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Cardiac Exam I: Inspection and Palpation

Overview

Source: Suneel Dhand, MD, Attending Physician, Internal Medicine, Beth Israel Deaconess Medical Center

The cardiac assessment is one of the core examinations performed by almost every physician whenever encountering a patient. Disorders of the cardiac system are among the most common reasons for hospital admission, with conditions ranging from myocardial infarction to congestive heart failure. Learning a complete and thorough cardiac examination is therefore crucial for any practicing physician.

If there is pathology in the heart or circulatory system, the consequences can also be manifested in other bodily areas, including the lungs, abdomen, and legs. Many physicians instinctively reach straight for their stethoscopes when performing cardiac exams. However, a large amount of information is gained before auscultation by going through the correct sequence of examination, starting with inspection and palpation.

Procedure

1. Introduction

As always, before examining any patient, wash hands thoroughly with soap and water or clean them with antibacterial wash.
Enter the examination room and introduce yourself to the patient, explaining that you are going to perform a cardiac examination.

2. Positioning

Have the patient undress down to the waist (females keeping on their underwear).
Position the patient on the examination table at a 30- to 45-degree angle, and approach the patient from the right side.
Have a general look at the patient first. Note whether the patient is comfortable or in any distress.

3. Peripheral examination

Ask the patient to hold his/her hands up and assess for the following:
1. Capillary refill: Press on the patient's thumbnail with your first finger while holding the other side of the patient's finger with your thumb. The skin under the nail will blanch (turn a white color). Measure the amount of time it takes to turn back to red. This should be less than 2 sec, which indicates good peripheral circulation.
2. Clubbing, which is defined as a decrease in angle between the nail and nail bed. Clubbing can be a sign of right-to-left shunt disease or bacterial endocarditis (infection of the heart valves): Ask the patient to put both thumbnails side-by-side. Note if a diamond-shape is formed on the inside. If clubbing is present, this doesn't happen.
3. Signs of bacterial endocarditis: splinter hemorrhages (tiny red hemorrhages under the nails), Osler's nodes (painful red papules often found on the ends of the fingers), Janeway lesions (painless red macules often found on the palms).
Palpate the radial pulse with the index and middle finger, and assess for the rate per minute, rhythm regularity, volume, and character. Low volume or faint pulses are a sign of a low flow state such as sepsis. An abnormally strong "bounding" pulse can be found in conditions such as anemia and congestive heart failure.
Examine the skin on the arms for xanthoma deposits, which may be observed near the elbows and can be a sign of hyperlipidemia.
Inspect the patient's head for any signs of cardiac disease:
1. de Musset's sign: a "bobbing" head movement associated with aortic regurgitation.
2. Malar flush: a flushing or red facial appearance indicative of mitral stenosis.
3. Inspect the cornea for corneal arcus, a gray-white discoloration around the cornea that is a sign of hyperlipidemia.
4. Inspect the skin around the eyes for yellow cholesterol deposits known as xanthelasma.
5. Inspect the fundus for retinopathy (which often occurs with cardiovascular disease and diabetes) and Roth's spots (pale-centered retinal hemorrhages that occur with bacterial endocarditis).
6. Ask the patient to open mouth and stick out tongue. The color of the tongue should be pink/red. If it is a bluish discoloration, this is a sign of central cyanosis.
Palpate the carotid pulse gently with your first two fingers, and assess the volume and character of the pulse. A slow rising pulse is a sign of aortic stenosis.
The jugular venous pressure (JVP) is nature's manometer of right atrial pressure and is elevated in congestive heart failure.
1. To measure the JVP, ask the patient to turn the head to the left while the patient is positioned at 45 degrees.
2. Observe for a double pulsation from the right internal jugular vein between the two heads of sternocleidomastoid (the sternal head and the clavicular head). The carotid pulse that sometimes can be seen in thin patients has a single pulsation and is palpable, while the jugular vein pulsation is not.
3. Locate the angle of Louis (manubriosternal joint), which is positioned about 5 cm above the center of the right atrium.
4. 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.
5. Using a vertically positioned ruler measure the distance from the angle of Louis to the card and calculate the JVP by adding 5 cm (the distance from the angle of Louis to the right atrium) to that number.
6. Another way to visualize the internal jugular vein is to press gently in the right upper quadrant of the abdomen, just below the costal margin. This maneuver induces so-called hepatojugular reflux (blood shift from abdominal vessels into the right atrium). Normally, a transient increase in JVP can be observed before a decrease. Sustained increase in JVP is seen in congestive heart failure and other conditions, such as tricuspid regurgitation and constrictive pericarditis.

4. Chest inspection

Inspect the patient's chest anteriorly and posteriorly for any visible scars. Look for any evidence of a median sternotomy scar (a sign of coronary artery bypass surgery or aortic valve surgery). A more lateral scar below the left nipple would be indicative of prior mitral valve surgery.

5. Palpation

The apex beat, also known as the point of maximal impulse (PMI), corresponds to the lower left heart border. It is the most inferior and lateral position that the cardiac impulse can be felt.
1. Locate the PMI in the fifth intercostal space in the mid-clavicular line by counting down from the second intercostal space adjacent to the angle of Louis.
2. Palpate with your first two fingers.
3. If this cannot be palpated, ask the patient to lie on his/her left side. The apex beat will be displaced laterally if the heart is enlarged (cardiomegaly).
Next, palpate for heaves and thrills (a thrill is a palpable murmur).
1. Place the palm of your hand in each of the four heart zones in the precordium and then on the upper left and right chest wall. A thrill feels like a vibration or buzzing underneath your hand.
2. Place your hand at the left sternal edge. A parasternal heave is a sign of right ventricular enlargement and feels like a "lifting feeling" under your hand.

6. Percussion of heart

Unlike many other examinations, percussion is rarely employed for the cardiac system; however, a few generations ago, physicians would use percussion of the borders of the heart to assess for cardiomegaly.

7. Other inspection and palpation

Palpate for an abdominal aneurysm in the midline of the abdomen using both hands placed parallel with each other.
Look at the legs and assess for any signs of edema.
Feel the peripheral pulses at the femoral, popliteal, anterior tibial, and dorsalis pedis locations.

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!

Application and Summary

A significant amount of clinical information is to be gained with a thorough comprehensive inspection and palpation of the cardiac system. The examiner should be able to tell whether a patient has a number of likely conditions, including atrial fibrillation, valvular heart disease, cardiomegaly, hyperlipidemia, and bacterial endocarditis. Unfortunately, during everyday clinical practice, these steps are often abbreviated or skipped. By learning the full examination technique, medical professionals gain a solid foundation on which to build their clinical skills, as they see more cardiac pathology. Going through a stepwise fashion of the cardiovascular system can lead physicians to diagnoses even before placing their stethoscopes on patients.