What areas are palpated during precordium examination and what are the normal and abnormal findings?

Palpation of the Precordium: Areas and Findings

The precordial examination should include systematic palpation of five key areas: the right ventricular area, left ventricular apex, left sternal border, aortic area, and pulmonary area to detect normal and abnormal cardiac findings. 1

The Five Areas of Precordial Palpation

1. Right Ventricular Area (Parasternal Area)

• Located at the left sternal border in the 4th and 5th intercostal spaces 1
• Normal finding: No palpable impulse or minimal movement 1
• Abnormal findings: Right ventricular heave or lift (suggests right ventricular hypertrophy or volume overload) 1

2. Left Ventricular Apex (Apical Area)

• Normally located in the 5th intercostal space at the midclavicular line, approximately 10 cm from the midsternal line 2, 3
• Normal finding: A discrete, localized impulse less than 3 cm in diameter that is brief in duration 2
• Abnormal findings: Displaced laterally beyond the midclavicular line (cardiomegaly), sustained impulse (pressure overload), hyperdynamic impulse (volume overload), or diameter greater than 3 cm (left ventricular enlargement) 2, 3

3. Left Sternal Border (3rd and 4th Intercostal Spaces)

• Located at the left sternal border in the 3rd and 4th intercostal spaces 1
• Normal finding: No palpable impulse 1
• Abnormal findings: Palpable systolic pulsation (suggests pulmonary hypertension or left atrial enlargement) 1

4. Aortic Area

• Located in the 2nd right intercostal space 1
• Normal finding: No palpable impulse 1
• Abnormal findings: Palpable systolic thrill (suggests aortic stenosis) 1

5. Pulmonary Area

• Located in the 2nd left intercostal space 1
• Normal finding: No palpable impulse 1
• Abnormal findings: Palpable systolic thrill (suggests pulmonary stenosis or increased pulmonary flow) 1

Technique for Proper Palpation

• Position the patient initially sitting with hands pushing tightly on hips to contract the pectoralis major muscles and enhance identification of asymmetries 1
• For detailed palpation, have the patient lie supine with the upper body elevated at a 30-45 degree angle 1
• Use the palmar surface of the fingers and hand to feel for impulses, thrills, and heaves 1
• Palpate systematically through all five areas, noting the location, size, amplitude, and duration of any impulses 1
• For apical impulse assessment, have the patient roll onto the left side (left lateral decubitus position) to bring the apex closer to the chest wall 2, 3

Normal Findings

• Apical impulse: Localized, discrete tap felt in the 5th intercostal space at the midclavicular line, less than 3 cm in diameter 2, 3
• No palpable pulsations in other precordial areas 1
• No thrills (palpable vibrations corresponding to murmurs) 1
• No heaves or lifts (sustained impulses suggesting ventricular hypertrophy) 1

Abnormal Findings

Displaced Apical Impulse

• Lateral displacement beyond the midclavicular line or more than 10 cm from midsternal line suggests cardiomegaly 2, 3
• Downward displacement to 6th intercostal space may indicate left ventricular enlargement or low diaphragm position 1

Abnormal Apical Impulse Character

• Sustained impulse: Suggests pressure overload (e.g., aortic stenosis, hypertension) 2
• Hyperdynamic impulse: Suggests volume overload (e.g., mitral regurgitation, aortic regurgitation) 1
• Diameter greater than 3 cm: Highly specific (91%) for left ventricular enlargement 2

Parasternal Heave/Lift

• Sustained impulse at left sternal border suggests right ventricular hypertrophy 1
• Common in conditions with pulmonary hypertension or right ventricular pressure/volume overload 1

Thrills

• Palpable vibrations that correspond to loud murmurs (grade IV/VI or greater) 1
• Aortic area thrill: Suggests aortic stenosis 1
• Pulmonary area thrill: Suggests pulmonary stenosis 1
• Left sternal border thrill: May indicate ventricular septal defect 1
• Apical thrill: May indicate mitral stenosis or regurgitation 1

Gallop Sounds

• S3 gallop: Palpable early diastolic impulse suggesting volume overload or heart failure 4
• S4 gallop: Palpable late diastolic impulse suggesting decreased ventricular compliance 4

Common Pitfalls in Precordial Palpation

• Incorrect identification of intercostal spaces: The sternal angle (angle of Louis) identifies the 2nd intercostal space; count down from there 5
• Failure to have the patient in proper position: Examination should be performed both sitting and supine 1
• Not using left lateral decubitus position to enhance detection of the apical impulse 2, 3
• Misinterpreting normal anatomic variants: The apical impulse may be difficult to palpate in obese patients or those with thick chest walls 3
• Sternal notch to xiphoid process length can help locate the 4th intercostal space (approximately 67% of this distance from the sternal notch) when traditional landmarks are difficult to palpate 5