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Physical Examinations I

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Cardiac Exam I: Inspection and Palpation



The cardiac assessment is one of the core physical examinations performed by every physician whenever they encounter a patient. Proper functioning of the cardiac system is vital for living, and disorders associated with it are among the most common reasons for hospital admissions across the globe. Therefore, learning how to perform a complete and thorough cardiac examination is crucial for any practicing clinician.

Many physicians instinctively reach straight for their stethoscope when performing a cardiac exam. However, a lot of information can be gained before auscultation by conducting thorough inspection and palpation. This video will review these two aspects of the cardiac exam in detail.

Let's go over the sequence of inspection and palpation steps for the cardiac system evaluation along with the expected findings. Before the exam, wash your hands thoroughly. Upon entering the room, introduce yourself to the patient and briefly explain the procedure you will perform. Have the patient undress down to their waist. Instruct them to lie down on the exam table positioned at a 30-45° angle, and approach the patient from their right side.

Start by inspecting the periphery. Ask the patient to hold one hand up, press on the thumbnail and watch the nail bed blanch. Then, release the pressure and estimate the time it takes to turn back to red. This is the capillary refill time, which serves as an indicator of peripheral circulation. Following the capillary refill test, instruct the patient to put their thumbnails side by side to check for nail clubbing. Note that a diamond-shape aperture is formed, which means clubbing is absent. If no aperture is formed, then it may suggest presence of chronic hypoxia conditions such as right-to-left shunt disease or bacterial endocarditis. To examine for other signs of bacterial endocarditis, inspect for red hemorrhages under the nails, referred to as the splinter hemorrhages. Then, look for the Osler's nodes, which are painful red papules on the finger ends. Also check if you can see the Janeway lesions, which are painless red macules on the palms. Moving to the wrist, palpate the radial pulse with the index and middle finger, and evaluate the pulse rate, rhythm regularity, pulse volume, and character. Next, inspect the skin on the arms, especially near the elbows, and look for yellowish deposits known as the xanthoma deposits, which is a sign of hyperlipidemia.

After examining the periphery, inspect the patient's head for the de Musset's sign, which is represented by rhythmic head nodding in synchrony with the heartbeats. This is associated with aortic regurgitation. Check the patient's face for Malar flush, which is a red facial appearance indicative of mitral stenosis. Next, inspect the skin around the eyes for yellow cholesterol deposits known as xanthelasma. Then examine the corneas for corneal arcus-a gray-white discoloration indicative of hyperlipidemia. To finish the facial inspection, ask the patient to open their mouth and stick out their tongue. Note the color to check for cyanosis.

Proceed to the neck region. First palpate the carotid arteries, which are right next to the trachea and can be felt about 2 cm below the angle of the mandible. Gently press at this spot with your first two fingers, and assess the pulse volume and character. Subsequently, measure the jugular venous pressure or JVP. To do that, you'll need to locate the right internal jugular vein and the Angle of Louis, which is the anterior angle formed at the manubriosternal joint. The internal jugular veins run between the two heads-sternal and clavicular- of the sternocleidomastoid muscle, which form a triangle with the clavicle at the bottom edge. In order to locate this vein, ask the patient to turn their head to the left. Observe for a double pulsation, which is produced by the right internal jugular vein. Next, locate the Angle of Louis by palpation, which is approximately 5 cm above the center of the right atrium and next to the second intercostal space. After locating the angle of Louis, extend a long rectangular object, such as a paper card, horizontally from the highest point at which the internal jugular vein pulsation can be seen, and then using a ruler measure the distance in cm from the angle of Louis to the paper card. The measured distance plus 5 equals JVP, which is normally 6 to 8.

Following JVP measurement, inspect the patient's chest anteriorly and posteriorly for any visible scars indicative of prior heart surgeries. Next step is to locate the point of maximal impulse or PMI. Using the Angle of Louis as the reference point, count down to the 5th intercostal space to palpate the PMI in the mid-clavicular line. If this cannot be palpated in seated position, request the patient to lie on their left side and then palpate. Note that the apex beat will be displaced laterally in cases of cardiomegaly. Next, use your palm to palpate the four heart zones in the precordium, and the upper left and right chest wall. Note any vibrations or buzzing underneath your hand, which could indicate thrills. To complete chest palpation, place your hand at the left sternal edge. If you experience a "lifting feeling" under your hand, it indicates a parasternal heave, which is a sign of right ventricular enlargement.

Moving down from the chest, palpate the abdomen for an aneurysm in the midline using both hands placed parallel with each other. Next, inspect and palpate the legs for any signs of edema. Finally, feel the peripheral pulses at the femoral, popliteal, posterior tibial, and dorsalis pedis locations. This concludes the inspection and palpation aspect of the cardiac exam.

You've just watched JoVE's video on inspection and palpation of the cardiac system. A significant amount of clinical information can be gained if a clinician performs all these steps in a careful, precise and thorough manner. By learning the full examination technique, a medical professional gains a solid foundation for building clinical skills in order to predict cardiac pathology in advance. As always, thanks for watching!

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