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)
·
Apex beat:
o Count down intercostal spaces (the 2nd space is the first one palpable, opposite the sternal angle). Find most
lateral and inferior point at which pulsations are felt
o Normal = 5th 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
·
A waste of time!
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