Precardium: Palpation

Slide 1: Precardium: Palpation To evaluate apical impulse. To assess dilatation and dynamics of RV, aorta and pulmonary artery.

Slide 2: Method Of Exam • Palpate the precordium with the palmar surface of your hand over the aortic, pulmonary, parasternal and apical areas of the heart.

Slide 3: Method Of Exam • Determine the lower and outermost precardiac impulse, the apical impulse.

Slide 4: Method Of Exam • Press your finger over the apical impulse identify its location, amplitude, duration and assess the rapidity of the upstroke and downstroke.

Slide 5: 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.

Slide 6: Abnormal Finding • Bulge: Note the site of bulge. Precordial bulge: RV hypertrophy, LA enlargement, LV aneurysm Aortic area bulge: Aortic aneurysm, Dilation (e.g., post stenotic dilation)

Slide 7: Abnormal Finding • Thrust: Note the site, size, amplitude , duration, upstroke and downstroke characteristics. 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)

Slide 8: Aortic area: (Aortic aneurysm) Aortic Pulmonic area: Prominent pulsation Pulmonic (Pulmonary artery dilatation ,Increased flow , Pulmonary hypertension) Apical impulse Apical  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)

Slide 9: • Thrill: It is a purring sensation. Note its location and timing. Parasternal area : (PDA, ASD, VSD) Parasternal Aortic area: ( Aortic stenosis) Aortic Pulmonic area: ( Pulmonary stenosis) Pulmonic Apical area: ( Mitral insufficiency, Mitral Apical stenosis)

Slide 10: • Tap: Loud sounds evoke a palpable feeling like a tap. Aortic area: Palpable A2 ( Hypertension) Aortic Pulmonic area: Palpable P2 ( Pulmonary Pulmonic hypertension) • Rub: Scratchy feeling. ( Pericardial) ( • Szorsy Gallops: Can be palpable

Slide 11: Knowledge Base • Anatomy of heart chambers and its relationship to precardium • Apical impulse • Conditions causing different chamber enlargement

Slide 12: Knowledge Base • Physiology of cardiac function • Surface anatomy of valves and major vessels • Hemodynamics of abnormal chambers and valves

Slide 13: Ref:: Bates, A Guide to Physical Exam....279-284. Review Dr. John McNulty's lesson, "Human cross sections". . “Nurses Informations” http://nursesinformations.blogspot.com