In medicine

Medicine

Medicine is the science and art of healing. It encompasses a variety of health care practices evolved to maintain and restore health by the prevention and treatment of illness....

, the precordial exam, also cardiac exam, is performed as part of a physical examination

Physical examination

Physical examination or clinical examination is the process by which a doctor investigates the body of a patient for signs of disease. It generally follows the taking of the medical history — an account of the symptoms as experienced by the patient...

, or when a patient presents with chest pain

Chest pain

Chest pain may be a symptom of a number of serious conditions and is generally considered a medical emergency. Even though it may be determined that the pain is non-cardiac in origin, this is often a diagnosis of exclusion made after ruling out more serious causes of the pain.-Differential...

 suggestive of a cardiovascular pathology

Pathology

Pathology is the precise study and diagnosis of disease. The word pathology is from Ancient Greek , pathos, "feeling, suffering"; and , -logia, "the study of". Pathologization, to pathologize, refers to the process of defining a condition or behavior as pathological, e.g. pathological gambling....

. In reality it's unlikely that this examination would be performed in isolation or in its entirety outside of a medical examination

Objective Structured Clinical Examination

An Objective Structured Clinical Examination is a modern type of examination often used in health sciences...

. It would typically be modified depending on the indication

Indication (medicine)

In medicine, an indication is a valid reason to use a certain test, medication, procedure, or surgery. The opposite of indication is contraindication.-Drugs:...

 and integrated with other examinations especially the respiratory examination

Respiratory examination

In medicine, the respiratory examination is performed as part of a physical examination, or when a patient presents with a respiratory problem or a history that suggests a pathology of the lungs...

.

Like all medical examinations, the precordial examination follows the standard structure of inspection, palpation and auscultation.

Positioning

The patient is positioned in the supine position

Supine position

The supine position is a position of the body: lying down with the face up, as opposed to the prone position, which is face down, sometimes with the hands behind the head or neck. When used in surgical procedures, it allows access to the peritoneal, thoracic and pericardial regions; as well as the...

 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 (JVP) 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

Pulmonary edema

Pulmonary edema , or oedema , is fluid accumulation in the air spaces and parenchyma of the lungs. It leads to impaired gas exchange and may cause respiratory failure...

 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.

• Inspect the neck for increased jugular venous pressure (JVP)or abnormal waves.

• Any abnormal movements such as head bobbing.
• There are specific signs associated with cardiac illness and abnormality however, during inspection any noticed cutaneous sign should be noted.

Inspect the hands for:

• Temperature - described as warm or cool, clammy or dry
• Skin turgor for hydration
• Janeway lesion
  Janeway lesion
  Janeway lesions are non-tender, small erythematous or haemorrhagic macular or nodular lesions on the palms or soles only a few millimeters in diameter that are pathognomonic of infective endocarditis. Pathologically, the lesion is described to be a microabscess of the dermis with marked necrosis...
  
  
• Osler's node
  Osler's node
  Osler's nodes are painful, red, raised lesions found on the hands and feet. They are associated with a number of conditions, including infective endocarditis, and are caused by immune complex deposition. They are named after Sir William Osler who described them in the early 20th century...
  
  
• At the nails Splinter hemorrhage
  Splinter hemorrhage
  Splinter hemorrhages are tiny lines that run vertically under nails. Splinter hemorrhage is a nonspecific finding and can be associated with subacute bacterial endocarditis, scleroderma, trichinosis, Systemic lupus erythematosus , rheumatoid arthritis, psoriatic nails, antiphospholipid syndrome,...
  
   and Quincke's pulsation should be looked for as well as any deformity of the nail such as Beau's lines
  Beau's lines
  Beau's lines are deep grooved lines that run from side to side on the fingernail. They may look like indentations or ridges in the nail plate. This condition of the nail was named by a French physician, Joseph Honoré Simon Beau , who first described it in 1846.Beau's lines are horizontal, going...
  
  , clubbing
  Clubbing
  In medicine, nail clubbing is a deformity of the fingers and fingernails that is associated with a number of diseases, mostly of the heart and lungs...
  
   or peripheral cyanosis.

Inspect the head for:

• Cheeks for the malar flush of mitral stenosis
  Mitral stenosis
  Mitral stenosis is a valvular heart disease characterized by the narrowing of the orifice of the mitral valve of the heart.-Signs and symptoms:Symptoms of mitral stenosis include:...
  
  .
• The eyes for corneal arcus and surrounding tissue for xanthalasma.
• Conjuctiva pallor a sign of anemia.
• The mouth for hygiene.
• The mucosa for hydration and pallor or central cyanosis
  Cyanosis
  Cyanosis is the appearance of a blue or purple coloration of the skin or mucous membranes due to the tissues near the skin surface being low on oxygen. The onset of cyanosis is 2.5 g/dL of deoxyhemoglobin. The bluish color is more readily apparent in those with high hemoglobin counts than it is...
  
  .
• The ear lobes for Frank's sign
  Frank's sign
  Frank's sign or Frank sign is a diagonal ear lobe crease extending diagonally from the tragus across the lobule to the rear edge of the auricle....
  
  .

Then inspect the precordium for:

• visible pulsations
• apex beat
• masses
• scars
• lesions
• signs of trauma and previous surgery (e.g. median sternotomy
  Median sternotomy
  Median sternotomy is a type of surgical procedure in which a vertical inline incision is made along the sternum, after which the sternum itself is divided, or "cracked"...
  
  )
• permanent Pace Maker
• praecordial bulge

Palpation

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:

• Bounding
  Watson's water hammer pulse
  Watson's water hammer pulse is the medical sign which describes a pulse that is bounding and forceful, or, in other words, rapidly increasing and subsequently collapsing, as if it were the hitting of a water hammer that was causing the pulse....
  
   as in large pulse pressure found in aortic regurgitation or CO2 retention.
• And the rhythm should be assessed as regular, regularly irregular or irregularly irregular.
• Consistency of the strength to assess for Pulsus alternans
  Pulsus alternans
  Pulsus alternans is a physical finding with arterial pulse waveform showing alternating strong and weak beats. It is almost always indicative of left ventricular systolic impairment, and carries a poor prognosis.-Pathophysiology:...
  
  .
• Slow rising as found in aortic stenosis known as parvus et radtus
• Jerky as found in HOCM
• Pulses can also be auscultated for features like Traube's pistol shot femoral pulse.

Palpation of the precordium

The valve areas are palpated for abnormal pulsations (palpable heart murmur

Heart murmur

Murmurs are extra heart sounds that are produced as a result of turbulent blood flow that is sufficient to produce audible noise. Most murmurs can only be heard with the assistance of a stethoscope ....

s known as thrills) and precordial movements (known as heaves

Parasternal heave

A parasternal heave is a praecordial impulse that may be palpable in patients with cardiac or respiratory disease. A parasternal impulse may be felt when the heel of the hand is rested just to the left of the sternum with the fingers lifted slightly off the chest. Normally no impulse or a slight...

). 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 intercostal space in the mid-clavicular line. It's can be impalpable for a variety of reason 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 oedema which is caused by right ventricular 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 word Kentucky 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.
• If S4 S1 S2 S3 Also known as a gallop rhythm
  Gallop rhythm
  A gallop rhythm refers to a rhythm of the heart on auscultation. It includes three or four sounds, thus resembling the sounds of a gallop....
  
  .
• diastolic murmurs (e.g. aortic regurgitation, mitral stenosis
  Mitral stenosis
  Mitral stenosis is a valvular heart disease characterized by the narrowing of the orifice of the mitral valve of the heart.-Signs and symptoms:Symptoms of mitral stenosis include:...
  
  )
• systolic murmurs (e.g. aortic stenosis, mitral regurgitation
  Mitral regurgitation
  Mitral regurgitation , mitral insufficiency or mitral incompetence is a disorder of the heart in which the mitral valve does not close properly when the heart pumps out blood. It is the abnormal leaking of blood from the left ventricle, through the mitral valve, and into the left atrium, when...
  
  )
• pericardial rub (suggestive of pericarditis
  Pericarditis
  Pericarditis is an inflammation of the pericardium . A characteristic chest pain is often present.The causes of pericarditis are varied, including viral infections of the pericardium, idiopathic causes, uremic pericarditis, bacterial infections of the precardium Pericarditis is an inflammation of...
  
  )
• The base of the lungs should be auscultated for signs of pulmonary oedema due to a cardiac cause such as bilateral basal crepitations.

Completion of examination

To complete the exam blood pressure should be checked, an ECG recorded, funduscopy performed to assess for Roth spots or papilledema

Papilledema

Papilledema is optic disc swelling that is caused by increased intracranial pressure. The swelling is usually bilateral and can occur over a period of hours to weeks. Unilateral presentation is extremely rare....

. A full peripheral circulation exam should be performed.

External links

• Examination of Cardiac Apex Beat