Clinical Examination Of Heart ( Precordium):

THEORY.

Precordium is the portion of the anterior aspect of the chest wall which overlies the heart. Its examination is carried out under following headings:

• Palpation
• Inspection
• percussion.
• Auscultation

1. Table of Contents

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    Inspection

Clothing of the patient should be removed upto waist. Look for:

• Veins 0n the Chest wall: Normally full and prominent veins are not seen in healthy subjects. They are seen in a. Subjects with skin unusually transparent, show thin and tiny veins.
• Shape and form of fhe chest: In healthy subject, it is bilaterally symmetrical.
• Intra-thoracic growth or aneurysm obstructs the venous return. c. Secondary to portal obstruction or obstruction to inferior vena cava.
•  Cardiac Impulse: It is the pulsation occurring due to the impact of the heart against the chest wall during systole. The area over which the impact is seen, is a circular area having diameter about 2.5 cm. Count the heart beat by counting the number of pulsations per minute. The lowest and outermost point of definite cardiac impulses, where it is seen or felt most forcibly, is called the apex beat. Normally it lies 9 cm from the midline or one cm internal to the mid-clavicular line in the 5th intercostal space. Failure to detect an apex beat is usually due to obesity but it may be a feature in patients with pleural or pericardial effusion, asystole and dextrocardia.

A real displacement of the apex beat may be due to disease of the surrounding viscera, which ‘push’ or ‘puil’ it from its usual site. Instances of ‘pushing’ are found in pleural effusion and pneumothorax, and ‘pulling’ in pulmonary fibrosis and collapse of the lung.

The left ventricular hypertrophy, the beat becomes more forceful and may extend outwards towards the axilla.

Apex beat becomes prominent due to nervousness, anxiety and exercise.

Other pulsations:

• Over the precordium: In thin lean subjects, especially in children, the cardiac impulse can be seen all over the precordium.
• In the neck: Carotid artery pulsations are visible on either side in the anterior triangle of the neck by the side of the sternomastold muscle. They are diffuse and are transmitted movements of the carotid pulse.
• In the epigastrium: Normally no pulsations are seen. If present, they can be because of nervousness or excitement (in a thin person), right ventricular hypertrophy and aneurysm of aorta.
• Palpation

It means examination by fingers and palm. Stand on the right Side of the subject and explain the test procedure to him and take the permission before hand. Ensure your hands are warm and that you will be as gentle as possible. Tell the subject to relax as best as he can.

Method:

Start by placing the right hand flat on the part to be palpate  with the wrist and forearm in the same horizontal plane, where possible. The art is to ‘mould’ the relaxed right hand to the body surface, and not to hold it rigid.

• Feel fora thrill: Any sound or murmur which is loud and low pitched will be palpable like a worm moving under the hand. These palpable vibration are called a thrill.
• Feel for cardiac impulse. confirm the findings obtained by inspection with respect to the location, extent, repetition rate and rhythm.
• Feel for temperature and texture of skin of chest.
• Feel the pulsations in neck. Carotid artery pulsations are to be felt and venous pulsation are best visible than palpation. Check the direction of blood flow in neck veins.
• Feel for right ventricular heave by heel of palm or by putting the hand at right angle to chest wall at left sternal border in 3rd, 4th and 5th intercostal space.
• Epiqastric pulsations: It is felt by gently pushing 3 fingers facing Upwards and downwards in the epigastrium.

3. Percussion:

Method:

Place the middle finger (pleximeter finger) of left hand firmly on the part to the percussed, other fingers should be well separated apart and should not touch the surface.

The back of middle phalanx of pleximeter finger is then struck with tip of the middle finger (plexor finger of right hand which is flexed at middle interphalangeal joint). Sound produced after percussion may be tympanic (from hollow viscera containing gas), resonant (as from lungs) and dull (from solid viscera)

•  The upper border of the heart cannot be defined accurately as the dullness of the heart tissue continuous with the dullness of the big vessels.
• The right border of the heart is just to the right of the sternum at the level of fourth rib. It is difficult to define since the sternum acts as a sounding board.
• By percussing the 3rd, 4thand 5th intercostal space from the left lung towards the heart, it is possible to define the left border more or less precisely.
• Similarly, the lower border of the heart cannot be defined as it lies in relation with the diaphragm and the left lobe of the liver below it.

Area of precordial dullness increases due to large pericardial effusion and aortic aneurysm. Area of precordial dullness decreases or absent in emphysema.

4. Auscultation:

Stethoscope is used to listen the heart sounds. The heartsounds produced by closure of heart valves can be heard all over the precordium but are heard best over four cardiac areas on the chest wall . These areas are customarily called by the name of the valve from which sounds and murmurs arise.

• The tricuspid area, which lies just to the left of the lower end of the sternum.
• The mitral area, which corresponds to the apex beat.
• The aortic area, which is to the right of the sternum in the second intercostal space.
• The pulmonary area, which is to the left of the sternum in the second intercostal space.

Usually two heart sounds are heard (S1 and S2) ‘lub’ and ‘dub’. First heart sound (S1) ‘5 because of closure of the mitral and tricuspid valves, it is low pitched loud sound at the onset of ventricular systole. Second heart sound (S2) is because of closure of pulmonary and aortic valves, it is high pitched sharp sound at the onset of ventricular diastole. Splitting of first heart sound is difficult to detect because mitral and tricuspid valves close almost at the same time. Splitting of second heart sound can be detected because pulmonary valves close after the aortic valve. Splitting is widest during inspiration and narrowest during expiration called as physiological splitting.

Third heart sound (S3) is due to flow of blood from atria into the ventricle and fourth heart sound (S4) is due to atrial contraction.

Murmurs are abnormal sounds which are produced due to turbulance in the. blood flow at or near a valve or an abnormal communication within the heart. Murmurs may be systolic, diastolic or continuous. The continuous murmurs is heard throughout systole and diastole.

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