Precordial examination
 | This article includes a list of references, but its sources remain unclear because it has insufficient inline citations. Please help to improve this article by introducing more precise citations. (April 2010) |
In medicine, the precordial exam, also cardiac exam, is performed as part of a physical examination, or when a patient presents with chest pain suggestive of a cardiovascular pathology.
The exam includes several parts:
- position/lighting/draping
- inspection
- palpation
- auscultation
Contents
Position/Lighting/Draping
Position - patient should be supine and the bed or examination table should be at a 45 degree angle. The patient's hands should remain at his or her sides with the head resting on a pillow.
Lighting - adjusted so that it is ideal for examinaton and the examiner does not obstruct the light falling on the patient.
Draping - the chest and neck should be fully exposed.
Inspection
General Inspection:
- inspect the patient status whether he or she is comfortable at rest or obviously short of breath.[1]
- Inspect the neck for increased jugular venous pressure (JVP)or abnormal waves.[2]
Then inspect the precordium for:
- visible pulsations
- apex beat
- masses
- scars
- lesions
- signs of trauma and previous surgery (e.g. median sternotomy)
- permanent Pace Maker
- praecordial bulge
Palpation
The valve areas are palpated for abnormal pulsations (known as thrills) and precordial movements (known as heaves). Heaves are best felt with the heel of the hand at the sternal border.
Palpation of the apex beat
The apex beat is typically palpable in the left fifth intercostal space and 1 cm medial to the mid-clavicular line. It is not palpable in some patients due to obesity or emphysema.
The apex beat should be described by the following characteristics (which can be remember with the mnemonic SALID:
- S - Size - Is it larger than one interspace?
- A - Amplitude - Is it weak?
- L - Location - Is it in the fifth intercostal space at the mid-clavicular line?
- I - Impulse - Is it monophasic or biphasic?
- D - Duration - Is it abnormally sustained?
Causes for absent apex beat:
- D - Dextrocardia
- R - Apex behind a Rib
- P - Pericardial Effusion
- O - Obesity
- P - Left Pleural Effusion
- E - Emphysema
To accurately determine the location of an apex beat which can be felt across a large area, feel for the most lateral and inferior position of pulsation. An apex beat in the axilla would indicated cardiomegaly or mediastinal shift. Note that the apex beat does not exactly correspond to the apex of the heart.
Auscultation
One should comment on
- S1 and S2 - if the splitting is abnormal or louder than usual. Should sound like [lub-dub lub-dub]
and the presence of
- S3 - think Kentucky - the emphasis and timing of the syllables in the word Kentucky is similar to the pattern of sounds in a precordial S3. Some examiners can hear these sounds better by listening for a [lub de dub] sound.
- S4 - think Tennessee - the emphasis and timing of the syllables in the word Tennessee is similar to the pattern of sounds in a precordial S4. Some examiners can hear these sounds better by listening for a [T lub-dub] sound.
- If S4 S1 S2 S3 were all present it would sound like [T-lub-de-dub] Also known as a quadruple gallop rhythm
- diastolic murmurs (e.g. aortic insufficiency, mitral stenosis)
- systolic murmurs (e.g. aortic stenosis, mitral regurgitation)
- pericardial rub (suggestive of pericarditis)
See also
References
- ↑ 250 cases in clinical medicine 3rd edition. R. R. Baliga
- ↑ 250 cases in clinical medicine 3rd edition. R. R. Baliga
External links
| 40x40px | Wikiversity has learning materials about Precordial Exam (OSCE) |
