Precordial Exam

• Preparation

  • Wash hands

  • Position: supine

  • Draping: male - uncover to upper abdo; female - uncover as needed

• Inspection

  • General

    • Precordial scars

    • Chest wall abnormalities: pectus excavatum, pectus carinatum

  • Apex beat

    • 5th (sometimes 4th) intercostal space, mid-clavicular line

  • Pulsations

    • Inspect for pulsations in areas corresponding to ascending aorta, pulmonary artery, R ventricle, L ventricle

    • Ascending aorta: RSB

    • Aortic arch: heads of clavicles

    • Pulmonary artery: 2nd intercostal space on LSB

    • R ventricle: sternum, LSB, sub-xiphoid area

• Palpation

  • Apex beat (most lateral impulse felt in precordium)

    • Supine

    • At 5th intercostal space, mid-clavicular line

    • Normal impulse just after S1

    • If not felt, try L lateral decubitus

    • Description (LADS)

      • Location: 4-5th intercostal space, mid clavicular line

      • Amplitude: brief outward motion in early systole; gentle tap

      • Duration: normal = < ⅔ of systole 

        • (time with auscultation or palpation of radial pulse)

      • Size: normal = 2-3 cm (size of quarter)

  • Precordium

    • Palpate A, P, T(RV) and M(LV) areas with pads of fingers

    • Thrills: palpable vibrations

      • Indicate underlying murmur

    • Heaves/lifts = diffuse movements

      • LSB, with heel of hand

      • Produced by enlarged heart structures

    • Cardiac apex

      • Feel for multiple impulses per beat

• Auscultation

  • Listen at all 4 areas

  • S1 and S2

    • S1 = closure of AV valves (M & T)

    • S2 = closure of semilunar valves (A & P)

  • Physiologic split S2 (best heard at pulmonic area)

    • Normal splitting of S2 on inspiration (delays P2 component)

  • Extra heart sounds (best heard with bell at apex, L decubitus position)

    • S3

      • Low frequency diastolic heart sound; heard in early-mid diastole

    • S4

      • Low frequency diastolic heart sound, heard in late diastole

  • Murmurs

    • Describe:

      • Timing: (systolic vs diastolic)

        • Time with radial pulse

        • Systolic murmur heard while feeling pulse

      • Location (where loudest)

      • Shape: Crescendo, decrescendo, midsystolic, holosystolic

      • Intensity grade

        • 1: very faint, not heard in all positions

        • 2: quiet, but heard immediately after placing stethoscope on chest

        • 3: moderately loud

        • 4: loud, palpable thrill

        • 5: very loud, heard with stethoscope partially off chest

        • 6: extremely loud, heard with stethoscope not contacting chest

      • Associated features

        • Pitch: high or low

        • Character: blowing, harsh

        • Radiation: to neck, axilla, back

    • Systolic murmurs (Between S1 and S2)

      • Blood ejected from ventricles

        • AV valves don’t shut properly (MR/TR)

        • Semilunar valves don’t open properly (AS/PS)

      • Midsystolic - most common

        • Can to innocent, physiologic (pregnancy) or pathologic (AS)

      • Holosystolic (pansystolic) - pathologic

        • Blood flow from high to low pressure, through valve/structure that should be closed

        • Ie: MR, VSD

    • Diastolic murmurs (between S2 and S1)

      • Blood fills the ventricles

        • AV valves don’t open properly (TS/MS)

        • Semilunar valves don’t shut properly (AR/PR)

      • Mid-late diastolic

        • Turbulent flow through stenotic valve (MS)

      • Early diastolic

        • Regurgitant flow through incompetent semilunar valve (AR)

• Post encounter questions:

  • What might an S3 indicate?

    • CHF, severe mitral regurg

  • What might an S4 indicate?

    • LVH, MI

  • List a cause of a systolic murmur.

    • MR/TR/AS/PS/VSD

  • List a cause of a diastolic murmur.

    • TS/MS/AR/PR

Rational Clinical exam

• Does This Patient Have an Abnormal Systolic Murmur? (1997)

• Does This Patient Have Aortic Regurgitation? (1999)