Praecordium - Physical Exam

Praecordium

Inspection of the Praecordium

·        Scars:

o  Median sternotomy: any surgery requiring cardiopulmonary bypass

o  Left lateral Thoracotomy: ?closed mitral valvotomy

·         Note structural abnormalities: Pectus excavatum (sunken chest = funnel chest) or kyphoscoliosis may distort position of heart and vessels (ie shifting the apex beat). If severe then ¯pulmonary function

·        Note presence of pacemaker

·        Pulsations: apex beat and others (eg over pulmonary artery in severe pulmonary hypertension)

Palpation of the Praecordium

·        Apex beat:

o  Count down intercostal spaces (the 2^nd space is the first one palpable, opposite the sternal angle). Find most lateral and inferior point at which pulsations are felt

o  Normal = 5^th intercostal space, mid-clavicular line

o  If not palpable then thick chest wall, emphysema, pericardial effusion, shock (or rarely dextrocardia – inversion of heart and great vessels onto right side) 

o  Pressure overloaded = systolic overloaded: Forceful, sustained, not displaced. Due to hypertension, aortic stenosis 

o  Volume loaded = diastolic overloaded = hyperkinetic: displaced, unsustained, uncoordinated, large area. Due to aortic or mitral regurgitation, dilation, LV dysfunction (eg anterior MI)

o  Double or triple impulse = hypertrophic cardiomyopathy

·        Parasternal impulse: heal of hand rested just to the left of the sternum. Feel movement with systole in right ventricular enlargement or severe left atrial enlargement (right ventricle pushed anteriorly)

·        Tap of pulmonary valve closure (P2) over pulmonary areas in pulmonary hypertension

·        Thrills = palpable murmurs. Apical thrills felt best with patient rolled onto left side. Pulmonary or Aortic thrills best felt with patient sitting up, leaning forward and on expiration. A thrill coinciding with the apex beat is a systolic thrill, otherwise a diastolic thrill

Percussion of the Praecordium

·        A waste of time!