Preparations & Draping

• Wash hands
• Patient should be laying flat, arms by the sides

For this exam, I need to expose your chest, so I need to lower your gown down to your waist. Is that OK? Can you slide both of your arm out of your gown for me?

<aside> 💡 Consider sliding out only the left arm for female patients to have some more privacy. Ask the patient if they are comfortable having their breasts exposed. Alternatively, use the Window Technique:

• Slide a drape over the patient to cover from the waist down
• Ask the patient to pull their gown up to their chest
• Perform the general inspection, then ask the patient to lower gown to below the nipple
• Perform palpation and auscultations of the upper chest from underneath the gown

When approaching the chest in female patients, it may be preferred to ask the patient to move the breast in order to access palpation/auscultation areas.

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“Left Arm Out” Method

“Window” Technique

Inspection

• General

  • Head to toe (level of consciousness, obvious breathing difficulties, general descriptions)
  • Scarring (surgical, pacemaker, defibrillator implantation)
  • Chest wall abnormalities (pectus excavatum, pectus carinatum)

• Apex Beat

  • Note any pulsation in the 5th (sometimes 4th) intercostal space in the mid-clavicular line

    <aside> 💡 Basically a bit right of the left nipple.

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• Pulsations

  • Attempt to identify pulsations corresponding to:
    • Ascending aorta (RSB @sternal angle)
    • Aortic arch (heads of clavicles)
    • Pulmonary artery (LSB @sternal angle)
    • Right ventricle (entire length of the LSB)
    • Left ventricle (same location as the apical beat)

Pulsation and palpation locations. A Ascending Aorta; P Pulmonary Artery; RV Right Ventricle; LV Left Ventricle.

I don’t see any scarring or discoloration. I don’t see any abnormalities including pectus excavatum and carinatum. I cannot see any visible pulsations.

Palpation

• Apical Beat
  • Palpate the location of apex beat pulsation (5th intercostal, mid-clavicular line)
  • Palpate the apex beat and the radial pulse simultaneously for the verbal description
  • Verbal Description (LADS) (click on arrow to expand)

<aside> 💡 If cannot feel the apical beat, place patient into left lateral decubitus position (flip them on the left side); see figure on the right.

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