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INSPECTION AND PALPATION
OF THE PRECORDIUM
Hakan Karpuz, MD
Dept. of Cardiology
Cerrahpaşa Medical School
Physical Examination
1-Inspection
2-Palpation
3-Percussion
4-Oscultation
... first evaluation of the patients for diagnosis of
cardiovascular disease begins with the first visual approach ...
Precordial inspection
The cardiac examination proper should
commence with inspection of the chest,
which can best be accomplished with
the examiner standing at the foot of the
bed or examining table.
Precordial inspection
-build
obesity, Marfanoid, heavy muscular thorax
(contrasting with less developped lower
extremities)
- respiration:
frequency, regularity and depth
- cutaneous abnormality:
dilation of veins,
Precordial inspection
-scars:
sternotomy, valvotomy, …
- deformity:
pectus excavatum,
pectus carinatum (pigeon chest)
- pulsations:
“danse des arteres”
Precordial inspection
- blue sclera
aortic dilatation
- conjuctival bleeding
infective endocarditis
- arcus senilis
hiperlipidemia
Precordial inspection
- clubbing
CHD,
pulmonary hypertension
- leg oedema
congestive heart failure
Precordial palpation
This checks in:
- left parasternal area
- right parasternal area
- cardiac apex
Precordial palpation
Left parasternal area :
- 2. left intercostal space:
pulmonary artery
- 3.-5. left intercostal space:
right ventricle’s activity
left atrium
some murmurs
Precordial palpation
Right parasternal area :
- 1. right intercostal space:
aorta
- 2. right intercostal space:
aortic valve, hypertension
- 3.-5. right intercostal space:
right atrium
Precordial palpation
Cardiac apex :
- 5. left intercostal space
(left midclavicular line):
left ventricular contraction
Precordial palpation
This checks for:
- thrills
- apex beat
- palpable sounds
- abnormal pulsation
Precordial palpation (thrills)
Systolic thrill
- aortic area: aortic stenosis
- left sternal edge: ventricular septal defect
- apex: ruptured mitral chordea
- pulmonary area: pulmonary stenosis
- subclavicular area: subclavian stenosis
Precordial palpation (thrills)
Diastolic thrill
(less common)
- apex: mitral stenosis
(patient lying on left side and breath held in expiration)
- left sternal edge: aortic regurgitation
(occasionally)
Precordial palpation (apex beat)
Cardiac apical impulse is normally localized in the fifth
left intercostal space, midclavicular line; It is palpable
but does not lift the finger off the chest.
Abnormalities
- forceful apical thrust:
left ventricular hypertrophy
- lateral and downward displacement of apex impulse:
left ventricular dilatation
Precordial palpation (apex beat)
- prominent presystolic impulse:
hypertension, aortic stenosis
- double systolic apical impulse:
hypertrophic cardiomyopathy
- sustained “lift” at lower left sternal border
right ventricular hypertrophy
- dyskinetic (outward bulge) impulse:
ventricular aneurysme, cardiomyopathy
Precordial palpation (palpable sounds)
Palpable heart sounds represent forceful valve closure, or
valve situated close to the chest wall, e.g. palpable
- S1 (mitral closure) in mitral stenosis
- P2 in pulmonary hypertension
- A2 in transposition
- both S1 and S2 in thin patients with tachycardia
Precordial palpation (abnormal pulsation)
Abnormal pulsations are very variable, e.g.
- ascending aortic aneurysm pulsating in aortic area
- right ventricular outflow tract aneurysm in pulmonary
area
- collateral pulsation round the back in coarctation
- pulsatile right ventricular outflow tract in atrial septal
defect
Precordial percussion
Percussion of cardiac dullness is
not clinically very useful; the Rx
gives a better idea of heart size.
Tıp teknolojisinin
iyi bir fizik muayene ile
kombinasyonu,
tanı yetersizlikleri
ve
aşırı tetkik isteme alışkanlığından
özellikle genç hekimleri kurtaracaktır.