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Examination of Precordium

The document describes examining the precordium through inspection, palpation, and auscultation. Inspection involves looking for visible pulsations, the apex beat, masses, scars, lesions, signs of trauma or surgery, and pacemakers. Palpation feels for abnormal pulsations, precordial movements, and locating the apex beat. Auscultation listens for heart sounds like S1, S2, S3, S4, murmurs, rubs, and lung sounds. It also describes the cardiac conduction system including the sinoatrial node, atrioventricular node, bundle of His, bundle branches, and Purkinje fibers.

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Himani Bisht
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52 views3 pages

Examination of Precordium

The document describes examining the precordium through inspection, palpation, and auscultation. Inspection involves looking for visible pulsations, the apex beat, masses, scars, lesions, signs of trauma or surgery, and pacemakers. Palpation feels for abnormal pulsations, precordial movements, and locating the apex beat. Auscultation listens for heart sounds like S1, S2, S3, S4, murmurs, rubs, and lung sounds. It also describes the cardiac conduction system including the sinoatrial node, atrioventricular node, bundle of His, bundle branches, and Purkinje fibers.

Uploaded by

Himani Bisht
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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EXAMINATION OF PRECORDIUM

INSPECTION

inspect the precordium for:

 visible pulsations
 apex beat
 masses
 scars
 lesions
 signs of trauma and previous surgery (e.g. median sternotomy)
 permanent Pace Maker
 praecordial bulge

PALPATION

The valve areas are palpated for abnormal pulsations (palpable heart murmurs known as thrills) and
precordial movements (known as heaves). Heaves are best felt with the heel of the hand at
the sternalborder.

The apex beat is found approximately in the 5th left intercostal space in the mid-clavicular line. It can be
impalpable for a variety of reasons including obesity, emphysema, effusion and rarely dextrocardia. The
apex beat is assessed for size, amplitude, location, impulse and duration. There are specific terms to
describe the sensation such as tapping, heaving and thrusting.
Often the apex beat is felt diffusely over a large area, in this case the most inferior and lateral position it
can be felt in should be described as well as the location of the largest amplitude.

AUSCULTATION

 S1 and S2 - if the splitting is abnormal or louder than usual.


 S3 - the emphasis and timing of the syllables in the word Kentucky is similar to the pattern of sounds
in a precordial S3.
 S4 - the emphasis and timing of the syllables in the word Tennessee is similar to the pattern of
sounds in a precordial S4.
 If S4 S1 S2 S3 Also known as a gallop rhythm.
 diastolic murmurs (e.g. aortic regurgitation, mitral stenosis)
 systolic murmurs (e.g. aortic stenosis, mitral regurgitation)
 pericardial rub (suggestive of pericarditis)
 The base of the lungs should be auscultated for signs of pulmonary oedema due to a cardiac cause
such as bilateral basal crepitations.

CONDUCTION SYSTEM OF HEART

The components of the cardiac conduction system include the sinoatrial


node, the atrioventricular node, the atrioventricular bundle, the
atrioventricular bundle branches, and the Purkinje cells
Sinoatrial (SA) Node
Normal cardiac rhythm is established by the sinoatrial (SA) node, a specialized clump of
myocardial conducting cells located in the superior and posterior walls of the right atrium in
close proximity to the orifice of the superior vena cava. The SA node has the highest inherent
rate of depolarization and is known as the pacemaker of the heart. It initiates the sinus
rhythm, or normal electrical pattern followed by contraction of the heart.

This impulse spreads from its initiation in the SA node throughout the atria through
specialized internodal pathways, to the atrial myocardial contractile cells and the
atrioventricular node. The internodal pathways consist of three bands (anterior, middle, and
posterior) that lead directly from the SA node to the next node in the conduction system, the
atrioventricular node. The impulse takes approximately 50 ms (milliseconds) to travel
between these two nodes. The relative importance of this pathway has been debated since the
impulse would reach the atrioventricular node simply following the cell-by-cell pathway
through the contractile cells of the myocardium in the atria. In addition, there is a specialized
pathway called Bachmann’s bundle or the interatrial band that conducts the impulse
directly from the right atrium to the left atrium. Regardless of the pathway, as the impulse
reaches the atrioventricular septum, the connective tissue of the cardiac skeleton prevents the
impulse from spreading into the myocardial cells in the ventricles except at the
atrioventricular node.

The electrical event, the wave of depolarization, is the trigger for muscular
contraction. The wave of depolarization begins in the right atrium, and the
impulse spreads across the superior portions of both atria and then down
through the contractile cells. The contractile cells then begin contraction
from the superior to the inferior portions of the atria, efficiently pumping
blood into the ventricles.

Atrioventricular (AV) Node


The atrioventricular (AV) node is a second clump of specialized myocardial conductive
cells, located in the inferior portion of the right atrium within the atrioventricular septum. The
septum prevents the impulse from spreading directly to the ventricles without passing through
the AV node. There is a critical pause before the AV node depolarizes and transmits the
impulse to the atrioventricular bundle (see Figure 3, step 3). This delay in transmission is
partially attributable to the small diameter of the cells of the node, which slow the impulse.
Also, conduction between nodal cells is less efficient than between conducting cells. These
factors mean that it takes the impulse approximately 100 ms to pass through the node. This
pause is critical to heart function, as it allows the atrial cardiomyocytes to complete their
contraction that pumps blood into the ventricles before the impulse is transmitted to the cells
of the ventricle itself. With extreme stimulation by the SA node, the AV node can transmit
impulses maximally at 220 per minute. This establishes the typical maximum heart rate in a
healthy young individual. Damaged hearts or those stimulated by drugs can contract at higher
rates, but at these rates, the heart can no longer effectively pump blood.
Atrioventricular Bundle (Bundle of His), Bundle
Branches, and Purkinje Fibers
Arising from the AV node, the atrioventricular bundle, or bundle of His, proceeds through
the interventricular septum before dividing into two atrioventricular bundle branches,
commonly called the left and right bundle branches. The left bundle branch has two fascicles.
The left bundle branch supplies the left ventricle, and the right bundle branch the right
ventricle. Since the left ventricle is much larger than the right, the left bundle branch is also
considerably larger than the right. Portions of the right bundle branch are found in the
moderator band and supply the right papillary muscles. Because of this connection, each
papillary muscle receives the impulse at approximately the same time, so they begin to
contract simultaneously just prior to the remainder of the myocardial contractile cells of the
ventricles. This is believed to allow tension to develop on the chordae tendineae prior to right
ventricular contraction. There is no corresponding moderator band on the left. Both bundle
branches descend and reach the apex of the heart where they connect with the Purkinje fibers.
This passage takes approximately 25 ms.

The Purkinje fibers are additional myocardial conductive fibers that spread the impulse to
the myocardial contractile cells in the ventricles. They extend throughout the myocardium
from the apex of the heart toward the atrioventricular septum and the base of the heart. The
Purkinje fibers have a fast inherent conduction rate, and the electrical impulse reaches all of
the ventricular muscle cells in about 75 ms. Since the electrical stimulus begins at the apex,
the contraction also begins at the apex and travels toward the base of the heart, similar to
squeezing a tube of toothpaste from the bottom. This allows the blood to be pumped out of
the ventricles and into the aorta and pulmonary trunk. The total time elapsed from the
initiation of the impulse in the SA node until depolarization of the ventricles is approximately
225 ms.

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