Download Practical physiology 2 nd class Examination of the precordium BY Dr

Practical physiology
2nd class
Examination
of the
precordium
BY Dr. BAN DOSH
The precordium:It is difficult to arrive a diagnosis of the
heart problem if we jump to listen to the
heart without interpreting other signs
related to CVS.
We should follow this order:Arterial pulses.
Blood pressure.
Venous pulse
Precordium.
Examination of precordium:By inspection we have to note the character
of the breathing,presence or absence of
cyanosis, detect any deformities of the chest
wall such as (Kyphosis, scoliosis & sternal
depression),to assess any dilated vein on the
chest wall as in superior vena caval
obstruction, and then identify the apex beat
and assess the cardiac impulse which is
located normally at left 5th intercostals
space, 1cm internal to mid-clavicular line, or
it may be hidden behind a rib.
By palpation we have to assess Thrills
(palpable murmurs)& palpable heart sounds
may be felt when we put our hands over the
heart area, e.g diastolic thrill in MS or
systolic thrill in VSD.
Percussion may be useful sometimes.
Auscultation:Use the diaphragm of stethoscope for high
pitched sounds, e.g AR, AS, or VSD.
Use the bell for low pitched sounds, e.g S3
or MS diastolic murmur.
Auscultatory areas:-
Auscultation is usually performed with the
patient sitting up or reclined at about 45°.
The best place to hear the heart valves is
not necessarily directly over the
anatomical site. In order to count
intercostal space feel for ridge which
marks the junction of the manubrium with
the body of the sternum which called
angle of Louis or sternal angle,the space
immediately below this is the 2nd
intercostal space.
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Mitral area:- At the apex beat, as the left
ventricle is closest to thoracic cage.
Tricuspid area :- It is just to the left of
the lower end of the sternum
Aortic area:- Right second intercostal
space close to the sternum is where the
ascending aorta is nearest to the
thoracic cage.

Pulmonary area:- Left second
intercostal space close to the sternum
is where the infundibulum is closest
to the thoracic cage
Other areas as required.
Heart sounds:S1(M1T1) due to closure of mitral &
tricuspid valves, described as "lub".
S2(A2P2) due to closure of aortic &
pulmonary valves, described as “dup”.
Both sounds are high pitched & heared
normally in health.
Occasionally we hear S3 (early in diastole,
rapid vent. Filling)
S4( late in diastole, due to strong atrial
contraction).
Both sounds are low pitched sounds.
Other sounds may be heared such as
1-opening snap due to MS.
2- ejection clicks due to AS,or PS or
mitral valve prolapse .
3-Pericardial knock (constrictive
pericardium).
Murmurs:- Note the timing of
murmurs. Is it systolic or diastolic?
First listen to the lub dub and then get
the timing. Some murmurs may
obscure the heard sounds. Systolic
murmurs can be innocent. Diastolic
murmurs are always pathological
Murmurs are due to :a. Turbulence in the blood flow at a
valve.
b. Abnormal communication within
the heart.
c. Increase flow through a normal
valve.