The left border of the heart is formed. Limits of relative and absolute dullness of the heart
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The method of percussion of the heart allows you to identify signs of dilatation of the ventricles and atria, as well as the expansion of the vascular bundle. The boundaries of relative and absolute cardiac dullness, the vascular bundle, and the configuration of the heart are determined.
Determination of the boundaries of relative dullness of the heart. First determine the right, left and upper limits of the relative dullness of the heart. It is known that the right border of the relative dullness of the heart, formed by the PP, 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 mid-clavicular line and coincides with the apical impulse; the upper border, formed by the LA auricle or pulmonary trunk, is normally located at the level of the third rib. It should be remembered that an increase in the size of the relative dullness of the heart occurs mainly due to the dilatation of individual cavities of the heart; one myocardial hypertrophy (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, the superior vena cava and the pulmonary artery, is rather difficult to determine 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.
Determining the configuration of the heart. To determine it, the boundaries of the right and left contours of the relative dullness of the heart are additionally revealed, percussing on the right in the III intercostal space, and on the left in the III and IV intercostal spaces. By connecting all the points corresponding to the boundaries of relative dullness, one gets an idea of the configuration of the heart. Normally, along the left contour of the heart between the vascular bundle and the left ventricle, an obtuse angle is clearly defined - the “waist of the heart”.
Determination of the boundaries of absolute dullness of the heart. When determining the boundaries, the quietest percussion is used. Percussion is performed from the previously found boundaries of the relative dullness of the heart towards the area of absolute dullness. The right border of the absolute dullness of the heart is normally located along the left edge of the sternum, the left one is 1-2 cm medially from the left border of the relative dullness of the heart, and the upper one is 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. one.
Table 1. Interpretation of the results of cardiac percussion
Changing the borders of the heart Causes Diseases and Syndromes
Displacement of the right border of relative cardiac dullness right Dilatation of the RV and/or RA
Dilatation of PP Right AV stenosis
Mediastinal shift to the right Left-sided hydrothorax, left-sided pneumothorax, right-sided obstructive atelectasis
Left "Hanging" ("drip") heart Asthenic body type
Mediastinal shift to the left Left-sided obstructive atelectasis
Shift of the left border of relative cardiac dullness Left Dilatation of the LV cavity Aortic heart disease, mitral insufficiency, hypertension, acute myocardial injury (myogenic dilatation), left ventricular heart failure
Mediastinal shift to the left Right-sided hydrotocrax, right-sided pneumothorax, left-sided obstructive atelectasis
"Lying" heart High standing diaphragm (ascites, flatulence, obesity)
right Mediastinal shift to the right Right-sided obstructive atelectasis
Shift of the upper limit of relative cardiac dullness Up LA dilatation
Heart configuration Mitral Dilatation of the LA and smoothing of the "waist of the heart" Mitral stenosis, mitral insufficiency
Aortic LV dilatation and accentuated "waist of the heart" Aortic heart disease, AH
Expansion of the vascular bundle right Dilation or aneurysm of the ascending aorta AH, aortic atherosclerosis, ascending aortic aneurysm
Left Dilation of the pulmonary artery High pressure in the pulmonary artery
Expansion of the descending aorta AH, aortic atherosclerosis
Right and left Expansion, lengthening and reversal of the aortic arch AH, aortic atherosclerosis
Expansion of absolute stupidity Dilatation of the pancreas Mitral stenosis, cor pulmonale, tricuspid valve insufficiency
Extracardiac causes High standing of the diaphragm, wrinkling of the lung edges, swelling of the posterior mediastinum
Reducing absolute dullness Extracardiac causes Emphysema, left-sided or right-sided pneumothorax, low standing diaphragm ("hanging" heart in patients with asthenic type of constitution)
(Fig. 325)
The right border of the heart - its definition begins with the establishment of the level of standing 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. It is only necessary to take into account the fact that the edge of the lung lies slightly below the level of the diaphragm: the dome of the diaphragm in the normosthenic is on the 5th rib, and the edge of the lung is on the 6th rib. In a hypersthenic, both levels may 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 normostenic, in an asthenic it is lower. With a high location of the diaphragm, the heart takes a horizontal position, which leads to some
Rice. 325. Percussion determination of the boundaries of relative cardiac dullness. 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 II intercostal space on the mid-clavicular line, percussion is carried out down to dullness, which corresponds to the dome of the diaphragm (V rib), then, having risen to the width of the rib from the dome of the diaphragm, the finger is placed vertically along the mid-clavicular 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 1 cm to the right of 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 apex beat; percussion is carried out along the intercostal space to the apex beat; dullness will correspond to the border of the heart. Normally, the border is 1 - 1.5 cm medially from the mid-clavicular line.
- The upper limit of relative cardiac dullness is determined: the finger is placed horizontally in the II 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 on the third rib.
The right dome of the diaphragm (relative hepatic dullness) is determined by loud percussion from the III intercostal space along the midclavicular line (it is possible along the parasternal line, if a large increase in the borders of the heart is not expected). The plessimer finger is located horizontally, its movement after a double blow should not exceed 0.5-1 cm, that is, intercostal spaces and ribs are percussed in a row. This should also be taken into account, since percussion along the edge gives a somewhat dull (shortened) sound. Women should be asked to abduct the right breast with their 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 the 5th intercostal space. In an asthenic, it is 1–1.5 cm lower, in a hypersthenic, it is higher.
After determining the dome of the diaphragm, it is necessary to rise to the 1st rib above, which usually corresponds to the 4th intercostal space, and, placing the finger vertically upwards on the mid-clavicular 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 lung sound.
Given the dependence of the right border of the heart on the type of constitution, it is necessary to additionally percussion in the 5th intercostal space in the asthenic, and in the 3rd intercostal space in the hypersthenic.
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.
The finger-pessimeter during percussion is located strictly vertically, its movement is no more than 0.5-1 cm. In the absence of an assumption about an increase in the left border of the heart, percussion can begin from the anterior axillary line. If the apex beat is not detected, then usually percuss 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 the lateral surface (the finger should always be in the frontal plane), and the blow should be applied strictly sagitally, that is, cut-off orthopercussion should be used, and not percussion perpendicular to the bend of the chest wall (Fig. 326 ). The strength of the percussion blow in comparison with the percussion of the right border should be less due to the proximity of the heart to the surface. The boundary mark should be made from the outside of the finger, from the side of the lung sound.
The position of the left border of the heart, as well as the right one, depends on the type of constitution, therefore, in a hypersthenic, it is necessary to additionally percuss 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 mid-clavicular line and coincides with the outer edge of the apex beat. In an asthenic, it can be located up to 3 cm medially from the mid-clavicular
nii, in hypersthenic - on the mid-clavicular 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. The 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 auricle 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 percussion along other intercostal spaces: on the right - in II, III, V, on the left - in
- III, IV, VI. In this case, the plesimeter finger should be parallel to the intended border. Connecting all the obtained points of relative cardiac dullness, we get the representation
The lower border of the heart is not determined by percussion due to the confluence of cardiac and hepatic dullness. It can be conditionally represented as an oval by closing the lower ends of the right and left contours of the heart, and thus get the full configuration of the heart, its projection on the anterior chest wall.
The transverse size of the heart (diameter of the heart, Fig. 315) is determined by measuring the most distant points of the cardiac borders to the right and left of the midline and the sum of these two perpendiculars with a centimeter tape. For a normosthenic man on the right, this distance is 3-4 cm, on the left - 8-9 cm, the total is 9-12 cm. In asthenics and women, this size is 0.5-1 cm less, in hypersthenics - 0.5-2 see more. The definition of 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, due to the low standing 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 contributes to an increase in the transverse dimensions of the heart.
The boundaries of absolute cardiac dullness (a section of the anterior surface of the heart not covered by the lungs) are determined in the same sequence as relative (Fig. 327). The finger-plessimeter is set parallel to the intended border at the point-mark of relative cardiac dullness. Using quiet percussion, moving the finger by 0.5 cm, they percuss until an absolutely dull sound appears. A mark is made along the outer edge of the finger. So they percuss, setting the right and upper boundaries. When determining the left border of absolute cardiac dullness, it is necessary to deviate 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 lung sound to dull. 
Having gained certain skills in percussion of the borders of the heart, absolute cardiac dullness can be determined by fragments simultaneously after the determination of relative dullness. For example, having found the right border of relative cardiac dullness with loud percussion, making a mark, without removing the pessimeter finger, they percuss further, but with quiet percussion until a dull sound appears, which will correspond to the border of absolute cardiac dullness on the right. Do the same 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 medially from it. Absolute cardiac dullness is formed by the right ventricle adjacent to the anterior chest wall.
The location of any organ in the human body is genetically determined and subject to certain rules. For example, the heart in humans is usually located on the left side of the chest, and the stomach is usually located on the left side of the abdominal cavity. The location and boundaries of any internal organ can be identified by a specialist with the help of probing and. The boundaries of the heart are determined by tapping the chest with fingers. This method is called percussion of the heart.
Although instrumental studies are the most informative in identifying, tapping often helps to make a preliminary diagnosis even during the initial examination of the patient.
Usually the human heart is located on the left side of the chest, slightly oblique, and in appearance resembles a cone. From above and from the sides, the organ is partially covered by the lungs, in front - by the chest, from below - by the diaphragm, and behind - by the organs of the mediastinum.
The anatomy of the borders of the heart is revealed by the sound that the doctor hears when he taps the chest wall:
- percussion of the cardiac region is usually accompanied by a dull sound;
- tapping of the lung area - clear pulmonary.
During the procedure, the specialist gradually moves his fingers from the front of the sternum to its center, and marks the border at the moment when the lung sound is replaced by a characteristic deaf one.
Border types
It is customary to distinguish two types of borders of dullness of the heart:
- Absolute border It is formed by an open area of the heart, and when it is tapped, a more deaf sound is heard.
- Limits of relative stupidity located in places where the heart is slightly covered by areas of the lungs, and the sound that is heard when tapping is dull.
Norm
The boundaries of the heart normally have approximately the following values:
- Right the border of the heart is usually found in the fourth intercostal space on the right side of the chest. It is determined by moving the fingers from right to left along the fourth gap between the ribs.
- Left located on the fifth intercostal space.
- Upper located on the third intercostal space on the left side of the chest.
The upper cardiac border indicates the location of the left atrium, and the right and left, respectively. When tapping, it is not possible to identify only the location of the right atrium.
The norm of the border of the heart in children varies according to the stages of growing up, and becomes equal to the values of adults when the child reaches the age of twelve. So, up to two years, the left border is 2 cm outward in the left part of the midclavicular line, the right one is along the right parasternal line, and the upper one is in the region of the second rib.
From two to seven years, the left border is 1 cm outward from the left side of the midclavicular line, the right one is shifted to the inside of the right parasternal line, and the upper one is located in the second intercostal space.
From seven years to twelve, the left border is located on the left along the midclavicular line, the right border is on the right edge of the chest, and the upper one is shifted to the region of the third rib.
The norm of the borders of the heart in adults and children gives an idea of where the heart borders should be. If the borders of the heart are not located where they should be, we can assume hypertrophic changes in any part of the organ due to pathological processes.
The causes of cardiac dullness are usually the following:
- Pathological enlargement of the myocardium or right heart ventricle, which is accompanied by a significant expansion of the right border.
- Pathological enlargement of the left atrium, resulting in a displacement of the upper cardiac border.
- Pathological enlargement of the left ventricle, due to which the left border of the heart expands.
- Hypertrophic changes in both ventricles at the same time, in which both the right and left cardiac boundaries are displaced.
Of all these deviations, the most common displacement of the left border, and often it is caused by persistent, against which a pathological increase in the left side of the heart develops.
In addition, changes in cardiac boundaries can provoke such pathologies as congenital heart anomalies, transferred, an inflammatory process in the heart muscle or cardiomyopathy, which has developed as a result of disruption of the normal functioning of the endocrine system and hormonal imbalance against this background.
In many cases, the expansion of the heart boundaries is due to a disease of the heart shirt and abnormalities in the work of neighboring organs - for example, the lungs or liver.
Uniform expansion of the boundaries is often caused by pericarditis - inflammation of the pericardial sheets, which is characterized by excess fluid in the pericardial cavity.
Unilateral displacement of the boundaries of the heart to the healthy side most often occurs against the background of excess fluid or air in the pleural cavity. If the cardiac boundaries are shifted to the affected side, this may indicate a collapse of a certain area of lung tissue (atelectasis).
Due to pathological changes in the liver, which are accompanied by a significant increase in the size of the organ, there is often a shift of the right heart border to the left.
Heart dullness
If during the examination the specialist reveals abnormally altered boundaries of the heart in the patient, he tries to determine as accurately as possible whether the patient has manifestations characteristic of cardiac pathologies or diseases of nearby organs.
Symptoms of cardiac dullness in most cases are as follows:
- Heart disease is characterized by swelling of the face and legs, palpitations, pain in the chest, both when walking and at rest.
- Pathologies of the lungs are accompanied by cyanosis of the skin, shortness of breath and cough.
- Violations in the work of the liver can be manifested by an increase in the abdomen, impaired stool, edema and jaundice.
Even if the patient does not have any of the above symptoms, a violation of the boundaries of the heart is an abnormal phenomenon, so the specialist should prescribe the necessary additional examination to the patient.
Usually, additional diagnostics include an electrocardiogram, an x-ray of the chest, heart, endocrine glands and abdominal organs, as well as a study of the patient's blood.
Treatment
Treatment of expanded or displaced borders of the heart is impossible in principle, since the main problem lies not so much in violation of the borders, but in the disease that provoked it. Therefore, first of all, it is necessary to determine the cause that caused hypertrophic changes in the cardiac regions or the displacement of the heart due to diseases of nearby organs, and only then prescribe the appropriate therapy.
The patient may require surgery to eliminate heart defects, stenting or bypass of blood vessels to exclude re-infarction.
In addition, medications are sometimes prescribed - diuretics, drugs to slow down the heart rate and lower blood pressure, which are used to prevent further enlargement of the heart.
The heart is the main organ of the human body. It is a muscular organ, hollow inside and having the shape of a cone. In newborns, the heart weighs about thirty grams, and in an adult - about three hundred.
The topography of the heart is as follows: it is located in the chest cavity, moreover, a third of it is located on the right side of the mediastinum, and two-thirds on the left. The base of the organ is directed upward and somewhat backward, and the narrow part, that is, the apex, is directed downward, to the left and anteriorly.
Organ borders
The borders of the heart allow you to determine the location of the organ. There are several of them:
- Upper. It corresponds to the cartilage of the third rib.
- Lower. This border connects the right side with the apex.
- Top. located in the fifth intercostal space, towards the left midclavicular line.
- Right. Between the third and fifth ribs, a couple of centimeters to the right of the edge of the sternum.
- Left. The topography of the heart at this border has its own characteristics. It connects the apex to the upper border, and itself passes along which it faces the left lung.
According to topography, the heart is located behind and slightly below half of the sternum. The largest vessels are located behind, in the upper part.
topography changes
The topography and structure of the human heart change with age. In childhood, the body makes two turns around its axis. The boundaries of the heart change during breathing and depending on the position of the body. So, when lying on the left side and when bending over, the heart approaches the chest wall. When a person is standing, it is lower than when he is lying down. Because of this feature, it shifts. According to anatomy, the topography of the heart also changes as a result of respiratory movements. So, on inspiration, the organ moves away from the chest, and on exhalation it returns back.
Changes in the function, structure, topography of the heart are observed in different phases of cardiac activity. These indicators depend on gender, age, as well as on the individual characteristics of the body: the location of the digestive organs.
The structure of the heart
The heart has an apex and a base. The latter is turned up, to the right and back. Behind the base is formed by the atria, and in front - by the pulmonary trunk and a large artery - the aorta.
The top of the organ is turned down, forward and to the left. According to the topography of the heart, it reaches the fifth intercostal space. The apex is usually located at a distance of eight centimeters from the mediastinum.
The walls of the organ have several layers:
- Endocardium.
- Myocardium.
- Epicardium.
- Pericardium.
The endocardium lines the organ from the inside. This tissue forms the valves.
The myocardium is a heart muscle that contracts involuntarily. The ventricles and atria also consist of muscles, with the former having more developed muscles. The surface layer of the atrial muscles consists of longitudinal and circular fibers. They are independent for each atrium. And in the ventricles there are the following layers of muscle tissue: deep, superficial and middle circular. Fleshy bridges and papillary muscles are formed from the deepest.
The epicardium is epithelial cells that cover the outer surface of both the organ and the nearest vessels: the aorta, vein, and also the pulmonary trunk.
The pericardium is the outer layer of the pericardial sac. Between the sheets there is a slit-like formation - the pericardial cavity.
holes
The heart has several openings, chambers. The organ has a longitudinal partition that divides it into two parts: left and right. At the top of each part are the atria, and below - the ventricles. There are openings between the atria and ventricles.
The first of them have some protrusion, which forms the heart eye. The walls of the atria have different thicknesses: the left one is more developed than the right one.
Inside the ventricles there are papillary muscles. There are three on the left and two on the right.
Fluid enters the right atrium from the superior and inferior pudendal veins and sinus veins. Four leads to the left. From the right ventricle it departs and from the left - the aorta.
valves
The heart has tricuspid and bicuspid valves that close the gastro-atrial openings. The absence of reverse blood flow and eversion of the walls is ensured by tendon filaments passing from the edge of the valves to the papillary muscles.
The bicuspid or mitral valve closes the left ventricular-atrial opening. Tricuspid - right ventricular-atrial opening.
In addition, in the heart there is one closes the opening of the aorta, and the other - the pulmonary trunk. Valve defects are defined as heart defects.
Circles of blood circulation
There are several circles of blood circulation in the human body. Consider them:
- The great circle (BCC) starts from the left ventricle and ends in the right atrium. Through it, blood flows through the aorta, then through the arteries, which diverge into precapillaries. After that, the blood enters the capillaries, and from there to the tissues and organs. In these small vessels, nutrients are exchanged between tissue cells and blood. After that, the reverse flow of blood begins. From the capillaries, it enters the postcapillaries. They form venules, from which venous blood enters the veins. Through them, it approaches the heart, where the vascular beds converge into the vena cava and enter the right atrium. This is how the blood supply to all organs and tissues occurs.
- The small circle (MKK) starts from the right ventricle and ends with the left atrium. Its beginning is the pulmonary trunk, which divides into a pair of pulmonary arteries. They carry venous blood. It enters the lungs and is enriched with oxygen, turning into arterial. Then the blood is collected in the pulmonary veins and flows into the left atrium. ICC is intended to enrich the blood with oxygen.
- There is also a crown circle. It starts from the aortic bulb and the right coronary artery, passes through the capillary network of the heart and returns through the venules and coronary veins, first to the coronary sinus, and then to the right atrium. This circle supplies nutrients to the heart.
The heart, as you can see, is a complex organ that has its own circulatory system. Its boundaries change, and the heart itself changes its angle of inclination with age, turning around its axis twice.