1. How can you best palpate for movement caused by a large RV?
ANS: a. Since the RV is an anterior structure, its enlargement may produce an increased left parasternal movement. Diffuse left parasternal movements are often best palpated with the proximal part of the palm (thenar and hypothenar areas). The movement is then transmitted to the entire arm. The shoulder becomes the fulcrum and this amplifies the hand movements that are at the end of the arm lever. b. Look for systolic downward movement in the epigastrium. If you place the pad of your right thumb pointing upward just beneath the xiphoid process, an impulse striking your thumb pad is usually due to a large RV. The downward impulse may be only palpable at the end of a deep, held inspiration.
Note: Occasionally the movement of a dilated pulmonary artery in the second left interspace imparts a movement to the overlying skin even though it is impalpable. Press firmly with one or two fingers over the second left interspace. Localized movements are best felt with the
In this patient with mitral stenosis, the physician is palpating the movement of a large RV, which was producing a right ventricular rock, i.e., a sustained left parasternal impulse and lateral retraction.
If your fingernails are long enough to cause discomfort when you push up into the epigastrium with your fingers, you may use the pad of your thumb to test for RV pulsations during a deeply held inspiration.
tips of the fingers. The degree of pulmonary artery dilatation that will cause a visible or palpable movement is usually seen only with the dilated RV caused by severe primary pulmonary hypertension or by RV volume overloads, such as with atrial septal defects.
2. How can you diagnose the presence of a large RV in the left lateral decubitus position?
ANS: Look for dominant lateral retraction.
A sustained left parasternal impulse with lateral retraction is a sign of a volume overload of the RV (and probably also with the addition of a pressure overload).
3. What causes the lateral retraction seen with RV enlargement due to severe tri-cuspid regurgitation (TR)?
ANS: The lateral retraction seen with severe TR has been explained by two phenomena. First, there is an abnormally large inward movement of the apical region, which is formed by the dilated RV. Added to this is the simultaneous anterior thrust of the RV against the left parasternal area caused by the ballistic recoil response of the RV as it ejects its blood through the incompetent tricuspid valve.
4. How can severe TR affect the entire right and left precordium?
ANS: If the TR is severe, the anterior left parasternal movement together with the apical retraction creates a rocking motion that has been called a right ventricular rock. Sometimes the entire right precordium may expand during systole due to the expanding right atrium, while the entire left precordium, including the parasternal area, retracts, probably because the RV, like an overdistended balloon in diastole, empties during systole and may draw in the entire left parasternal area and even the entire left chest.
5. When will the most lateral ventricular impulse retract deeply in systole without the initial outward movement that is seen in RV overload?
ANS: In constrictive pericarditis. The apical retraction in systole is usually followed by a diastolic outthrust. The outward impulse at the apex is diastolic and not systolic as is seen with the usual apex beat.
6. What is the significance of a fixed anterior left chest bulge as seen from the foot of the bed?
ANS: You should suspect an atrial septal defect with pulmonary hypertension, because the left chest bulge here is presumably due to the occurrence in infancy of a large shunt with hyperkinetic pulmonary hypertension. The large hyperactive and hypertrophied RV under high pressure can push the left chest forward as the skeleton is developing. The RV never enlarges to the right on chest X-rays, i.e., the right border of the heart with no congenital malpositions is never due to the RV, no matter how large it becomes. Therefore, RV enlargement does not affect the right anterior chest but instead will cause a left precordial bulge.
Note: A systolic VSD shunt cannot enlarge the RV during systole, but a large shunt can increase end-diastolic volumes up to 2 1/2 times normal by shunting during isovolumic relaxation and also during diastole.
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