Precordial Exam (OSCE)

Inspection edit

  • 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 edit

  • 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 edit

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

S1 edit

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

S2 edit

  • 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) edit

  • 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) edit

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

Other sounds edit

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

Murmurs edit

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


L2-4 ICS

Lean foward

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 edit

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 edit

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

External link edit

Other OSCE modules edit