig.3.75. Normal heart configuration.

1 - contours of relative dullness; 2 - absolute stupidity; 3 - heart waist.

Fig.3.76. Determination of the boundaries of absolute dullness of the heart: 1 - midclavicular line; 2 - anterior midline; 3 - left chest line; 4 - absolute dullness of the heart .

Determination of the boundaries of relative dullness of the heart, Propaedeutics of internal diseases

When determining the boundaries of relative dullness of the heart, the right boundary is first established, then the left, and then the upper.

To identify the right limit of relative dullness of the heart along the right midclavicular line, set the upper limit of absolute dullness of the liver (or lower lung border), which is normally located in the VI intercostal space (Fig. 39, a). After this, going up to the IV intercostal space (to get away from hepatic dullness masking cardiac dullness), the pessimeter finger is placed parallel to the desired border and moved towards the heart along the IV intercostal space (Fig. 39, b). A change in percussion sound from clear pulmonary to dull will indicate reaching the limit of relative dullness of the heart. It should be noted that the pessimeter finger should be moved a short distance each time so as not to miss the boundaries of cardiac dullness. The first appearance of dullness indicates that the inner edge of the finger has crossed the border and is already within the location of the heart. The right border is marked along the outer edge of the finger, facing the clear percussion sound. It is formed by the right atrium and is normally located in the IV intercostal space, protruding 1-1.5 cm beyond the right edge of the sternum.

Rice. 39. Determination of the boundaries of relative dullness of the heart:

a - preliminary stage (establishing the upper limit of absolute liver dullness);

b, c, d - definition of the right, left and upper boundaries, respectively;

d - dimensions of the diameter of the relative dullness of the heart.

Before establishing the left border of the relative dullness of the heart, it is necessary to determine the apical impulse (see Fig. 38), which serves as a guide. If it cannot be detected, percussion is performed in the 5th intercostal space starting from the anterior axillary line towards the sternum. The plessimeter finger is placed parallel to the desired boundary and, moving it, percussion blows of medium strength are applied until dullness appears. The mark of the left border of relative dullness is placed along the outer edge of the pessimeter finger, facing the clear percussion sound. Normally, it is formed by the left ventricle, is located in the 5th intercostal space at a distance of 1-1.5 cm medially from the left midclavicular line (Fig. 39, c) and coincides with the apical impulse.

When determining the upper limit of the relative dullness of the heart (Fig. 39, d), a pessimeter finger is placed near the left edge of the sternum parallel to the ribs and, moving it down along the intercostal spaces, blows of medium strength are applied until dullness appears. A mark is placed along the upper edge of the pessimeter finger, facing the clear percussion sound. The upper limit of the relative dullness of the heart is formed by the contour of the pulmonary artery and the appendage of the left atrium and is normally located on the third rib along the left parasternal line.

Normally, the distance from the right border of relative dullness to the anterior midline is 3-4 cm, and from the left - 8-9 cm. The sum of these distances (11-13 cm) represents the diameter of the relative dullness of the heart (Fig. 39, e) .

The limits of relative cardiac dullness may depend on a number of factors, both extracardiac and cardiac in nature. For example, in people of asthenic physique, due to the low position of the diaphragm, the heart takes a more vertical position (a hanging “drip” heart) and the limits of its relative dullness decrease. The same is observed with prolapse of internal organs. In hypersthenics, due to the opposite reasons (higher position of the diaphragm), the heart takes a horizontal position and the limits of its relative dullness, especially the left one, increase. During pregnancy, flatulence, and ascites, the limits of relative dullness of the heart also increase.

The shift in the boundaries of the relative dullness of the heart, depending on the size of the heart itself, occurs primarily due to the increase (dilatation) of its cavities and is only to some extent determined by the thickening (hypertrophy) of the myocardium. This can happen in all directions. However, significant expansion of the heart and its cavities is prevented forward by the resistance of the chest wall, and downward by the diaphragm. Therefore, expansion of the heart is possible mainly backwards, upwards and to the sides. But percussion reveals only expansion of the heart to the right, up and to the left.

An increase in the right border of the relative dullness of the heart is most often observed with expansion of the right ventricle and right atrium, which occurs with tricuspid valve insufficiency and narrowing of the pulmonary artery orifice. With stenosis of the left atrioventricular orifice, the border shifts not only to the right, but also upward.

A shift of the left border of the relative dullness of the heart to the left occurs with a persistent increase in blood pressure in the systemic circulation, for example, with hypertension and symptomatic hypertension, with aortic heart defects (aortic valve insufficiency, aortic stenosis). With aortic defects, in addition to the displacement of the left border of the relative dullness of the heart to the left, it also shifts down to the VI or VII intercostal space (especially with aortic valve insufficiency). A shift of the left border of relative dullness to the left and up is observed with bicuspid valve insufficiency.

Rice. 40. Normal (a), mitral (b) and aortic (c) configurations of the heart.

To determine the configuration of the heart, percussion is performed sequentially in each intercostal space: to the right of IV and above II, to the left of V and above - to II. In this case, the pessimeter finger is positioned, as usual, parallel to the expected dullness. The percussion blow should be of medium strength. The points obtained during percussion are connected to each other and, thus, the configuration of the heart is revealed (Fig. 40, a). It may vary depending on the nature of his pathology. Thus, with mitral heart defects (insufficiency mitral valve, mitral stenosis), the heart acquires a “mitral configuration” (Fig. 40, b). Due to the expansion of the left atrium and left ventricle, the waist of the heart is flattened due to an increase in the size of the left atrium. With aortic defects (aortic valve insufficiency, narrowing of the aortic opening), with pronounced forms of hypertension, the heart, as a result of isolated expansion of the left ventricle, acquires an “aortic configuration” - the appearance of a “boot” or “sitting duck” (Fig. 40, b). In the case of combined and concomitant defects, all parts of the heart may enlarge. When there is a very sharp displacement of the boundaries of the heart in all directions, it is called “bull”.

The purpose of percussion is to determine the boundaries of the heart and its configuration. Due to the fact that the heart is partially covered by pulmonary tissue, relative and absolute dullness of the heart is distinguished by percussion. Most often, relative dullness is determined, corresponding to the true boundaries of the heart; absolute dullness, which implies the borders of the heart not covered by the lungs, is defined less frequently in practice.

To determine relative dullness, the most commonly used method is loud percussion, in which the plessimeter finger (third finger of the left hand) is pressed tightly to the skin, and the hammer finger (slightly bent third finger of the right hand) delivers quick and short blows of equal force to the second phalanx of the finger. - plessimeter.

When performing percussion, it should be borne in mind that the size of the heart in a vertical position of the patient is smaller than in a horizontal position.

Determination of the boundaries of relative cardiac dullness:

left border of the heart

find the apical impulse;

place a pessimeter finger outward from the apical impulse perpendicular to the intercostal space and percussion towards the sternum until the sound becomes dull (NB! It is the moment of dullness in the sound that gives grounds to mark the desired point);

if the apical impulse is not detected, percussion begins in the 5th intercostal space along the anterior axillary line;

right border of the heart

determine the lower border of the right lung along the midclavicular line;

place a finger-pessimeter on the 1st intercostal space above the found border perpendicular to the intercostal space and percussion towards the sternum until the sound becomes dull;

upper border of the heart

place a pessimeter finger perpendicular to the sternum on the left under the collarbone and percussion downwards until the sound becomes dull.

Normal limits of relative cardiac dullness:

left border – coincides with the apical impulse and is determined 1–2 cm inward from the left midclavicular line;

right border - 1 cm outward from the right edge of the sternum;

the upper border is on the 3rd rib.

A shift in the boundaries of cardiac dullness is observed mainly in the following conditions:

an increase in the size of the heart (it should be borne in mind that a significant increase in the right parts can lead to a displacement of the left ventricle to the left);

accumulation of liquid or gas in the pleural cavities;

The purpose of percussion is to determine the boundaries of the lungs and their mobility (topographic percussion) and compare the percussion sound from the left lung and the right lung (comparative percussion). The study usually begins with comparative percussion: from the apex of the lungs downwards, first in front and then behind. The pessimeter finger is located parallel to the intercostal spaces, with the exception of the interscapular region, where it is placed parallel to the spine.

A change in percussion sound can be caused primarily by the following conditions: a decrease in the airiness of the lung tissue; complete absence air or filling the pleural cavity with fluid; increased airiness of the lung tissue; the presence of air in the pleural cavity; the presence of pleural cords.

With topographic percussion, the boundaries of the lungs are determined.

Normal location of the lung borders:

the upper borders of the lungs are normally located 3–4 cm above the collarbones;

the lower boundaries of the right and left lungs are presented in the table.

Determination of mobility of the lower boundaries of the lungs:

find the lower border of the lungs along the midclavicular, anterior axillary and scapular lines;

ask the patient to take a deep breath and hold his breath;

again determine the border of the lungs along one of the lines;

on the patient’s next deep breath, determine mobility along the other line, etc.

The difference in centimeters between the first and second measurements is the amount of mobility of the lower edge of the lung and normally ranges from 2–3 cm along the scapular and midclavicular lines to 3–4 cm along the anterior axillary line.

In the same way, you can determine the mobility of the lower borders of the lungs during exhalation.

A decrease in the mobility of the lower edge of the lungs is observed, as a rule, in the following conditions: inflammatory processes in the lungs; congestive congestion of the lungs; emphysema; fluids in the pleural cavities; fusion or obliteration of the pleural layers.

Percussion of the liver in everyday practice most often consists of determining the lower limit of the relative dullness of the liver.

Determination of the left border: the plessimeter finger is placed perpendicular to the edge of the left costal arch at the level of the 7th–9th ribs and percussed to the right until a dull sound appears.

Determination of the right border: a pessimeter finger is placed in the area of the right half of the abdomen along the anterior axillary line parallel to the intended edge of the liver and percussed upward until a dull sound appears.

Normal location of the left border of the liver:

The right border of the liver is normally located along the lower border of the right costal arch, but can shift 1–2 cm lower during percussion in an upright position of the body, as well as in people of asthenic physique.

An enlarged liver is early symptom heart failure, and it is important to monitor its size over time. The preservation of increased liver size against the background of achieved compensation of cardiac activity is the basis for suspecting independent liver disease (hepatitis) and carrying out appropriate diagnostic procedures(biochemical samples, analysis for viral hepatitis etc.).

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Physical examination: cardiac percussion

The cardiac percussion method makes it possible to detect signs of dilatation of the ventricles and atria, as well as expansion of the vascular bundle. The boundaries of relative and absolute cardiac dullness, vascular bundle, and heart configuration are determined.

Determination of the boundaries of relative dullness of the heart. First, the right, left and upper limits of the relative dullness of the heart are determined. It is known that the right border of the relative dullness of the heart, formed by the RA, is normally located along the right edge of the sternum or 1 cm outward from it; the left border (LV) is located 1-2 cm medially from the left midclavicular line and coincides with the apical impulse; the upper border, formed by the LA appendage or pulmonary trunk, is normally located at the level of the third rib. It should be remembered that the increase in the size of the relative dullness of the heart occurs mainly due to dilatation of individual cavities of the heart; Myocardial hypertrophy alone (without dilatation), as a rule, does not change the percussion dimensions of the heart.

Determination of the boundaries of the vascular bundle. The vascular bundle, which includes the aorta, superior vena cava and pulmonary artery, is quite difficult to determine by percussion. Normally, the boundaries of the vascular bundle coincide with the right and left edges of the sternum, its width does not exceed 5-6 cm.

Determination of heart configuration. To determine it, the boundaries of the right and left contours of the relative dullness of the heart are additionally identified, percussing on the right in the third intercostal space, and on the left in the third and fourth intercostal spaces. By connecting all the points corresponding to the boundaries of relative dullness, we get an idea of the configuration of the heart. Normally, along the left contour of the heart between the vascular bundle and the LV, an obtuse angle is clearly defined - the “waist of the heart”.

Determination of the boundaries of absolute cardiac dullness. When determining boundaries, the quietest percussion is used. Percussion is performed from the previously found boundaries of relative dullness of the heart towards the area of absolute dullness. The right border of absolute dullness of the heart is normally located along the left edge of the sternum, the left - 1-2 cm medially from the left border of relative dullness of the heart, and the upper - at the level of the IV rib.

The most common causes of changes in the boundaries and configuration of the heart are presented in table. 1.

Table 1. Interpretation of cardiac percussion results

Complaints, anamnesis, physical examination

To accurately interpret changes when analyzing an ECG, you must adhere to the decoding scheme given below.

In routine practice and in the absence of special equipment for assessing tolerance to physical activity and objectification of the functional status of patients with moderate and serious illnesses heart and lungs, you can use the walking test for 6 minutes, corresponding to submaximal.

Electrocardiography is a method of graphically recording changes in the potential difference of the heart that arise during the processes of myocardial excitation.

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

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.

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.

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

Normal values for the boundaries of cardiac dullness

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

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

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).
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 noted 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:

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 a displacement of the left - the corresponding pathology of the left ventricle. The most common is an expansion of the left border of cardiac dullness, and the most common disease that leads to the borders of the heart being expanded 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.

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.

Can changes in the boundaries of the heart manifest clinically?

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.

Additional examination methods

Most likely, after detecting the expanded boundaries of cardiac dullness, the doctor will prescribe further examination - an ECG, chest x-ray, ultrasound of the heart (echocardioscopy), ultrasound of the internal organs and thyroid gland, and blood tests.

When might treatment be needed?

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.

(Fig. 325)
The right border of the heart - its determination begins with establishing the level of the right dome of the diaphragm. Some clinicians determine not the dome of the diaphragm, but the edge of the lung - using quiet percussion. You just need to take into account that the edge of the lung lies slightly below the level of the diaphragm: the dome of the diaphragm in a normosthenic is located on the V rib, and the edge of the lung is on the VI rib. In a hypersthenic person, both levels can coincide.
The right border of the heart depends on the position of the dome of the diaphragm, which, in turn, determines the type of constitution in healthy people - in a hypersthenic, the dome of the diaphragm lies higher than in a normosthenic, and lower in an asthenic. When the diaphragm is located high, the heart takes a horizontal position, which leads to some

Rice. 325. Percussion determination of the boundaries of relative cardiac dullness. The percussion is loud.
Stages of percussion.

The right border of relative cardiac dullness is determined, the finger is placed horizontally on the right in the second intercostal space on the midclavicular line, percussion is carried out down to dullness, which corresponds to the dome of the diaphragm (V rib), then, rising to the width of the rib from the dome of the diaphragm, the finger is placed vertically along the midclavicular lines and along the IV intercostal space are percussed to the edge of the sternum until dullness appears, which will correspond to the border of the heart. Normally, the border is located 1 cm to the right from the edge of the sternum.
The left border of relative cardiac dullness is determined: the finger is placed vertically in the 5th intercostal space at the level of the anterior axillary line, that is, to the left of the apical impulse; percussion is carried out along the intercostal space to the apical impulse; the dullness will correspond to the border of the heart. Normally, the border is 1 - 1.5 cm medially from the midclavicular line.
The upper limit of relative cardiac dullness is determined: the finger is placed horizontally in the second intercostal space 1.5 cm from the left edge of the sternum (between the sternal and parasternal lines); percussion is carried down until dullness appears, which corresponds to the upper border of the heart. Normally, the upper border of the heart is located on the third rib.

mu increase in the boundaries of relative cardiac dullness on the right and left. When the diaphragm is low, the heart acquires a vertical position, the right and left boundaries shift to the sides/midline, that is, the boundaries of the heart decrease.
The right dome of the diaphragm (relative hepatic dullness) is determined by loud percussion from the third intercostal space along the midclavicular line (possibly parasternally, if a large increase in the borders of the heart is not expected). The plessimer finger is positioned horizontally, its movement after a double blow should not exceed 0.5-1 cm, that is, both intercostal spaces and ribs are percussed in a row. This must also be taken into account, since percussion along the edge gives a somewhat dull (shortened) sound. Women should be asked to move the right mammary gland with her right hand up and to the right. The dome of the diaphragm in a normosthenic is located at the level of the 5th rib or 5th intercostal space. In an asthenic person it is lower by 1 - 1.5 cm, in a hypersthenic person it is higher.
After determining the dome of the diaphragm, it is necessary to rise to the first rib above, which usually corresponds to the fourth intercostal space, and, placing a finger vertically upward on the midclavicular line, percuss with loud percussion along the intercostal space towards the heart, moving 0.5-1 cm until dullness appears . A mark is made along the edge of the finger facing the pulmonary sound.
Considering the dependence of the right border of the heart on the type of constitution, in an asthenic patient it is necessary to additionally perform percussion in the 5th intercostal space, and in a hypersthenic patient - in the 3rd intercostal space.
In a normosthenic, the right border of relative cardiac dullness is 1 cm outward from the right edge of the sternum in the IV intercostal space, in an asthenic - at the edge of the sternum in the IV-V intercostal space, in a hypersthenic

1.5-2 cm to the right from the edge of the sternum in the IV-III intercostal space. The right border of the heart is formed by the right atrium.

During percussion, the plessimeter finger is positioned strictly vertically, its movement is no more than 0.5-1 cm. The hammer finger should strike the intercostal space to avoid the spread of vibrations along the rib over a large area. If there is no assumption that the left border of the heart is enlarged, percussion can begin from the anterior axillary line. If the apical impulse is not detected, then it is usually percussed at the level of the 5th intercostal space.
Percussion of the left border has the following features. At the beginning of percussion, the plessimeter finger should be pressed tightly against the chest with its lateral surface (the finger should always be in the frontal plane), and the blow to it should be applied strictly sagittally, that is, cutting off orthopercussion should be used, and not percussion perpendicular to the bend of the chest wall (Fig. 326 ). The force of percussion in comparison with percussion of the right border should be less due to the proximity of the heart to the surface. The boundary mark should be made on the outside of the finger, on the side of the pulmonary sound.
The position of the left border of the heart, as well as the right, depends on the type of constitution, therefore in a hypersthenic it is necessary to additionally percussion in the IV intercostal space, and in an asthenic in the VI intercostal space.
In a normosthenic, the left border of relative cardiac dullness is 1-1.5 cm medially from the midclavicular line and coincides with the outer edge of the apex beat. In an asthenic person, it can be located up to 3 cm medially from the midclavicular line
nii, in hypersthenics - on the midclavicular line. The left border of the heart is formed by the left ventricle.
The upper limit of relative cardiac dullness is determined from the first intercostal space along a line located 1 cm from the left edge of the sternum (between the sternal and parasternal lines). The plessimeter finger is positioned horizontally so that the middle of the percussed phalanx falls on this line. Impact force is average.
The upper border of the heart is located on the third rib, it does not depend on the type of constitution, it is formed by the cone of the pulmonary artery and the appendage of the left atrium.
The configuration of the heart is determined by loud percussion. To do this, in addition to the most distant points already found (right, left and upper border of the heart), it is necessary to carry out percussion along other intercostal spaces: on the right - in II, III, V, on the left - in

III, IV, VI. The pessimeter finger should be located parallel to the expected border. By connecting all the obtained points of relative cardiac dullness, we get the idea

about the configuration of the heart.
The lower border of the heart is not determined by percussion due to the fusion of cardiac and hepatic dullness. It can be conventionally represented in the form of an oval, closing the lower ends of the right and left contours of the heart, and thus obtaining the full configuration of the heart, its projection onto the anterior chest wall.
The transverse size of the heart (diameter of the heart, Fig. 315) is determined by measuring with a centimeter tape the most distant points of the cardiac boundaries to the right and left of the midline and the sum of these two perpendiculars. For a normosthenic man on the right this distance is 3-4 cm, on the left - 8-9 cm, the sum is 9-12 cm. For asthenics and women this size is 0.5-1 cm smaller, for a hypersthenic man - 0.5-2 cm see more. Determining the diameter of the heart very clearly reflects the position of the heart in the chest, the position of its anatomical axis.
In a normosthenic, the anatomical axis is in an intermediate position at an angle of 45°. In an asthenic person, due to the low position of the diaphragm, the heart takes a more vertical position; its anatomical axis is located at an angle of 70°, and therefore the transverse dimensions of the heart are reduced. In a hypersthenic diaphragm,) lies high, because of this the heart takes a horizontal position at an angle of 30°, which helps to increase the transverse dimensions of the heart.

The boundaries of absolute cardiac dullness (the area of the anterior surface of the heart not covered by the lungs) are determined in the same sequence as relative ones (Fig. 327). The pessimeter finger is installed parallel to the expected border at the marking point of relative cardiac dullness. Using quiet percussion, moving the finger 0.5 cm, percussion until an absolutely dull sound appears. A mark is made along the outer edge of the finger. This is how they percussion, establishing the right and upper boundaries. When determining the left border of absolute cardiac dullness, it is necessary to step back from the relative border to the left by 1-2 cm. This is due to the fact that in many cases absolute and relative dullness coincide, and in accordance with the rules of percussion it is necessary to go from the pulmonary sound to the dull one.
Having acquired certain skills in percussion of the borders of the heart, absolute cardiac dullness can be determined from fragments simultaneously following the determination of relative dullness. For example, having found the right border of relative cardiac dullness with loud percussion, making a mark without lifting the plessimeter finger, they percussion further, but with quiet percussion until a dull sound appears, which will correspond to the border of absolute cardiac dullness on the right. The same is done when examining the upper and left borders.
The right border of absolute cardiac dullness is located at the left edge of the sternum, the upper one is on the IV rib, the left one either coincides with the border of relative cardiac dullness or is located on

1.5 cm inward from it. Absolute cardiac dullness is formed by the right ventricle adjacent to the anterior chest wall.

4. Practical part of the lesson

5. Progress of the lesson

1. Name the main complaints of patients with diseases of the circulatory system.

2. Name the features of pain syndrome in angina pectoris and myocardial infarction.

3. Describe pain in myocarditis, pericarditis, cardioneurosis, dissecting aortic aneurysm.

4. How is the occurrence of palpitations and heart failure explained?

5. Name the patient’s complaints with cardiac asthma and pulmonary edema.

6. Name the clinical variants of dyspnea of cardiac origin.

7.Name the patient’s complaints that arise from stagnation of blood in the systemic circulation.

8. Name the mechanism of edema occurrence in heart failure.

9. List the clinical variants of headaches in diseases of the cardiovascular system.

10.Give a clinical description of the “dead finger” symptom.

11.What is a symptom of intermittent claudication?

12. What is a Stokes collar?

13. List the characteristic changes in the patient’s face with heart disease.

14. Name the types of forced position of the patient in case of heart failure, angina pectoris, pericarditis.

15. Method of determining pulse. Name the main characteristics of the pulse in normal and pathological conditions.

16. What is cardiac hump, apical impulse, negative apical impulse, cardiac impulse? Diagnostic value of these symptoms.

17. Palpation of the heart area.

18. Under what conditions is the apical impulse shifted to the left, right, or up?

19. What is the symptom of “cat purring”? Diagnostic value.

20. Name the rules for performing cardiac percussion. How to determine the boundaries of absolute and relative dullness of the heart.

5 Pulmonary artery; 6 – aorta; 7 – superior vena cava

21. Name the limits of absolute and relative dullness of the heart in a healthy person.

22. Under what pathological conditions is there an expansion of the borders of the heart to the right? Left? Up?

23. What is the configuration of the heart in a healthy person? List the pathological configurations of the heart.

24. Determination of the size of the vascular bundle.

25. Under what pathological conditions is the measurement of the boundaries of absolute and relative dullness of the heart observed?

26.Questions for self-control of knowledge.

7. It is not typical for exudative pericarditis:

10. Left ventricular hypertrophy is characterized by:

25. Stagnation in a large circle is most often observed when:

20. Name the rules for performing cardiac percussion. How to determine the boundaries of absolute and relative dullness of the heart.

When performing percussion, the following general rules are required: rules:

1. The doctor is positioned to the right of the patient, with his back to the light source.

2. The doctor’s hands should be warm, nails should be cut short.

3. The patient should be in a comfortable position (preferably standing or sitting).

4. The pessimeter finger should fit tightly to the percussed surface.

5. The percussion blow must be applied strictly perpendicular to the surface of the pessimeter finger.

6. The percussion blow should be applied by moving the hand at the wrist joint and be short, jerky, and of equal strength.

7. When performing percussion, the finger-pessimeter must be placed strictly parallel to the border of the heart, a mark should be made along the edge of the pessimeter facing the clearer sound

8. Determining the boundaries of relative dullness of the heart begins with determining the height of the diaphragm, then the right, left and upper boundaries of the relative dullness of the heart are determined, the strength of percussion is weak (quiet).

9. Determination of the boundaries of absolute dullness of the heart is made from the boundaries of relative dullness of the heart found by percussion; the force of percussion is the quietest.

Percussion of the heart area includes the determination of:

1) boundaries of relative cardiac dullness (borders of the heart);

2) heart position;

3) heart configuration;

4) dimensions of the heart and vascular bundle;

5) the boundaries of absolute cardiac dullness (the area of the anterior surface of the heart not covered by the lungs).

Defining the right border

The pessimeter finger is located in the second intercostal space along the right midclavicular line, then percussion of medium strength is percussed downward until the clear pulmonary sound changes to dull; the border is marked from the side of the pessimeter finger facing the clear (pulmonary) sound (VI intercostal space). Then the finger-pessimeter is moved 2 ribs or 1 intercostal space up (in the 4th intercostal space), placed parallel to the right edge of the sternum and percussed (quiet percussion) from the midclavicular line to the right edge of the sternum until the pulmonary sound changes to dull (this is the right border of relative dullness heart), determine the distance to the right edge of the sternum in centimeters.

Normally, the right border of the relative dullness of the heart in the fourth intercostal space is 1-1.5 cm from the right edge of the sternum, formed by the right atrium.

Defining the left borderrelative dullness of the heart.

It begins with palpation of the apical impulse, after which the finger-pessimeter is placed vertically in the intercostal space in which the apical impulse is located 1-2 cm outward from the outer edge of the apical impulse (or from the anterior axillary line). If the apical impulse is not detected, percussion is performed in the 5th intercostal space from the left anterior axillary line. The blows are applied quietly until the pulmonary percussion sound changes to dull. The border is marked along the edge of the pessimeter finger on the side of the clear pulmonary sound (outside).

Normally, the left border of the relative dullness of the heart is located in the 5th intercostal space 1-1.5 cm medially from the midclavicular line, formed by the left ventricle.

Determining the upper limitrelative dullness of the heart.

The pessimeter finger is placed under the left clavicle parallel to the desired border along a line located 1 cm to the left of the left edge of the sternum. Percussion blows are applied quietly. When the pulmonary sound changes to dull, the upper limit of the relative dullness of the heart is marked along the upper edge of the pessimeter finger.

Normally, the upper limit of the relative dullness of the heart is at the level of the upper edge of the third rib and is formed by the conus of the pulmonary artery.

Determination of the limits of relative dullness of the heart: a – preliminary stage (establishing the upper limit of absolute dullness of the liver); b, c, d – definition of the right, left and upper boundaries, respectively.

Contours of the heart: 1,2 – left and right ventricles; 3.4 – right and left atria;

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