The Cardiac Exam: Percussion

The Cardiac Exam: Palpation

Introduction

Palpation, using touch to elucidate physical findings, plays an important role in the thorough cardiac exam.  Palpation,although its role in the cardiac exam is much less then in other partsof the physical exam such as the abdominal or pulmonary exam.

Because palpation is best explained using pictures and video, two ReadVideo clips of palpation are included.  The first video demonstrates palpation with the patient in the supine position.  The second video demonstrates palpation with the patient in the left lateral decubitus position.  As explained in the second video, for a complete cardiac exam, palpation should be performed in both positions.

PalpationVideo #1 (Real Video) (~1 minute, ~3MB) - James Carter, MD, performing palpation on a normal volunteer in the supine position.
If you do not already have it, you will need to download a free basic RealVideo player from http://www.real.com/realplayer.html to view this video.

PalpationVideo #2 (Real Video) (~ 25 seconds, ~1MB) - James Carter, MD, performing palpation on a normal volunteer in the left lateral decubitus position.
If you do not already have it, you will need to download a free basic RealVideo player from http://www.real.com/realplayer.html to view this video.

Each component of palpation is described in more detail below.
 

Point of Maximal Impact (PMI)

The point of maximal impact (PMI) is the locationon the anterior chest wall where the apex of the heart is felt most strongly.  It can be felt in 70% of individuals in the sitting/standing position orin the left lateral decubitus position.  Palpate for the PMI as follows:
  1. Place the patient's chest so that the heart is thrustanteriorly either in the upright position (either sitting or standing) or left lateral decubitus position (NOT in the supine position).
  2. Place your fingertips in the fifth intercostal space and the left midclavicular line (PMI is normally within 10 cm ofthe sternum on the left side).
  3. Note the location of the PMI.
  4. Note the size of the PMI (PMI is normally 2-3 cmin diameter).
A large, laterally displaced, or diffuse PMI generally indicates some form of cardiomegaly.

Localized Motion

Palpate for localized motion as follows:
  1. Place the patient in the supine position.
  2. Place your fingertips in each of the four precordial regions (aortic, pulmonary, tricuspid, and mitral).
  3. Note any impulses felt (e.g. a systolic impulse atthe second left intercostal space could indicate pulmonary hypertension).

Generalized Motion

Palpate for generalized motion as follows:
  1. Place the patient in the supine position.
  2. Place the proximal part of your hand (not fingers) in each of the four precordial regions.
  3. Note any heaves, lifts, or rocks (synonymous wordsindicating large cardiac pulsations felt on palpation).

Thrills

Thrills are vibratory sensations caused by the heart and felt on the body surface.  Thrills are always associated withmurmurs.  Palpate for thrills as follows:
  1. Place the patient in the supine position.
  2. Use the proximal part of your hand (not fingers)and press gently over the anterior chest wall over the heart.
  3. Note any thrills appreciated.
(18 December 2008)
david.kaelber@case.edu --Copyright1999-2009 --Unauthorized use prohibited