The precordium

Inspection:
o From the foot of the bed, comment on : contour, symmetry of the chest wall,
deformaities, moves with respiration equally.
o The right side of the bed, comment:
No Chest wall deformities.
No Vein engorgements.
 Normal Hair distribution.
 No Skin lesions
No Visible apex beat pulsation.(you have to use torch, lean at the level of the
bed to see pulsation)
 No Scars:
Midline sternotomy: CABG, aortic valve replacement.
Left submamary scar: mitral valvotomy.
Infraclavicular scars: defibrillator or pacemaker implantation.
Palpation
o Keep eye contact and ask about painful areas.
o General palpation using the flat of your right hand over the precordium for general
impression of cardiac impulse.
o Palpate the apex beat:
comment on position and character: Normally it is in the left 5th intercostal space
midclavicular line , gently tapping (first with fingers parallel to the intercostal
space then locate it with index and middle finger, roll the patient to the left side if
it is not palpable).
It is tapping in mitral stenosis; a double apex beat is characteristic of HOCM.
.
o Palpate for heaves (an impulse lifting the hand) using the heal of the right
hand firmly over two areas :
 Apex heave is caused by left ventricular hypertrophy, systemic hypertension,
aortic stenosis (place your hand horizontally).
 Left lower parasternal heave is caused by right ventricular
hypertrophy, pulmonary hypertension, pulmonary stenosis (place your hand
vertically, with holding breath on expiration). Comment no heave.
o Palpate for thrill (palpable vibrations) using the bony prominence of
the metacarpo-phalangeal joints:
At the apex: mitral regurgitation.
Right and left lower parasternal regions: VSD.
Other areas for loud murmurs(right upper sternal border for aortic stenosis which
radiates to the carotid artery). Comment no thrill.
Auscultation
o You should keep your thumb on carotid artery while you auscultate for identification of
S1, S2 and timing of murmurs (S1 occurs with the pulse).
o By using the diaphragm, auscultate mitral valve (at the apex), tricuspid valve( at the left
4th intercostal space or left lower sternal edge ), pulmonary valve ( at the left 2nd
intercostal space), aortic valve( at the right 2nd intercostal space).
 o Carotid auscultation: (ask the patient to hold his breath to reduce
tracheal transmission) for aortic stenosis radiation.
o Left axillary auscultation for mitral regurgitation radiation.
o Use the bell for listening to:
S3( normally or pathological: heart failure and mitral regurgitation , S4(systemic
hypertension, aortic stenosis, hypertrophy cardiomyopathy) and mitral
stenosis at the apex.
Tricuspid stenosis and right sided S3 in right ventricular failure on the left 4th
intercostal space.
o Maneuvers:
Roll the patient to the left side without removing the bell from over
the apex and listen for mitral stenosis.

Put the diaphragm over the right 2nd intercostal space and 3rd left intercostal space
(Erb’s area) while the patient is supine, ask the patient to lean forward,
expire and hold his breath without removing the diaphragm and listen for aortic
regurgitation.
o After auscultation, comment: normal S1, S2, normal S2 splitting, no added
sounds( opening snap, ejection click, friction rub), no S3, no S4.
o Report any murmurs if found, collected in one word which is SCRIPT (Site, Character,
Radiation, Intensity, Pitch, Timing):
Ejection systolic murmur: AS (harsh crescendo and decrescendo in character), PS,
HOCM and AS (pulmonary flow murmur).
Late systolic murmur: MVP.
Pan-systolic murmur: MR (high pitch, high velocity, blowing in character), TR
(High V wave in JVP) and VSD.
Early diastolic murmur: AR and PR.
(Graham Steele murmur due to pulmonary hypertension).
Mid-diastolic murmurs extending to pre-systole: MS ( Malor flushing), TS,
and Austin Flint murmur.
 Early diastolic murmur: AR
Pan-diastolic murmur: ASD in children (tricuspid flow murmur).
 Continuous murmur ( patent ductus arteriosus ).
o Report any added sounds if found:
Ejection click of AS (early in systole after S1).
Mid-systolic click of MVP.
Opening snap of MS (early in diastole after S2).
S3 after S2.
S4 before S1.
Others HOCM AS
Pulmonary crackles.
Crepitation. Valsava ↑ ↓
Ascites. Squats ↓ ↑
Lower limb edema. EC × √
Hepatomegaly. Murmur of AR × √