Precordial exam: Position patient at 30 degree elevation for exam. MS.
AID
Inspection Murmurs: MR. ASS
1. First I am going to start with inspection SEADS. 1.very faint
2. Now I am going to look specifically at the sternum I am looking for: pectus 2.quiet but heard easily with steth
carinatum (pigeon chest) which is generally seen in males during a growth 3. Moderately loud
spurt or can be associated with a vitamin D deficiency in kids or scoliosis. 4. w/thrill
5. Thrill + may be heard with steth
pectus excavatum is usually a congenital anomaly but can impair cardio-resp
slightly off
function.
3. I am also looking at the chest to see if I can notice any pulsations in areas like
the aortic, pulmonic areas which are right and left to the 2nd ICS and then the tricuspid which runs along the left
sternal border at the 3rd-5th ICS and mitral landmark which runs just medial to the left midclavicular line at the 5th
ICS.
Palpation → done with heel of hand
1. I am first going to palpate feeling for lift/heave or a thrill which could indicate a murmur grade 4 or >.
2. While in the mitral or PMI I can normally feel the heartbeat. It should be:
a. Position: just medial to left mid clav line (or w/in 10cm of left midsternal line)
b. Amplitude: should be brisk (and not diffuse,
tapping, sustained)
c. Duration: 2/3rds of systole (need to palpate radial
pulse to comment on this one)
d. Size: norm =1- 2.5 cm in size.
Auscultation: While auscultating I will be listening with both bell
and diaphragm applying light pressure I can use the bell and
firmer pressure the diaphragm. With the bell I can hear LF better
for S3, S4 and stenosis. And the diaphragm (HF) is better for S1,
S2 and regurgitation sounds.
1. APTM → listening for S1 and S2 and any extra heart sounds
like S3,S4 or murmurs.
a. S1 = closure of MT valves → start of systole
b. S2= closure of AP valves → start of diastole. Can get a splitting of
S2 (A2/P2) during inspiration.
c. S3 = occurs right after S2. Rapid deceleration of blood across MV. Can be normal in athletes.
d. S4= occurs just before S1. Blood into stiff ventricle.
2. LLD: with the patient in the LLD I am going to use my bell at the PMI, in this position I can hear S3/S4 + mitral
murmurs better. If I had any concern about extra sounds or murmurs from the previous position I could listen
again here, is this something you would like me to do now?
3. Instruct patient to sit up and lean forward they will need to exhale completely and hold. With the patient in this
position I am going to listen with diaphragm along LSB. This position can increase aortic regurg and friction rubs.
Pulses: I am going to listen to the carotid pulse with my diaphragm for any bruits. (also palpate radial pulse, ask patient to
hold their breath and listen) I can hear the upstroke of the carotid pulse it should come shortly after S1 but precede S2. I
hear no bruits. If there was any obstruction, kinking or thrills in carotid I could assess the brachial artery.
Next I am going to assess Jugular Venous Pressure which can give an
indication to RA pressure and volume status of patients.
● Since I have already located the carotid artery I will now try and locate the
internal jugular vein. First I will locate the EJV just posterior to the SCM and
the IJV pulsations can usually be seen just medial to this. I will know I have
located IJV pulsations and not carotid pulsations because IJV pulsations
are:
○ Occludable and Biphasic (a and v waves)
○ Non-palpable
○ Changes in position with respiration
● Measure from sternal angle (0-3 cm is normal) if you add 5 cm = distance to
RA (5-8 cm cutoff of normal).
Special Test: Hepatojugular Reflux:
● Press on RUQ watch JVP increase and hold 10 seconds. When release
JVP should return to normal in 10 seconds.
