Precordial examination

In medicine, the precordial exam, also cardiac exam, is performed as part of a physical examination, or when a patient presents with chest pain suggestive of a cardiovascular pathology.

The exam includes several parts:

• position/lighting/draping
• inspection
• palpation
• auscultation

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Position/Lighting/Draping

Position - patient should be supine and the bed or examination table should be at a 45 degree angle. The patient's hands should remain at her sides with her head resting on a pillow.

Lighting - adjusted so that it is ideal.

Draping - the chest and neck should be fully exposed.

Inspection

Careful inspection for:

• visible pulsations
• apex beat
• masses
• scars
• lesions
• signs of trauma and previous surgery (e.g. median sternotomy)
• Praecordial bulge
• increased in jugular venous pressure (JVP)

Palpation

The valve areas are palpated for abnormal pulsations (known as thrills) and precordial movements (known as heaves). Heaves are best felt with the heel of the hand at the sternal border.

Palpation of the apex beat

The apex beat is typically palpable in the fifth intercostal space and 1cm medial to the mid-clavicular line. It is not palpable in some patients due to obesity or emphysema.

The apex beat should be described by the following characteristics (which can be remember with the mnemonic SALID:

• S - Size - Is it larger than one interspace?
• A - Amplitude - Is it weak?
• L - Location - Is it in the fifth intercostal space at the mid-clavicular line?
• I - Impulse - Is it monophasic or biphasic?
• D - Duration - Is it abnormally sustained?

To accurately determine the location of an apex beat which can be felt across a large area, feel for the most lateral and inferior position of pulsation. An apex beat in the axilla would indicated cardiomegaly or mediastinal shift. Note that the apex beat does not exactly correspond to the apex of the heart.

Auscultation

One should comment on

• S1 and S2 - if the splitting is abnormal or louder than usual. Should sound like [lub-dub lub-dub]

and the presence of

• S3 - think Kentucky - the emphasis and timing of the syllables in the word Kentucky is similar to the pattern of sounds in a precordial S3. Some examiners can hear these sounds better by listening for a [T-lub dub] sound.
• S4 - think Tennessee - the emphasis and timing of the syllables in the word Tennessee is similar to the pattern of sounds in a precordial S4. Some examiners can hear these sounds better by listening for a [lub-de-dub] sound.
• If S4 S1 S2 S3 were all present it would sound like [T-lub-de-dub] Also known as a gallop rhythm
• diastolic murmurs (e.g. aortic insufficiency, mitral stenosis)
• systolic murmurs (e.g. aortic stenosis, mitral regurgitation)
• pericardial rub (suggestive of pericarditis)

See also

• Heart sounds
• Physical examination
• Precordial thump