Comprehensive Guide to Precordial Examination and Cardiac Assessment

 

EXAMINATION OF PRECORDIUM

The area of the chest wall that covers the heart is called the precordium. The precordium can be examined by taking the following actions

• Examination
• Palpation
• Percussion
• Auscultation

INSPECTION

Keep an eye out for these physical indicators:

1. Chest malformation (see respiratory system for discussion).
2. Expands the precordium.
3. Scars, notably around the sternum or intercostal gaps (they imply past cardiac surgery).

Heartbeats

Apex beat

1. Pulses originating from right ventricular hypertrophy that are located near the parasternal boundary.
2. Pulses in the left second intercostal space, maybe brought on by the pulmonary artery dilatation.
3. Pulses in the right second intercostal space, maybe brought on by an aortic aneurysm.
4. Suprasternal notch pulses, including those resulting from regurgitation of the aorta.
5. Suprasternal notch pulses, such as those brought on by aortic regurgitation.
6. Heartbeats within the epigastrium.
7. These are typically seen in thin people because of the aorta.
8. These may also result from an abdominal aortic aneurysm, pulsatile liver (tricuspid regurgitation), or right ventricular hypertrophy.
9. If the heart is significantly enlarged, the entire precordium moves with each cardiac beat.
10. Obstruction of the superior vena cava resulting in prominent veins.

PALPATION

Using the flat of your palm, palpate the precordium beginning in the lower left quadrant of the chest, moving along the left parasternal border, and ending in the upper right quadrant. Take note of the following bodily indicators:

Peak beat (character and location)

Right ventricular heave, also known as left parasternal heave
Heart sounds that are palpable
Thrill (a discernible mutter)
Vertebral pericardial massage

Beat Apex

The outermost and lowest region of the precordium where a distinct cardiac impulse is sensed is its designated location. The left ventricle typically forms the apex beat.

Technique

It is recommended that the patient lie supine. Lay the palm flat across the left side of the chest so that the tips of the fingers reach the lateral side of the chest wall and the fourth to seventh intercostal gaps are covered. Once pulsations are detected, use the tip of a finger to find their outermost and lowest parts. In the event that the patient's apex beat cannot be felt while they are supine, have them shift to their left side or urge them to sit up, lean forward, and feel again. Alteration in the patient's position causes a little shift in the apex beat. Find the location and quality of the apex beat when it becomes tangible.

Place-Based

The manubriosternal angle, also known as the Louis angle, is the first prominence you will feel while moving your finger along the middle of the sternum from the suprasternal notch. The second intercostal gap is located below the second costal cartilage, which is attached at this location. Count the intercostal spaces from this point on to determine which space the palpable apex beat is. Away from the sternum, spaces are easier to feel. The apex beat's distance from the midline is expressed in terms of different hypothetical vertical lines or can be quantified in centimeters. A vertical line drawn from a clavicle point halfway between its medial and lateral ends is known as the midclavicular line. While the midaxillary line is drawn from the axilla's center, the anterior and posterior axillary lines are drawn along the corresponding axillary folds. The 4th or 5th intercostal gap, roughly 1 cm medial to the midclavicular line, is where the normal apex beat occurs. In the event of left ventricular enlargement, the apex beat shifts.

Reasons for the apex beat's change

Cardiac reasons

1. Ventricular septal defect
2. Aortic regurgitation
3. Aortic stenosis
4. Mitral regurgitation
5. High blood pressure
6. Heart failure with an ischemic episode
7. Dilated cardiomyopathy
8. The apex beat may occasionally change due to a substantially inflated right ventricle.

Reasons other than cardiac

• The patient's left lateral or sitting forward position
• Chest deformities
• Diseases of the lungs that cause the mediastinum to move

Impalpable apex beat causes

• A thick wall of the chest
• Asthma
• Emboli around the heart
• Dextrocardia, in which the right side's apex beat can be felt.

Apex Beat's Character

A typical apex beat is neither strong nor does it elevate the finger that is being palpated—it is neither heaving nor tapping. When the apex beat is tapped, it is stronger than usual but the palpating finger remains in position. Sensation feels like a forceful tap on a locked door. In mitral stenosis, it is caused by a palpably loud 1-inch heart sound.

Heaving apex beat

The palpating finger is raised and the apex beat is stronger than usual.

Unstained heave

Finger is raised momentarily. It happens when the left ventricle has to expel too much blood, as in the case of aortic and mitral regurgitation.

Well-maintained heave

Finger is raised for a longer amount of time. It happens when the left ventricle must contract against strong resistance, such as in the case of hypertension or aortic stenosis. Usually, it is not moved.

Diffuse and displaced apex beat

The apex beat is displaced inferiorly and laterally, felt over a wide area, and is not particularly powerful in left ventricular dilatation found in advanced heart disease of any origin (e.g., ischemic heart disease, cardiomyopathy, hypertension, valvular heart disease).

Parasternal heave to the left

It is caused by right ventricular hypertrophy and is also known as right ventricular heave. If the hand moves with each cardiac contraction when placed vertically at the left parasternal border, left parasternal heave is evident. The epigastrium might also experience right ventricular heave.

Why does left parasternal heave occur?

1. Chronic lung disease
2. Mitral stenosis/regurgitation a. Pulmonary hypertension
3. Persistent ductus arteriosus, ventricular septal defect, and long-standing atrial septal defect
4. Pulmonary stenosis
5. Primary pulmonary hypertension
6. The Tetralogy of Fallot

Feel able Heartbeats

When the first and second heartbeats are strong, they can be felt. In mitral stenosis, the first heart sound, known as the tapping apex beat, is perceptible at the apex. In cases of pulmonary hypertension, the pulmonary component of the second heart sound (P2) may be perceptible at the pulmonary area. At the same location, dilated pulmonary artery pulses are also felt. In patients with systemic hypertension, the aortic component of the second heart sound (A) may be felt at the aortic area. It's possible to feel the third and fourth heart sounds.

Excitement

Called carotid shudder, the thrill of aortic stenosis is also detectable in the neck. A loud murmur that is felt is referred to as thrill. Cat purring is the finest example of it. Once encountered, it is effortlessly recalled. By matching the noises and thrills to the carotid pulsations, they are timed. Systolic are those that accompany carotid pulsations, while diastolic are those that occur in between. With the exception of the thrill of mitral stenosis, which is better felt in the left lateral position, thrills are best experienced by the patient leaning forward and holding his breath during expiration. If you feel a thrill, take note of its location and timing (diastolic or systolic).

Two palpable symptoms near the apex are the diastolic thrill of mitral stenosis and the systolic thrill of mitral regurgitation.

PERCUSSION

Nowadays, precordium percussion is rarely frequently used to check for cardiac dullness because a chest radiograph is a routine inquiry that provides precise information about the size and structure of the heart. Percussion may nevertheless reveal increased cardiac dullness as a result of a substantial pericardial effusion. For the right border percussion, begin at the midclavicular line and work your way laterally to the medially located 2nd, 4th, or 5th intercostal gaps. In the fourth intercostal gap, normal cardiac dullness is located lateral to the right lateral edge of the sternum. For the left border percuss, begin at the axilla and work laterally to medially in the third to fifth intercostal spaces (or lower, if needed). In the fourth intercostal gap, normal cardiac dullness is located medial to the midclavicular line.

EXAMINATION

This is the most crucial stage in the cardiovascular system evaluation process.

Stethoscope

It includes:

• Chest piece
• Pipes
• A portion of ear

Chest Portion 

It is made up of a bell and a diaphragm. The low-pitched noises are filtered by the diaphragm, making the high-pitched sounds easier to hear. It needs to be firmly pressed to the wall of the chest. The low-pitched noises are produced by the bell. It must be applied gently to avoid stretching the skin underneath, since this could cause it to become a diaphragm. The mid-diastolic murmur of mitral stenosis and the third and fourth cardiac sounds are the common low-pitched sounds.

Tubing

It need to be consistent in quality and thick. A 25 cm average length is suitable.

Earphone

Its spring should be strong enough to keep the ears in place, and its knobs should fit into the ears with ease. The earpieces of the stethoscope are worn with their tips slightly forward to align with the external auditory canal.

Area of Auscultation:

Experience has shown that, with rare exceptions, sounds generated at a given valve are more easily audible at a specific location inside the precordium. There is a unique such place for every valve, and that area is named after that particular valve. These regions do not correspond to the valves' anatomical surface projections.

• The apex and the mitral region are the same.
• On the left side, the tricuspid region is near the base of the sternum.
• The pulmonary region is situated near the sternum in the left second intercostal space.

The right second intercostal space, near the sternum, is home to the A1 (aortic 1), while the left third intercostal space, near the sternum, is home to the A2 (aortic 2). If the term "aortic area" is used in the discussion that follows, it will refer to A1.

Auscultation Technique

1. Not just the regions mentioned, but the entire precordium should be auscultated.
2. When describing clinical results and generating inferences, the aforementioned areas are helpful; otherwise, auscultation shouldn't be limited to them.
3. The entire precordium should be auscultated. You can start at the apex and work your way up the left parasternal border to the pulmonary area and then to the A1 area, or you can start at the A1 area and work your way towards the apex.
4. While in the supine posture, auscultate using the bell and then the diaphragm.
5. Place the patient in a left lateral posture and use the bell to auscultate the patient's apex for a mid-diastolic mitral stenosis murmur.
6. Request that the patient sit up, bend forward, and use their diaphragm to auscultate the pulmonary and region A.
7. When there is a murmur of pulmonary regurgitation, the patient should retain his breath; when there is a murmur of aortic regurgitation, he should release it.
8. Auscultate the back bases of the lungs for basal crepitations prior to concluding.

Notation for auscultatory sounds

Heart sounds are recorded via phonocardiography, and they appear as vertical blips with height denoting intensity and width time. Shadows are murmuring. Auscultatory results are described using similar graphic notations. Systole is the interval between the first heart sound, S1, and the second heart sound, S2, and diastole is the gap between S2 and S1.
When you auscultate, take note of the following:

1. The first, second, third, and fourth heartbeats
2. Additional noises (ejector systolic click, mid-systolic click, prosthetic valve sounds, opening snap)
3. Sighs
4. Rubs on the heart

Heartbeats

The heart contains four valves. Their opening is often silent, but their conclusion makes noise. Atrioventricular valves are those that are found between the atria and ventricles, whereas semilunar valves are found between the ventricles and the main vessels.

• With three cusps, the tricuspid valve is located between the right atrium and the right ventricle.
• The three-cusped, aortic valve is located between the left ventricle and the aorta.
• With three cusps, the pulmonary valve is located between the pulmonary artery and the right ventricle.

Heart Sounds, First and Second

The mitral and tricuspid valves close to produce the first cardiac sound. It signifies the start of the systole. The tricuspid component is quite quiet; the mitral component is the main component. At the peak, it is at its strongest. The closure of the aortic and pulmonary valves results in the production of the second heart sound. It signals the start of diastole and the conclusion of systole. The aortic component can be heard throughout the precordium, peaking in intensity at the A1 area, whereas the pulmonary component is restricted to the pulmonary area.