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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. 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.