CARDIAC EXAMINATION ; INSPECTION,

PALPATION & PERCUSSION…

DR. RAJESH BHAT U,

ASSOC. PROFESSOR & INTERVENTIONAL CARDIOLOGIST,
KASTURBA MEDICAL COLLEGE & HOSPITAL,
MANGALORE.
“When there is a disparity
between a clinical finding
and a lab/imaging report,
Patient is usually right”
 INSPECTION…

General Physical

Inspection

Precordial ( Cardiorespiratory)
 Precordial Inspection…
Pulsations of the anterior chest are more easily visualized when the
examiner uses tangential light to look at the surface of the chest so that
movements inscribe a maximal arc to the examiner’s eye.

Motions of the apical impulse

can often be amplified by using
a thin applicator stick .
(or tongue blade or light pencil)
to act as a fulcrum;
 Precordial Inspection…
 Size and shape of the precordium:
Look for any bulging or flattening of the precordium (Barrel chest;
Pectus Excavatum, Pectus Carinatum).

Patients with congenital heart disease may have a

prominence of the anterior chest that is frequently asymmetrical..

 Apex beat or apical impulse:

Visible/Not Visible
Location.
Retractions
 Precordial Inspection…
 Visible pulsations:
Suprasternal pulsations are visible in thin persons, high aortic arch,
aneurysm of arch of aorta, anaemia, thyrotoxicosis etc.

Carotid pulsations are prominent in anxious or agitated

persons, in hypertension and regurgitation .

 Masses :
Bulging or prominence of the precordium is seen in
mediastinal tumors, left sided pleural effusion etc.
 Precordial Inspection…
 Scars from trauma and previous surgery
Median sternotomy ( CABG; Valve replacement, ICR)
Lateral Thoracotomy ( CMV, PDA ligation)

 Permanent Pace Maker insertion.

 Engorged Veins
Venacaval Obstructions
Mondor’s Disease.
 Palpation.
Apex Cardiogram..
 Palpation.
Apex Cardiogram..
 Palpation.
Apex Cardiogram..
 Palpation….
 The palm and proximal metacarpals are preferred for initial localization of
palpalble cardiac motion.

 Pads of fingers are used for precise localization & assessment of impulse.

Palms Larger low frequency movements such as parasternal lift of

RVH
Head of Metacarpals High frequency sounds as ejection clicks, Opening snaps &
valve closing sounds.

Fingers Low frequency sounds as S3, S4 & double apical impulse.

 Assessment of Palpatory Event:

A. Topographic Location : where is the impulse situated ?

(LV- apex; RV inflow- 3rd / 4th L ICS; RV outflow- 2nd L ICS; RA- R lower sternal border; Asc. Aorta- R 2nd
ICS)

B. Timing in cardiac Cycle : Early, Mid or Late systolic or Diastolic ?

C. Duration : How much of cardiac cycle does it occupy

D. Characteristics : Vigour of movement , Amplitude & Contour.

E. Maximum Area Occupied : in cms or IC spaces.

 Different Palpatory Events:
1. Point of Maximal Impulse,

2. Apex Beat,

3. Palpable Sounds,

4. Chamber Enlargement,

5. Thrills.
 Point of Maximal Impulse :

Not necessarily be apex beat.

 May hypertrophied RV, Dilated Aorta/PA

 LV wall motion abnormality.

 Apex Beat :

Definition :
It is the lowermost & outermost point of definite cardiac impulse, which can be
appreciated.

Mechanism :
LV rotates in a counterclockwise direction along its long axis, and the juxta-
apical region lifts and makes contact with the anterior chest wall.

The IVS & anteroseptal aspect of the LV make contact with inner thoracic
cage.
Apex Beat
 Apex Beat.
Characteristics of Apex Beat :
1.Location:
a. Medial & superior to intersection of Left MCL & 5th ICS,
b. Always within 10 cm. from midsternal line.

2.Size:
a. Occupies only 1 intercostal space,
b. < 2.5 cms. ( > 3 cms. Is an accurate sign of LV enlargement.

3.Duration: felt only during 1st 1/3rd of systole ends well before last 1/3 rd . (0.08 secs)

4.Amplitude: A gentle non sustained Tap. May not be felt in Obese, Emphysema, Pleural/ Pericardial
Effusion, CAD,DCM or elderly.

5.RV impulses and Diastolic events are normally not palpable..

 Abnormal Apex Beat
Sustained Apical Impulse:
Area > 3cms, or occupies >1 ICS,

 Increased Amplitude & Prolonged duration with outward movement extending into
last 1/3rd of systole.

 Remains palpable during Carotid pulse downstroke,

Retraction of L parasternal area ie, Medial retraction.

 Conditions;
 Abnormal Apex Beat
Hyper dynamic Apical Impulse:

Area > 3cms, or occupies >1 ICS,

 Increased Amplitude but normal duration (ie,outward movement

extending into last 1/3rd of systole.

 Not palpable during Carotid pulse downstroke,

 Conditions;
Volume overload of LV (MR; AR)
 Abnormal Apex Beat
Hypokinetic Impulse

Area < 2 cms, or occupies <1 ICS,

 Decreased Amplitude of systolic motion,

 Reduced velocity and amplitude

of medial retraction.

 Conditions;
DCM; Ac MI
 Abnormal Apex Beat
Ectopic Impulse (Rocking Impulse) :

 Located superior and medial to apical impulse usually at mid precordium,

several cms away from apex.

 It can be both seen & palpated.

 Caused by Ant. Wall Dyskinesia or Aneurysm.

 Termed “Paradoxical” because it bulges during mid & late systole when
normal Ant. Systolic motion of apical impulse has ceased.
 Abnormal Apex Beat
HOCM:

 Double outward thrust of LV.

 Often exhibit a typical presystolic cardiac expansion (palpable

S4).

 Called “Double/Triple/quadraple Apical Impulse”

 Abnormal Apex Beat
Constrictive Pericarditis:

 Apex retracts in systole b’cos of restraining by rigid pericardium, more pronounced

by at apex.

 Also characterized by systolic retraction of ribs in left axilla (“Broadbent sign”)

 Precordial diastolic movement in CCP may be palpable and is termed “Diastolic

Heart Beat”.
 Palpable Sounds.
Sounds Site Condition
Prominent S1 Apex MS with mobile AML
A2 2nd Right ICS - HTN

-Aortic root dilation

with small PA ( TOF. Pul
Atresia).

- Aorta is Anterior to PA
(TGA).

P2 2nd Left ICS PAH,

Rarely Dilatation of PA’s
Aortic Ejection Sounds Apex Congenital AS,

Base Aortic Root Dilatation.

Pul. Ejection Sound 2nd left ICS. & may be felt only Congenital PS
during expiration.
 Palpable Sounds.

Sounds Site Condition

S3 Apex; Rarely palpable Accentuated Rapid Ventricular

Filling
MR; AR
S4 Apex Accentuated atrial filling,
HCM; AS; HTN
 Chamber Enlargement.
Left Parasternal Lift (RV impulse):
Methods of Palpation.
- Heel of the hand,
- 3 finger tips in Left 3rd, 4th & 5th ICS,
- index finger in Subxiphoid region.

Dressler’s Grades of PSL:

Grade 1 : faintly felt
Grade 2 : Felt, seen, but can be obliterated with Pressure,
Grade 3 : Cannot be obliterated with Pressure.
 Chamber Enlargement.

Left Parasternal Lift (RV impulse):

Causes.
Hyper dynamic ASD; TR
Sustained impulse PS; PAH
 Chamber Enlargement.
Other Chambers:
Chamber Site Cause
LA Left PS; begins & terminates after LV thrust Severe MR,
Severe MS.

RA Right lower thorax Severe TR ( may be a/c

Hepatic pulsation.

Severe TS

Bi V systolic Left PSA : LV & RV impulses are separated by Biventricular enlagement.

motion a zone of retraction.

PA’s 2nd L ICS ; better seen than felt PAH; increased PBF
Aorta SC Joint / SC fossa Aneurysm.
 Thrills.
Thrills are palpable vibrations from murmurs or bruits,
ordinarily associated with > 4/6 murmurs.

Analysis :
 Timing (systolic, Diastolic or continuous)
 Location,
 Radiation / Conduction,
 Duration.
 Thrills.
Systolic Thrills :

Base AS, PS

Apex MR, HOCM

Left PSA VSD

 Thrills.
Diastolic Thrills :

Early diastolic Left PSA AR, PR

ApexMS

Suprasternal Notch AS, PS,AR,PDA, CoA

 Don’t forget….

 Dextrocardia, the apex beat is located on the right side.

 Palpate the back to appreciate SUZZMANN’ S SIGN

 Pregnancy, ascites, abdominal tumors, the apex beat is shifted

upwards.
 Don’t forget….
 Pleural effusion and pneumothorax when the mediastinum is pushed towards
the opposite side and the apex beat is also shifted.

 Pulmonary fibrosis and collapse of the lung pulls the mediastinum towards the
same side.

 Hypertrophy and dialatation of the ieft ventricle results in downward and

outward shift of the apex beat.

 Scoliosis and Kyphosis.

 PERCUSSION
By percussion gross enlargement or shift in position of the
heart can be made out.

This is not very reliable and has been superseded by chest

X-ray or Echo- cardiography.

Usually the right, left, and lower borders of the heart are
percussed.
 PERCUSSION
Percussion of the right Border,
first percuss out the upper border of the liver.

Then percuss from right axilla to the right sternal

border in a line just above the liver dullnes.

The right border corresponds to the right sternal border from the third
to the sixth intercostal space.
 PERCUSSION

Percussion of Left border:

Percuss from the 5th left intercostal space in the

axilla to the area of apex beat.

It corresponds to a curved line drawn from the apex to

a point on the lower border of 2nd left costal cartilage
11/2 inches from the median plane.
 PERCUSSION
The lower border corresponds to a line drawn from the 6th right costal cartilage near
sternum to the apex.

The upper border corresponds to the 2nd left intercostal space.

In cardiomegaly the area of cardiac dullness is increased.

In emhysema the area of cardiac dullness is diminished.

In pericardial effusion area of cardiac dullness is increased and will not correspond to
Apex.