Cardiovascular Examination - Part Two: Inspection and palpation of the precordium
Inspection and palpation of the precordium usually follows the assessment of jugular venous pressure (described la…
VOL: 103, ISSUE: 26, PAGE NO: 26
Phil Jevon, PGCE, BSc, RN, is resuscitation officer/clinical skills lead and honorary clinical lecturer, University of Birmingham Medical School
Alan Cunnington, FRCP, MD, is consultant physician; both at Manor Hospital, Walsall
Inspection and palpation of the precordium usually follows the assessment of jugular venous pressure (described last week; NT Clinical, 1 June, p28). The process precedes auscultation of the precordium.
The precordium is the front of the chest wall over the heart (Fig 1). Of particular importance when inspecting and palpating the precordium is the apex/mitral area (left 5th intercostal space, mid-clavicular line), as this is where the apex beat can usually be felt (and where mitral valve sounds are best auscultated) (Cox and Roper, 2005).
CHEST SCARS AND DEFORMITY
When inspecting the precordium it is important to look for scars suggesting cardiac surgery. A mid-line sternotomy suggests a coronary artery bypass graft (CABG) or valve replacement. A left sub-mammary thoracotomy scar suggests mitral valvotomy. It is also important to note if the patient has an implantable pacemaker or cardiovertor/defibrillator. There will be a scar just below the left (occasionally right) clavicle and a bulge in the skin may be visible.
Signs of chest deformity should be noted as this can affect examination of the heart. For example, pectus carinatum (‘pigeon chest’) or pectus excavatum (funnel chest) can displace the heart, affecting palpation and auscultation of the precordium.
THE APEX BEAT
The apex is the tip or summit of the heart and the apex beat is the impact of the organ against the chest wall during systole. It is primarily due to recoil of the heart’s apex as blood is expelled during systole. As it correlates with left ventricular contraction, apex beat assessment provides an indication of left ventrical functioning (Scott and MacInnes, 2006).
Sometimes the apex beat is not palpable. This is usually due to a thick chest wall, emphysema, pericardial infusion, shock or dextrocardia. Rolling the patient into the left lateral position may enable the apex beat to be palpated (Scott and MacInnes, 2006).
The location and the character of the apex beat should be noted. Its normal location is the 5th/6th intercostal space mid-clavicular line, with the patient lying in a supine position at approximately 45 degs. Causes of a displaced apex beat include:
- Cardiomegaly - a common cause of inferior or lateral displacement;
- Mediastinal shift - a large pleural effusion or tension pneumothorax can push the apex beat (and sometimes the trachea) away from the affected side; a collapsed lung can draw the apex beat towards the affected side;
- Dextrocardia (Douglas et al, 2005; O’Neill et al, 1989).
ASSESSMENT OF THE APEX BEAT
Experienced practitioners can assess the character of the apex beat. A normal apex beat is short and sharp. Abnormal findings of the apex beat include: l Heaving - a sustained and forceful heave caused by an obstruction, for example aortic stenosis or systemic hypertension, to the flow of blood out of the heart;
- Thrusting - caused by volume overload;
- Tapping - felt in mitral stenosis;
- Diffuse - left ventricular failure and cardiomyopathy;
- Thrills - transmitted heart murmurs - similar to a purring cat (Longmore et al, 2007).
- Explain the procedure to the patient (NMC, 2004).
- Ensure the patient is in a supine position at an angle of 45 degs.
- While ensuring privacy and maintaining dignity, expose the patient’s chest.
- Ask the patient to breathe normally.
- Inspect the precordium for cardiac surgery-related scars. In a female patient, it may be necessary to lift up the left breast to allow full inspection of the precordium. Note any chest shape deformity and unusual pulsations.
- Locate and palpate the apex beat (Fig 2). This is usually the 5th/6th intercostal space mid-clavicular line. To locate, place the right hand with the fingers outstretched against the left side of the patient’s chest wall.
- If locating the apex beat is difficult, roll the patient into the left lateral position (Fig 3). Although this may make it easier to locate the apex beat, the lateral position will push the apex beat further outwards as the heart has a degree of mobility in the chest.
- Using the tip of your finger, assess the character of the apex beat (Fig 4).
- If the apex beat is displaced, check that the trachea is central (Fig 5) - if the trachea is deviated, this indicates mediastinal shift.
- Palpate to the left of the sternum to ascertain whether the hand visibly lifts with each ventricular contraction. Place the heel of the right hand with the fingers pointing upwards over the precordium to the left of the sternum (Fig 6). In normal circumstances the movement related to respirations will be felt. If the hand is lifted with each ventricular contraction then this is referred to as a left parasternal heave, usually due to right ventricular hypertrophy or volume overload.
- Proceed to auscultation of the precordium (Scott and MacInnes, 2006). This process is described in next week’s article in this series.
This procedure should be undertaken only after approved training, supervised practice and competency assessment, and carried out in accordance with local policies and protocols.
This article has been double-blind peer-reviewed.