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 |
Other OSCE modules
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