Precordial Exam

Precordial Exam

General

  • Wash your hands upon entering the room
  • Introduce yourself and the exam to the patient in a way that the patient will understand
  • Patient should be supine or sitting
  • Drape the patient so the chest is exposed from the waist up.
    • For female patients, keep the chest draped and only expose intermittently as necessary

Vital Signs

Vital signs should be measured on every patient. They include:

  • Blood pressure
  • Heart rate
  • Respiratory rate
  • Temperature
  • Oxygen saturation may also be included

Precordial Landmarks

When conducting the precordial exam, it is important to identify specific landmarks.

  • Begin by identifying the Angle of Louis, also called the Sternal Angle
    • Identify the sternal notch, then work down to a ridge which marks where the manubrium and sternum meet. This is the Angle of Louis and represents the level of the 2nd intercostal space
    • Use this as a reference for locating other precordial landmarks
  • Identify the aortic, pulmonic, tricuspid and mitral valve areas
    • Aortic area - Located in the 2nd intercostal space at the right sternal border
    • Pulmonic area - Located in the 2nd intercostal space at the left sternal border
    • Tricuspid area - Located in the 4th intercostal space at the left sternal border
    • Mitral area - Located in the 5th intercostal space at the midclavicular line

Figure 1: Surface anatomy of aortic, pulmonic, tricuspid, and mitral valves 

Figure 1: Surface anatomy of aortic, pulmonic, tricuspid, and mitral valves

Inspection

When inspecting the precordial area, you should be looking for the following things:

  • General appearance
    • Does the patient look sick? Are they in any obvious distress?
  • Masses, scars, lesions
    • Scars from previous surgery
    • Bony abnormalities such as pectus carinatum (pigeon chest) or pectus excavatum (funnel chest)
  • Signs of cyanosis
    • Central cyanosis - Bluish mucous membranes
    • Peripheral cyanosis - Cool/bluish extremities
  • Pulsations
    • Apex beat - Clasically found in the left 5th intercostal space at the midclavicular line. This may not be visible in all patients.
    • Examine the aortic, pulmonic, tricuspid and mitral valve areas for pulsations
    • Heaves - Best seen along the left sternal border
  • Jugular venous pressure (JVP)
    • See article on measuring the JVP

Palpation

Palpation of the precordium should include the following items:

  • Apex beat (Also called the Point of Maximal Impulse or PMI)
    • Typically found in the left 5th intercostal space at the midclavicular line
    • When palpating the apex beat, you should note the following (LADS):
      • Location: Normal is in the left 5th intercostal space at the midclavicular line
      • Amplitude: Normal is described as "a tap"
      • Duration: Normal is 2/3 the length of systole. Determine this by simultaneously palpating the radial pulse
      • Size: Normal is approximately 2.5cm, or the size of a quarter
    • If you are unable to palpate the apex beat with the patient supine, try palpating the apex beat with the patient in the left lateral decubitus position

 Figure 2: Palpating the apex beat with the patient in the left lateral decubitus position

Figure 2: Palpating the apex beat with the patient in the left lateral decubitus position

  • Heaves
    • Palpate using the palm or heel of your hand along the left sternal border for signs of heaves.
    • The presence of heaves is not normal.
  • Thrills
    • Palpate in each of the valve areas for thrills. Thrills are often described as similar to what one would feel when a hand is placed on a purring cat. 
    • The presence of a thrill is not normal
    • Caused by leaky valves, stenosed valves or abnormal blood flow
  • Carotid Pulse
    • The carotid artery should be auscultated before palpated. Palpating a carotid artery with an unstable plaque may cause it to rupture
    • Palpate the carotid pulse for rate, rhythm and amplitude
    • Do not palpate both carotids at the same time as it may reduce blood supply to the brain causing the patient to lose consciousness

Auscultation

It is important to auscultate the precordium in a systematic way, covering all 4 valve areas. It is also important to auscultate using both the diaphragm and the bell

  • Auscultate the valve areas (Aortic, Pulmonic, Tricuspid, Mitral) for the following:
    • Characteristics of the heart sounds
      • Rate (ex: 60/minute)
      • Rhythm (regular vs irregular)
      • Amplitude
    • Normal heart sounds (S1 & S2)
      • S1 - Caused by closure of atrioventricular valves
      • S2 - Caused by closure of aortic and pulmonic valves
      • Note: Splitting of S2 on inspiration is normal, be careful not to confuse this with an S3
    • Extra heart sounds (S3 or S4) - Often best heard using the bell with the patient in the left lateral decubitus position
      • S3 - Heard closer to S2 than S1
      • S4 - Heard closer to S1 than S2. Represents a stiff ventricle, often due to ventricular hypertrophy

 Figure 3: Timing of heart sounds showing S3 and S4

Figure 3: Timing of heart sounds showing S3 and S4

    • Murmurs
      • Can be heard during systole or diastole.
      • Note the location of the murmur, grade of the murmur (see table 1) and the characteristics of the sound (crescendo, descrescendo, holosystolic)
      • Systolic murmurs - Heard between S1 and S2:
        • Aortic stenosis
        • Mitral regurgitation
      • Diastolic murmurs - Heard between S2 and S1:
        • Aortic regurgitation
        • Mitral stenosis

Figure 4: Examples of cardiac murmursFigure 4: Examples of cardiac murmurs

Table 1: Grading cardiac murmurs (Adapted from Bates page 368)

Table 1: Grading cardiac murmurs (Adapted from Bates page 368)

  • Auscultate for carotid artery bruits
    • Presence of a bruit suggests a stenosed or constricted vessel