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

Leave a Comment