In medicine, the cardiac examination, also precordial exam, is performed as part of a physical examination, or when a patient presents with chest pain suggestive of a cardiovascular pathology. It would typically be modified depending on the indication and integrated with other examinations especially the respiratory examination. Like all medical examinations, the cardiac examination follows the standard structure of inspection, palpation and auscultation.
Positioning
The patient is positioned in the supine position tilted up at 45 degrees if the patient can tolerate this. The head should rest on a pillow and the arms by their sides. The level of the jugular venous pressure should only be commented on in this position as flatter or steeper angles lead to artificially elevated or reduced level respectively. Also, left ventricular failure leads to pulmonary edema which increases and may impede breathing if the patient is laid flat. Lighting should be adjusted so that it is not obscured by the examiner who will approach from the right hand side of the patient as is medical custom. The torso and neck should be fully exposed and access should be available to the legs.
Inspection
General Inspection:
Inspect the patient status whether he or she is comfortable at rest or obviously short of breath.
The pulses should be palpated, first the radial pulse commenting on rate and rhythm then the brachial pulse commenting on character and finally the carotid pulse again for character. The pulses may be:
The valve areas are palpated for abnormal pulsations and precordial movements. Heaves are best felt with the heel of the hand at the sternal border.
Palpation of the apex beat
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. Finally the sacrum and ankles are checked for pitting edema which is caused by right ventricular failure in isolation or as part of congestive cardiac failure.
Auscultation
One should comment on
S1 and S2 - if the splitting is abnormal or louder than usual.
S3 - the emphasis and timing of the syllables in the wordKentucky 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.
