INSPECTION AND PALPATIONOF THE PRECORDIUM

Hakan Karpuz, MDDept. of Cardiology

Cerrahpaşa Medical School

Physical ExaminationPhysical Examination

1-Inspection1-Inspection2-Palpation2-Palpation3-Percussion3-Percussion4-Oscultation4-Oscultation

... first evaluation of the patients for diagnosis of ... first evaluation of the patients for diagnosis of

cardiovascular disease begins with the first visual approach ...cardiovascular disease begins with the first visual approach ...

The cardiac examination proper should The cardiac examination proper should

commence with inspection of the chest, commence with inspection of the chest,

which can best be accomplished with which can best be accomplished with

the examiner standing at the foot of the the examiner standing at the foot of the

bed or examining table.bed or examining table.

Precordial inspectionPrecordial inspection

-buildbuild

obesity, Marfanoid, heavy muscular thorax obesity, Marfanoid, heavy muscular thorax

(contrasting with less(contrasting with less developped lower developped lower

extremities)extremities)

- respiration: - respiration:

frequency, regularity and depth frequency, regularity and depth

- cutaneous abnormality: - cutaneous abnormality:

dilation of veinsdilation of veins, ,

Precordial inspectionPrecordial inspection

-scars: scars:

sternotomy, valvotomy, … sternotomy, valvotomy, …

- deformity: - deformity:

pectus excavatum, pectus excavatum,

pectus carinatum (pigeon chest) pectus carinatum (pigeon chest)

- pulsations: - pulsations:

“danse des arteres”“danse des arteres”

Precordial inspectionPrecordial inspection

- blue sclerablue sclera

aortic dilatationaortic dilatation

- - conjuctival bleedingconjuctival bleeding

infective endocarditisinfective endocarditis

- - arcus senilisarcus senilis

hiperlipidemiahiperlipidemia

Precordial inspectionPrecordial inspection

- clubbingclubbing

CHD, CHD,

pulmonary hypertensionpulmonary hypertension

- - leg oedemaleg oedema

congestive heart failurecongestive heart failure

Precordial inspectionPrecordial inspection

This checks in:This checks in:

- left parasternal area- left parasternal area

- right parasternal area - right parasternal area

- cardiac apex- cardiac apex

Precordial palpationPrecordial palpation

Left parasternal area :Left parasternal area :

- 2. left intercostal space: - 2. left intercostal space:

pulmonary artery pulmonary artery

- 3.-5. left intercostal space: - 3.-5. left intercostal space:

right ventricle’s activityright ventricle’s activity

left atriumleft atrium

some murmurssome murmurs

Precordial palpationPrecordial palpation

Right parasternal area :Right parasternal area :

- 1. right intercostal space: - 1. right intercostal space:

aortaaorta

- 2. right intercostal space: - 2. right intercostal space:

aortic valve, hypertension aortic valve, hypertension

- 3.-5. right intercostal space: - 3.-5. right intercostal space:

right atriumright atrium

Precordial palpationPrecordial palpation

Cardiac apex :Cardiac apex :

- 5. left intercostal space - 5. left intercostal space

(left midclavicular line): (left midclavicular line):

left ventricular contractionleft ventricular contraction

Precordial palpationPrecordial palpation

This checks for:This checks for:

- thrills- thrills

- apex beat- apex beat

- palpable sounds - palpable sounds

- abnormal pulsation- abnormal pulsation

Precordial palpationPrecordial palpation

Systolic thrillSystolic thrill

- aortic area: aortic stenosis- aortic area: aortic stenosis

- left sternal edge: ventricular septal defect- left sternal edge: ventricular septal defect

- apex: ruptured mitral chordea- apex: ruptured mitral chordea

- pulmonary area: pulmonary stenosis- pulmonary area: pulmonary stenosis

- subclavicular area: subclavian stenosis- subclavicular area: subclavian stenosis

Precordial palpation (thrills)Precordial palpation (thrills)

Diastolic thrillDiastolic thrill(less common)(less common)

- apex: mitral stenosis - apex: mitral stenosis

(patient lying on left side and breath held in expiration)(patient lying on left side and breath held in expiration)

- left sternal edge: aortic regurgitation - left sternal edge: aortic regurgitation

(occasionally)(occasionally)

Precordial palpation Precordial palpation (thrills)(thrills)

Cardiac apical impulse is normally localized in the fifth Cardiac apical impulse is normally localized in the fifth

left intercostal space, midclavicular line; It is palpable left intercostal space, midclavicular line; It is palpable

but does not lift the finger off the chest.but does not lift the finger off the chest.

AbnormalitiesAbnormalities

- forceful apical thrust: - forceful apical thrust:

left ventricular hypertrophyleft ventricular hypertrophy

- lateral and downward displacement of apex impulse:- lateral and downward displacement of apex impulse:

left ventricular dilatationleft ventricular dilatation

Precordial palpation Precordial palpation (apex beat)(apex beat)

- prominent presystolic impulse:- prominent presystolic impulse:

hypertension, aortic stenosis hypertension, aortic stenosis

- double systolic apical impulse: - double systolic apical impulse:

hypertrophic cardiomyopathyhypertrophic cardiomyopathy

- sustained “lift” at lower left sternal border- sustained “lift” at lower left sternal border

right ventricular hypertrophyright ventricular hypertrophy

- dyskinetic (outward bulge) impulse:- dyskinetic (outward bulge) impulse:

ventricular aneurysme, cardiomyopathyventricular aneurysme, cardiomyopathy

Precordial palpation Precordial palpation (apex beat)(apex beat)

Palpable heart sounds represent forceful valve closure, or Palpable heart sounds represent forceful valve closure, or

valve situated close to the chest wall, e.g. palpablevalve situated close to the chest wall, e.g. palpable

- S- S1 1 (mitral closure) in mitral stenosis(mitral closure) in mitral stenosis

- P- P2 2 in pulmonary hypertensionin pulmonary hypertension

- A- A2 2 in transpositionin transposition

- both S- both S1 1 and Sand S2 2 in thin patients with tachycardiain thin patients with tachycardia

Precordial palpation Precordial palpation (palpable sounds)(palpable sounds)

Abnormal pulsations are very variable, e.g.Abnormal pulsations are very variable, e.g.

- ascending aortic aneurysm pulsating in aortic area- ascending aortic aneurysm pulsating in aortic area

- right ventricular outflow tract aneurysm in pulmonary- right ventricular outflow tract aneurysm in pulmonary

area area

- collateral pulsation round the back in coarctation- collateral pulsation round the back in coarctation

- pulsatile right ventricular outflow tract in atrial septal- pulsatile right ventricular outflow tract in atrial septal

defect defect

Precordial palpation Precordial palpation (abnormal pulsation)(abnormal pulsation)

Percussion of cardiac dullness is Percussion of cardiac dullness is

not clinically very useful; the Rx not clinically very useful; the Rx

gives a better idea of heart size.gives a better idea of heart size.

Precordial percussionPrecordial percussion

Tıp teknolojisinin Tıp teknolojisinin

iyi bir fizik muayeneiyi bir fizik muayene ile kombinasyonu, ile kombinasyonu,

tanı yetersizlikleri tanı yetersizlikleri

ve ve

aşırı tetkik isteme alışkanlığından aşırı tetkik isteme alışkanlığından

özellikle özellikle genç hekimlerigenç hekimleri kurtaracaktır. kurtaracaktır.