Archive: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 > S2 in LLSB
• S2 > S1 in LUSB

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

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

Other sounds

Ejection click - between S1 and S2 Carotid bruit Pericardial friction

Murmurs

DESCRIBE a MURMUR in its TIMING, SHAPE, INTENSITY, RADIATION

Type	Character	Best Heard	Radiation
Aortic stenosis	systolic, crescendo-decrescendo	AV, lean forward ↓with Valsalva	carotids, clavical
Aortic regurg	early diastolic decrescendo	L2-4 ICS Lean foward	Apex
Mitrial Stenosis	Mid diastolic rumble	Apex, LLD	No radiation
Mitrial Regurge	pansystolic	apex	L axilla
VSD	pansystolic, harsh	L sternal border
PDA	continuous	aortic valve	L clavical

Intensity

1/6 = quieter than S1
2/6 = same as S1
3/6 = louder than S1 with 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

Other OSCE modules

Observed structured clinical examination

Acute Confusion - Acute Coronary Syndrome Orders - Anemia - Arterial Blood Gasses - Asthma - Blood Pressure - Chest pain - Chest XRay - CHF - Coma - COPD - Cranial Nerves - Diabetic History - Diabetic Foot - Dysphagia - EKGs - Gallbladder and Liver - Liver Disease - Gait and Balance - Headache - Hematemesis - Hypertension - Jugular Venous Pulses - Knee Exam - Lymph Nodes - Community Acquired Pneumonia - Parkinson Disease - Peripheral Arterial Insufficiency - Pneumonia Examination - Precordial Exam - STD's - Spleen - Swollen Leg Exam - Thyroid Exam - Upper vs Lower Motor Neuron Lesions - Urinary Incontinence