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(a) Size and shape of the precordium:

The precordium is the part of the anterior chest wall which overlies the heart. Look for any bulging or flattening of the precordium. Bulging or prominence of the precordium is seen in mediastinal tumors, pericardial effusion, left sided pleural effusion etc.

(b) Engorged veins over the precordium, Present in superior or inferior vena caval obstruction

(c) Pulsation over the precordium

(i) Apex beat or apical impulse:

        Look whether the apex beat is visible or not, with the subject sitting up or lying down. The apex beat is defined as the lowermost and outermost point of definite cardiac impulse that can be best seen or felt. Even in healthy adults, especially in the recumbent posture, apex beat may be invisible. It is also invisible in personswith thick chest wall orwhen it is located behind a rib. If invisible when lying down, look for it with the subject sitting up. Failure to detect the apex beat may also be due to pericardial effusion.

(ii) Other pulsations over the precordium: Look for any other pulsations over the precordium. Suprasternal pulsations are visible in thin persons, high aortic arch, aneurysm of arch of aorta, anaemia, thyrotoxicosis etc. Carotid pulsations are prominent in anxious or agitated persons, in hypertension and regurgitation.

          Epigastric pulsation is seen in thin nervous persons, aneurysm of abdominal.aorta and in pulsatile liver in bicuspid regurgitation. In pulmonary hypertension pulsations may be seen in the second left intercostal space. In aneurysm of the ascending aorta and in aortic regurgitation pulsations may be noticed in the second right intercostal space.

2. PALPATION: This is done to confirm the findings of inspection and to get more details of the inspection findings.

Palpation is done with the palm of the hand and tips of the fingers.

(a) Apex beat: Position of the apex beat is confirmed by palmar and digital palpation. It is normally located in the

5th left intercostal space 1 cm medial to the midclavicular line. Displacement of the apex beat occurs in

(i) Pleural effusion and pneumothorax when the mediastinum is pushed towards the opposite side and the apex

beat is also shifted.

(ii) Pulmonary fibrosis and collapse of the lung pulls the mediastinum towards the same side.

(iii) Hypertrophy and dialatation of the ieft ventricle results in downward and outward shift of the apex beat

(iv) Dextrocardia, the apex beat is located on the right side

(v) Pregnancy, ascites, abdominal tumours. the apex beat is shifted upwards.

(vi) Scoliosis and Kyphosis.

(b) Thrill is a palpable murmur. It is a vibrating sensation produced due to the turbulence of flow in CVS, transmitted to the palpating hand and stimulates the purring of a cat. It is associated with very loud murmurs and can be felt over the precordium or over major vessels in diseases. Thrill can be a systolic or diastolic thrill.

(c) Left parasternal heave: This sign is present in right ventricular hypertrophy. This is felt by placing the ulnar border of the hand firmly over the precordium just lateral to the left sternal border, where a definite lift of the hand may be detected.

Look for any other pulsations palpable over the precordium, Intercostal spaces and epigastrium.


          By percussion gross enlargement or shift in position of the heart can be made out. This is not very reliable and has been superseded by chest X-ray or echo- cardiography. Usually the right, left, and lower borders of the heart are percussed.

         To percuss the right border, first percuss out the upper border of the liver. Then percuss from right axilla to the right sternal border in a line just above the liver dullnes. The right border corresponds to the right sternal border from the third to the sixth intercostal space. Left border is percussed from the 5th left intercostal space in the axilla to the area of apex beat. It corresponds to a curved line drawn from the apex to a point on the lower border of 2nd left costal cartilage 11/2 inches from the median plane.

         The lower border corresponds to a line drawn from the 6th right costal cartilage near sternum to the apex. The upper border corresponds to the 2nd left intercostal space.

         In pericardial effusion and cardiomegaly the area of cardiac dullness is increased. In emhysema the area of cardiac dullness is diminished.



There are four auscultarory areas over the precordium, where the heart sounds are best heard.

(a) Mitral area: - 5th left intercostal space 1 cm medial to the midclavicular line

(b) Tricuspid area: - Lower end of the sternum to the left side

(c) Aortic area: - 2nd right intercostal space close to the sternum

(d) Pulmonary area: - 2nd left intercostal space close to the sternum

There is another area - Second Aortic area: 3rd and 4th left intercostal spaces close to the sternum.

The first heart sound is best heard in the mitral and tricuspid area and the second sound is best heard in theaortic and pulmonary area.

      The 1 st-heart sound is longer, soft in quality and low pitched. It resembles the word”lubb”. It is due to closure of AV valves. The 2nd heart. sound is shorter, high pitched and sharp in quality. It resembles “dup”. It is due to closure of semi lunar valves.

           The events in each area should be noted separately and reported. The events to be noted at first and second heart sounds, their intensity, any additional sounds ie. third or fourth sound and presence of any adventitious sound eg: murmur, opening snap or click. Murmur is the vibration produced by turbulence of flow in the heart which is audible on auscultation. Similar sound produced at the level of blood vessels outside the precordium is called bruit. Opening snap and click are produced at the level of mitral and semi lunar valves in diseases. Any split in the lstor2nd heart sound should be also observed.