This document describes how to palpate the precordium to evaluate the heart. It outlines how to locate the apical impulse and assess its characteristics. Abnormal findings include precordial bulges or thrills which may indicate conditions like ventricular hypertrophy. The timing and location of thrills can provide clues about underlying heart valves or vessels. A thorough precordial exam requires knowledge of cardiac anatomy, physiology, and how abnormalities affect hemodynamics and present on physical exam.

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

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.

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

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.

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.

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)

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)

8. Aortic area : ( Aortic aneurysm) Pulmonic area : Prominent pulsation (Pulmonary artery dilatation ,Increased flow , Pulmonary hypertension) 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)

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

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

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

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

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