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

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.