Inspection of precordium
Precordial examination starts with inspection, though inspection and palpation are often combined in regular practice. Some of the features to look for are:
- Sternal deformities: Pectus excavatum is concavity of the sternum, and is the commonest congenital malformation of the chest wall which may be associated with congenital heart diseases like ventricular septal defect. Pectus carinatum is sternal prominence, also known as pigeon chest, which can occur in congenital heart disease with large left to right shunts in infancy.
- Visible pulsations: Suprasternal pulsations can be seen in aortic aneurysm and aortic regurgitation. A large dilated pulmonary artery can cause pulsation in the second left intercostal space. Left parasternal pulsations can be seen in right ventricular enlargement. Grossly enlarged left atrium with mitral regurgitation and dilated right ventricular outflow tract in Ebstein’s anomaly are other rare causes of left parasternal pulsations. Right ventricular outflow tract pulsations in Ebstein’s anomaly are often better seen than felt. It is a wavy pulsation. Similar right ventricular outflow tract pulsations may be seen in right ventricular endomyocardial fibrosis as well. Enlarged right ventricle can also cause epigastric pulsations. Pulsations above the apical impulse are noted in left ventricular aneurysm. Right parasternal pulsations may occur with grossly dilated aortic root.
- Surgical scars: Midline sternotomy scar is probably the commonest in the adult and can be after coronary artery bypass grafting or valve replacements. Anterolateral thoracotomy scars are noted after closed mitral valvotomy and some pericardial surgeries. Posterolateral thoracotomy scars are seen after surgeries on great vessels like closure of patent ductus arteriosus and repair of coarctation of aorta.
- Dilated veins: Dilated veins can occur with obstruction of superior or inferior vena cava. The direction of blood flow in the dilated veins will be downwards in superior vena cava obstruction and upwards in inferior vena cava obstruction.
- Dilated arteries: Dilated intercostal arteries and anastomosis around the scapula may be visible in coarctation of aorta. But they are often better felt than seen.
- Apex beat is better characterized by palpation, though it is often visible.