An approach to… PRECORDIAL EXAM

 

Inspection (from the foot of the bed)

·  Chest wall deformity (pectus excavatum, carinatum)

·  Scars (thoracotomy, pacemaker)

·  Heaves (ventricular hypertrophy) and lifts

·  Visible apical beat

·  Impulses (under xiphoid – can mean RVH or Aorta)

 

Palpation

- Using finger pads, palpate for apex impulse (PMI) - accurately measure MCL

·  Location, size - one ICS

·  Amplitude - if increased, suggests volume/pressure overload

·  Duration - check in relation to carotid pulse (> 2/3 systole → sustained, LVH)     - If carotid is delayed = parvus et tardus → AV stenosis

- Thrills - palpate at each of the 4 valve zones = grade 4 murmur

- Heaves (with heel of hand)

·  Left sternal border → LVH

·  PV → pulmonary hypertension

·  AV → systemic hypertension

·  Inferior to xiphoid - RVH

 

Auscultation

* listen specifically for one sound at a time

* calibrate your timing to the radial pulse

 

S1

      - Louder → ↓ PR interval, ↑CO, ↑HR

      - Quieter → ↑ PR interval, MR, severe MS

      - Splitting → RBBB

 

S2

      - Splitting ↑ by continued inspiration (while patient not holding in breath)

      - Loud S2 → hypertension (systemic or pulmonary circulation)

      - Wide split S2 - RBBB, PS

      - Fixed split - ASD

      - Paradoxical - LBBB, severe AS

 

      S1 > S2 in LLSB

      S2 > S1 in LUSB

 

S3 (ventricular gallop)

      - Lightly use bell at apex, best heard in LLD

      - Can be normal in young people and the pregnant

      - Noted in volume overload, increased transvalvular flow (TR, MR)

 

S4 (atrial gallop) - lower pitched

      - Indicates stiff LV– LVH, post-MI

 

 

Ejection click - between S1 and S2

Carotid bruit

Pericardial friction rub

 

MURMUR - TIMING, SHAPE, INTENSITY, RADIATION

 

TYPE	CHARACTER	BEST HEARD	RADIATION
AS	systolic, crescendo-decrescendo	- AV, lean forward - ↓ with Valsava	- carotids, clavicle
AR	- early diastolic, - decrescendo	- L 2-4 ICS - lean forward	- apex
MS	- mid diastolic rumble	- apex, LLD	- no radiation
MR	- pansystolic	- apex	- L axilla
VSD	- pansystolic, harsh	-  L sternal border
PDA	- continuous	- aortic valve	- L clavicle

 

* AR murmur best heard with patient sitting up and leaning forward

 

Intensity:

 

1/6 = not heard by the medical student

2/6 = faint

3/6 = loud but no thrill

4/6 = thrill present

5/6 = heard with edge of scope in contact with skin

6/6 = heard with scope off of the chest

 

Special tests

 

- ↑ blood flow to heart (leg raise, squatting)

      - ↑ AS, ↓HoCM, ↓MR

- ↓ blood flow to heart (Valsalva)

      - ↓ AS, ↑ MR, ↑HoCM