Method Of Exam
* Palpate the precordium with the palmar surface of your hand over the aortic, pulmonary, parasternal and apical areas of the heart.
* Determine the lower and outermost precardiac impulse, the apical impulse.
* Press your finger over the apical impulse identify its location, amplitude, duration and assess the rapidity of the upstroke and downstroke.
Normal: In thin individuals, the apical impulse is recognizable. Apical impulse is normally in 5th interspace just medial to midclavicular line and is about 1-2 cm in diameter. The apical impulse feels like a gentle tap and is small in amplitude and corresponds to first two thirds of systole.
Abnormal Finding
* Bulge: Note the site of bulge.
o Precordial bulge: RV hypertrophy, LA enlargement, LV aneurysm
o Aortic area bulge: Aortic aneurysm, Dilation (e.g., post stenotic dilation)
* Thrust: Note the site, size, amplitude , duration, upstroke and downstroke characteristics.
o Parasternal area :
+ Marked increase in amplitude with little change in duration; Volume overload of RV (ASD)
+ Marked increase in amplitude and duration; Pressure overload of RV (Pulmonic stenosis, Pulmonary hypertension)
o Aortic area: (Aortic aneurysm)
o Pulmonic area: Prominent pulsation (Pulmonary artery dilatation ,Increased flow , Pulmonary hypertension)
o Apical impulse
+ Sustained lift : Pressure overload, LV hypertrophy ( Aortic stenosis)
+ Hyperdynamic: Marked increase in amplitude Volume overload (Mitral insufficiency, Aortic insufficiency)
+ Undetectable apical impulse: (Obesity, Emphysema, Muscular chest, Pericardial effusion)
+ Hypokinetic apical impulse and displaced to left:(Dilated failing Heart)
* Thrill: It is a purring sensation. Note its location and timing.
o Parasternal area : (PDA, ASD, VSD)
o Aortic area: ( Aortic stenosis)
o Pulmonic area: ( Pulmonary stenosis)
o Apical area: ( Mitral insufficiency, Mitral stenosis)
* Tap: Loud sounds evoke a palpable feeling like a tap.
o Aortic area: Palpable A2 ( Hypertension)
o Pulmonic area: Palpable P2 ( Pulmonary hypertension)
* Rub: Scratchy feeling.
o ( Pericardial)
* Szorsy Gallops: Can be palpable
Knowledge Base
Anatomy of heart chambers and its relationship to precardium
Apical impulse
Conditions causing different chamber enlargement
Physiology of cardiac function
Surface anatomy of valves and major vessels
Hemodynamics of abnormal chambers and valves
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