Heart examination

Heart examination
Other names: Precordial exam
SpecialtyCardiology

A heart examination, also known as a cardiac examination,[1] is performed as part of a physical examination, or when a person presents with chest pain suggestive of a cardiovascular disease. It would typically be modified depending on the indication and integrated with other examinations especially the respiratory examination.[2]

The examination follows the structure of inspection, palpation and auscultation.[1] The heart is examined with the person sitting up and lying down.[1]

Listening to the chest has been a key part of examination of the heart for over 200 years.[3]

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 (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 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.[4]
  • Inspect the neck for increased jugular venous pressure (JVP) or abnormal waves.[5]
  • 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:

Inspect the head for:

Then inspect the precordium for:

  • visible pulsations
  • apex beat
  • masses
  • scars
  • lesions
  • signs of trauma and previous surgery (e.g. median sternotomy)
  • 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:

Palpation of the precordium

The valve areas are palpated for abnormal pulsations (palpable heart murmurs known as thrills) and precordial movements (known as heaves). 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 fifth 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 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.
  • diastolic murmurs (e.g. aortic regurgitation, mitral stenosis)
  • systolic murmurs (e.g. aortic stenosis, mitral regurgitation)
  • pericardial rub (suggestive of pericarditis)
  • 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. A full peripheral circulation exam should be performed.

History

Diorama showing René Laennec examining a patient at the Neck Wellcome L0058191

References

  1. 1 2 3 Simel, David L. (2020). "6. Approach to the patient: history and physical examination". In Goldman, Lee; Schafer, Andrew I. (eds.). Goldman-Cecil Medicine. Vol. 1 (26th ed.). Philadelphia: Elsevier. p. 26. ISBN 978-0-323-55087-1. Archived from the original on 2023-10-31. Retrieved 2023-10-30.
  2. ↑ Mills, Nicholas L.; Japp, Alan G.; Robson, Jennifer (2018). "4. The cardiovascular system". In Innes, J. Alastair; Dover, Anna R.; Fairhurst, Karen (eds.). Macleod's Clinical Examination (14th ed.). Edinburgh: Elsevier. pp. 39–75. ISBN 978-0-7020-6991-8. Archived from the original on 2023-10-31. Retrieved 2023-10-30.
  3. ↑ Montinari, Maria Rosa; Minelli, Sergio (3 June 2019). "The first 200 years of cardiac auscultation and future perspectives". Journal of Multidisciplinary Healthcare. 12: 183–189. doi:10.2147/JMDH.S193904. ISSN 1178-2390. PMC 6408918. PMID 30881010. Archived from the original on 29 April 2022. Retrieved 6 November 2022.
  4. ↑ 250 cases in clinical medicine 3rd edition. R. R. Baliga
  5. ↑ 250 cases in clinical medicine 3rd edition. R. R. Baliga
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