Vitals

Precordial Exam

Inspection
- General impression
- SEADS
- Deformities: pectus excavatum, pectus carinatum - associated with mitral valve prolapse
- Pacemaker, defibrillator implant
- Cardiac apex visibility (midC 5 ICS)
- Signs of Respiratory Distress
- Clubbing - Shamroth’s window / Cyanosis

Apex beat:
- If cannot palpate supine → roll over: left lateral recumbent position.
- With one hand palpating the beat, another hand palpating radial pulse
- Normal LADS
  - Location: 4-5th ICS, midC (may differ in left lateral recumbent position)
  - Amplitude: brief outward motion, “gental rap”
  - Duration: less than 2/3 of systole, S1 → impulse → S2
  - Size: 2-3 cm, size of a quarter
- Abnormality
  - Location: 6 ICS, lateral (auxiliary line) = Cardiomegaly ****
  - Size: > 3 cm Diameter in LV enlargement
  - Amplitude: increased in volume overload at LV
  - Impulse sustained: > 2/3 systole – valvular obstruction (aortic stenosis), severe pressure overload
Heaves and Thrills - Sternal border
- Heaves:
  - Diffused outward motion felt by heel of hand
  - Location: Left sternal border
  - Enlarged heart structures, e.g. Right ventricular hypertrophy
- Thrills:
  - Murmur that are 4+ in grade
  - vibration caused by turbulent blood flow, high pitched valvular sound felt by fingertip
  - Location: upper right sternal border (URSB), upper left sternal border (ULSB), lower left sternal border (LLSB), apex (each of the heart valve)