Precordial Exam (OSCE)

Inspection

• from the foot of the bed
  • chest wall deformity (pectus excavatum, carinatum)
  • scars (thoracotomy, pacemaker)
  • heaves (ventricular hypertrophy) and lifts
  • visible apical beat
  • impulses (under xiphoid – can mean RVH or Aorta).
  • dilated veins

Palpation

• using finger pads, palpate for apex impulse (PMI) - accurately measure MCL
  • location, size - one ICS
  • amplitude - if increased, suggests volume/pressure overload
  • duration - check in relation to carotid pulse (> 2/3 systole → sustained, LVH)
  • if carotid is delayed = parvus et tardus → AV stenosis

• thrills - palpate at each of the 4 valve zones = grade 4 murmur
• heaves (with heel of hand)
  • left sternal border → LVH
  • PV → pulmonary hypertension
  • AV → systemic hypertension
  • inferior to xiphoid - RVH

Auscultation

• listen specifically for one sound at a time
• calibrate your timing to the radial pulse
• S1 > S2 in LLSB
• S2 > S1 in LUSB

S1

• louder → ↓ PR interval, ↑CO, ↑HR
• quieter → ↑ PR interval, MR, severe MS
• splitting → RBBB

S2

• splitting ↑ by continued inspiration (while patient not holding in breath)
• Loud S2 → hypertension (systemic or pulmonary circulation)
• Wide split S2 - RBBB, Pulmonary stenosis
• Fixed split S2 - ASD
• Paradoxical: LBBB, severe AS

S3 (Ventricular Gallop)

• lightly use bell at apex, best heard in LLD
• can be normal in young people and the pregnant
• noted in volume overload, increased transvalvular flow (TR, MR)

S4 (Atrial Gallop)

• lower pitched
• indicates stiff LV– LVH, post-MI

Other sounds

• Ejection click - between S1 and S2
• Carotid bruit
• Pericardial friction

Murmurs

Describe a murmur in its timing, shape, intensity and radiation

Type	Character	Best Heard	Radiation
Aortic stenosis	systolic, crescendo-decrescendo	AV, lean forward ↓with Valsalva	carotids, clavical
Aortic regurg	early diastolic decrescendo	L2-4 ICS Lean foward	Apex
Mitrial Stenosis	Mid diastolic rumble	Apex, LLD	No radiation
Mitrial Regurge	pansystolic	apex	L axilla
VSD	pansystolic, harsh	L sternal border
PDA	continuous "machine like"	aortic valve	L clavical

Intensity

1/6 = quieter than S1
2/6 = same as S1
3/6 = louder than S1 with no thrill
4/6 = thrill present
5/6 = heard with edge of scope in contact with skin
6/6 = heard with scope off of the chest

Special tests

• ↑ blood flow to heart (leg raise, squatting)
  • ↑ AS, ↓HoCM, ↓MR
• ↓ blood flow to heart (Valsalva)
  • ↓ AS, ↑ MR, ↑HoCM

External link

• Auscultation Reference Guide - Heart and lung sound lessons, audio and animations
• Heart and Lung Sounds - Audio examples of heart and lung sounds.