Precordial Exam (OSCE)
Appearance
Inspection
[edit | edit source]- 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 | edit source]- 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 | edit source]- 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 | edit source]- louder → ↓ PR interval, ↑CO, ↑HR
- quieter → ↑ PR interval, MR, severe MS
- splitting → RBBB
S2
[edit | edit source]- 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 | edit source]- 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 | edit source]- lower pitched
- indicates stiff LV– LVH, post-MI
Other sounds
[edit | edit source]- Ejection click - between S1 and S2
- Carotid bruit
- Pericardial friction
Murmurs
[edit | edit source]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
[edit | edit source]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 | edit source]- ↑ blood flow to heart (leg raise, squatting)
- ↑ AS, ↓HoCM, ↓MR
- ↓ blood flow to heart (Valsalva)
- ↓ AS, ↑ MR, ↑HoCM
External link
[edit | edit source]- Auscultation Reference Guide - Heart and lung sound lessons, audio and animations
- Heart and Lung Sounds - Audio examples of heart and lung sounds.