Cardiac- Inspection, Palpation, Auscultation

Question 1

Inspection

Question 2

Palpation

Answer 2

visible on inspection.
- The apex beat is defined as the most lateral and inferior position at which the cardiac impulse can be felt.
- A heave is a palpable impulse that noticeably lifts your hand
- A thrillis the tactile equivalent of a murmur and is a palpable vibration.

Question 3

Palpation exam sequence

Answer 3

• Explain that you wish to examine the chest and ask the patient to remove all clothing above the waist.
• Keep a female patients chest covered with a sheet as far as possible.
• Inspect the precordium with the patient sitting at a 45-degree angle with shoulders horizontal.
• Look for surgical scars, visible pulsations and chest deformity,
• Place your right hand flat over the precordium to obtain a general impression of the cardiac impulse then lay your fingers on the chest parallel to the rib spaces to locate the most inferior and lateral position at which the impulse is palpable (the apex beat);if you cannot feel it, ask the patient to roll onto their left side
• Assess the character of the apex beat and note its position by counting down the intercostal spaces from the second,which is just below the sternal angle.
• Apply the heel of your right hand firmly to the left parasternal area and feel for a right ventricular heave.
• Ask the patient to hold their breath in expiration (see Fig.4.17C).
• Palpate for thrills at the apex and on both sides of the sternum using the flat of your fingers.

Question 4

Palpation- scars and meanings

Answer 4

• A midline stemotomy scar usually indicates previous valve replacement or coronary artery bypass surgery, in which case it may be accompanied by the saphenous vein or radial artery graft harvest scars.
• A left submammary scar is usually the result of mitral valvotomy or transapical-transcatheter aortic-valve implantation.
• Infraclavicular scars are seen after pacemaker or defibrillator implantation, and the bulge of the device may be obvious in this position.

Question 5

Palpation- what is normal

Answer 5

• A normal apical impulse briefly lifts your fingers and is localised, but it may be impalpable, particularly in overweight or muscular people, or in patients with hyperinflated lungs due to obstructive airways disease

Question 6

Palpation- apex beat

Answer 6

• The apex beat is normally in the fifth left intercostal space at, or just medial to, the midclavicular line.
• It may be displaced laterally, to the anterior or mid-axillary line, or inferiority to the sixth or seventh intercostal space when the left ventricle is dilated e.g. in patients with heart failure or severe aortic regurgitation.
• When detected, a displaced apex beat is one of the most helpful clinical signs for identifying patients with LVSD
• In dextrocardia the cardiac apex is palpable on the right side

Question 7

Palpation- heave and thrills meaning

Answer 7

• A sustained and forceful but undisplaced apical impulse, known as an apical ‘heave’ is sometimes detected in patients with left ventricular hypertrophy due to hypertension or severe aortic stenosis
• whilst a diffuse and less forceful impulse is more characteristic of left ventricular dilatation.
• Pulsation over the left parasternal area (right ventricular heave) indicates right ventricular hypertrophy or dilatation, most often accompanying pulmonary hypertension.
• The ‘tapping’ apex beat in mitral stenosis represents a palpable first heart sound and is not usually displaced.
• The most common thrill is that of aortic stenosis,which isusually palpable over the upper right sternal border.
• The thrill caused by a ventricular septal defect is best felt at the left andright sternal edges.
• Diastolic thrills are very rare.