Supplementary Notes for the Precordial Examination:
Draping: The patient must be uncovered to the upper abdomen so a full inspection of the precordium can be performed. Female patients can be uncovered intermittently, as needed during the course of the examination.
Apex Beat: Also known as “the Point of maximum impulse”. If it is visible, one should note its location using the chest landmarks (i.e. The 5th interspace in the mid-clavicular line).
Inspection for pulsations: inspect the chest for pulsations in the areas corresponding to the valves of the heart (see figure 2).
Palpation of the Apex beat: If palpable, one should describe the apex beat in terms of size (usually smaller that a Canadian quarter), impulse (mono- or biphasic?), location, amplitude, and duration (usually less that 2/3 of systole).
Palpation for any thrills, parasternal heaves, or
epigastric pulsations:
1. Thrill- a palpable vibration caused by turbulent blood flow.
2. Parasternal heaves: large movements best felt with the heel of the
examiner’s hand, along the left sternal border. They are associated with
conditions like right ventricular hypertrophy.
3. Epigastric pulsations: aortic pulsations can be felt in the epigastruim,
but an abnormally large pulsation may suggest pathology such as an abdominal
aortic aneurysm.
Auscultation of S1 and S2: S1 is the sound made by
the closure of the atrioventricular (AV) valves (the mitral and tricuspid).
The AV valves close when the pressure in the ventricles exceeds the pressure
in the atria. S2 is the sound made by the closure of the aortic and pulmonic
valves. The aortic and pulmonic valves close when the pressure in those
vessels exceeds the pressure in the respective ventricles. To distinguish
between S1 and S2, time the sounds with the carotid pulse (check for carotid
bruits first!). S1, pulse, S2.
Auscultation for S3 and S4: S3 and S4 are low frequency abnormal diastolic sounds that occur when there is rapid ventricular filling. An S3 occurs early in diastole and S4 occurs as the atria contract (late in diastole), during the ”atrial kick”. Placing the patient in the left lateral decubitus position accentuates S3 and S4.
