Precordial Exam (OSCE)

Inspection

from the foot of the bed
- chest wall deformity (pectus excavatum, carinatum)
- scars (thoracotomy, pacemaker)
- heaves (ventricular hypertrophy) and lifts
- visible apical beat
- impulses (under xiphoid – can mean RVH or Aorta).
- dilated veins

Palpation

using finger pads, palpate for apex impulse (PMI) - accurately measure MCL
- location, size - one ICS
- amplitude - if increased, suggests volume/pressure overload
- duration - check in relation to carotid pulse (> 2/3 systole → sustained, LVH)
- if carotid is delayed = parvus et tardus → AV stenosis

thrills - palpate at each of the 4 valve zones = grade 4 murmur
heaves (with heel of hand)
- left sternal border → LVH
- PV → pulmonary hypertension
- AV → systemic hypertension
- inferior to xiphoid - RVH

Auscultation

listen specifically for one sound at a time
calibrate your timing to the radial pulse
S1 > S2 in LLSB
S2 > S1 in LUSB

S1

louder → ↓ PR interval, ↑CO, ↑HR
quieter → ↑ PR interval, MR, severe MS
splitting → RBBB

S2

splitting ↑ by continued inspiration (while patient not holding in breath)
Loud S2 → hypertension (systemic or pulmonary circulation)
Wide split S2 - RBBB, Pulmonary stenosis
Fixed split S2 - ASD
Paradoxical: LBBB, severe AS

S3 (Ventricular Gallop)

lightly use bell at apex, best heard in LLD
can be normal in young people and the pregnant
noted in volume overload, increased transvalvular flow (TR, MR)

S4 (Atrial Gallop)

lower pitched
indicates stiff LV– LVH, post-MI

Other sounds

Ejection click - between S1 and S2
Carotid bruit
Pericardial friction

Murmurs

Describe a murmur in its timing, shape, intensity and radiation

Type	Character	Best Heard	Radiation
Aortic stenosis	systolic, crescendo-decrescendo	AV, lean forward ↓with Valsalva	carotids, clavical
Aortic regurg	early diastolic decrescendo	L2-4 ICS Lean foward	Apex
Mitrial Stenosis	Mid diastolic rumble	Apex, LLD	No radiation
Mitrial Regurge	pansystolic	apex	L axilla
VSD	pansystolic, harsh	L sternal border
PDA	continuous "machine like"	aortic valve	L clavical

Intensity

1/6 = quieter than S1
2/6 = same as S1
3/6 = louder than S1 with no thrill
4/6 = thrill present
5/6 = heard with edge of scope in contact with skin
6/6 = heard with scope off of the chest

Special tests

↑ blood flow to heart (leg raise, squatting)
- ↑ AS, ↓HoCM, ↓MR
↓ blood flow to heart (Valsalva)
- ↓ AS, ↑ MR, ↑HoCM

External link

Auscultation Reference Guide - Heart and lung sound lessons, audio and animations
Heart and Lung Sounds - Audio examples of heart and lung sounds.

Other OSCE modules

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