Precardium Examination Video [Comprehensive_For Under & Post Graduates]

[0:02]Assalamualaikum. Dear all, we are going to examine the precardium in this middle-aged gentleman. And I'll be telling you all the protocols which we are supposed to follow whenever we are going to examine precardium. We will be going in a sequential way.

[0:20]And I'll be describing few things in between for better understanding as well.

[0:27]So before examination, you are supposed to sanitize your hands and after sanitization, we'll start the examination. And as a general rule for all the examinations,

[0:39]We need to follow the four standard protocols right at the start of examination and then two at the end of examination and these four points are approach from the right side. Then introduction, telling your name to the patient and asking about his name.

[0:57]Then proper consent and exposure. And only onwards after the completion of examination, we'll be saying thanks to the patient and we'll be recovering the exposed parts.

[1:10]So always remember these four basic principles after sanitizing, approaching from the right side, introduction, consent and proper exposure.

[1:19]So what is the proper exposure for precardium for precardium, patients shirt should be taken off and proper exposure is at least up to the umbilicus. Patient should be at 45 degree. So this is how we are going to start with the things.

[1:34]The first thing which we are going to see, which we are going to do is inspection. As I'll be proceeding with the examination,

[1:40]One thing is inspection, second is palpation, percussion is obsolete, no more done, and uh then finally, we'll do the auscultation.

[1:52]It's always better that if you are examining a certain patient and you are having this thing in your memory that how many steps you are going to perform in a certain method then you can memorize things the better way.

[2:06]So, in inspection, we will be checking for four things. In palpation, we'll be checking for five things and in auscultation, we'll be doing, we'll be checking for four things.

[2:18]What are the four things on inspection? On inspection, we'll be assessing for the shape of the precardium, that's very important.

[2:29]Because we are examining the precardium. Then shape of the chest. The shape of the chest has got an impact on the shape of the precardium and apex can be shifted in certain odd shapes of chest like in kyphoscoliosis that may be shifted on one direction.

[2:43]In scoliosis or in kyphosis or in other settings where a chest is deformed, the apex can be shifted, so we need to focus on those things as well.

[2:51]So shape of precardium, shape of chest, then visible pulsations is one of the most important thing as far as the inspection is concerned and then finally we'll be looking for scar marks.

[3:04]How to examine? For proper examination we need to be at two places. So I'll be besides the bed of the patient.

[3:11]And here not only I'll be watching that way, I'll be watching very closely in that whole area of precardium, but I'll be watching at the level of the precardium as well.

[3:26]Because sometimes the pulsations and the bulge can be better seen if you are at the level of that precardium. Then we are supposed to be at the foot end as well. Why we are supposed to be at the foot end?

[3:39]At the foot end we can examine the chest the better way. We can assess the deformity, we can assess some depressed side of chest. So it's always must to be once at least on the foot end as well.

[3:55]After checking for these two things, then we are supposed to look for visible pulsations closely and where are the visible pulsations?

[4:03]One in the apical area, then you would be looking for pulsations at uh tricuspid area, at pulmonary area.

[4:14]Then you would be watching for pulsations in the supra-sternal notch as well as in the epigastric area. In supra-sternal notch there may be unfolded aortic arch, there may be some aneurysm.

[4:24]Here you can find some aortic aneurysm abdominal aortic aneurysm. So we are supposed to look for pulsations at these particular areas.

[4:35]In addition to the uh pulses examination, examination for uh these appreciable pulsations at different sides.

[4:47]The next thing is then looking for scar marks. Always remember, now as far as the scar marks are concerned in exams, you may find a patient who is having a significant hairy chest.

[4:57]And when somebody is having hairy chest, you might not be able to pick a scar mark of a certain procedure which has been done like if some valvular surgery has been done, the chest is quite hairy.

[5:07]Many a time it's just below the nipple a scar mark is there of mitralotomy procedure or sometime replacement. So you need to look very closely for the scar marks.

[5:16]And you need to have a source, light source with you. You will throw that light, you will watch very closely and then you can appreciate.

[5:26]And you need to sometime move the hair sideways. Same way, uh a scar mark of midsternotomy scar mark for cabbage, that is very important. It is in the center and you need to watch it closely as well.

[5:39]So after completion of these four things, then you move to the palpation part.

[5:46]Now in winter, a patient, I mean your hands might be very cold, so it's always appropriate and better to rub your hands first to make them little warm and then start examining.

[5:57]And when you are going to examine, although you have taken consent right at the start of examination, do ask the patient again, Aapko kahin chati mein kisi jagah pe koi dard toh nahi hai?

[6:07]Kisi jagah pe koi dard ho toh mujhe bata denge main wahin pe ruk jaunga, theek hai ji. Sahi aur main mayna karne laga hoon aapka. Aapko Inshallah koi takleef nahi hogi.

[6:17]Phir bhi kahin mehsoos ho bata denge main wahin pe ruk jaunga. So you are supposed to tell to patient clearly that you do you have tenderness anywhere over your precardium.

[6:27]And if somebody is having that tenderness, you should let the patient know that I'll be examining carefully. And do always do let them know that whenever you would be asking me to stop, I'll stop then and there.

[6:38]So how to start with the things? Palpation include five things. I'll first be checking for apex beat, its site and character.

[6:48]Then I'll be palpating the heart sounds. Then I'll be checking for palpable thrill.

[6:54]Then I'll be examining for left parasternal heave and epigastric heave and finally, we can palpate the pericardial rub as well. Where to place your hand, that's very important.

[7:05]You are supposed to place your hand by first looking at this second space and third and fourth. This is how you are supposed to place your hand.

[7:16]That, that is the sternal border. I'm placing my hand in fourth, fifth, sixth and seventh intercostal space that way.

[7:27]And I'm trying to palpate the apex of this gentleman. And if I am not able to palpate it, I should move like that.

[7:32]I should move once that way and I should come back to that way, so that I'll be covering the whole area.

[7:41]Say after covering that whole area, still I am not able to appreciate the apex beat, then what next? Then I'll be checking for the other side as well. A person might be dextrocardic.

[7:50]So I have to move to the other side as well. Still I'm not able to appreciate the apex. I'll be asking the patient to lean forward for me.

[8:00]And in leaning forward position I'll be examining the same area, I'll be placing my hand that way. Still I'm not able to palpate, then what next?

[8:10]I'll be tilting the patient to the left lateral direction and I'll be trying to look for that apex beat.

[8:18]And the order should be, order should be first looking that way, then going towards this side, then asking the patient to tilt to one side and after completion of these three things, then asking the patient to lean forward so that you won't keep moving patient again and again.

[8:36]So say I am now able to palpate the apex at a certain place.

[8:44]And that's almost here. So now I am able to palpate that apex. What is the next step? After placing my finger here, so that examiner may watch it carefully where I have found the apex beat, then I'll be looking for that second rib.

[8:58]Second space, third space, fourth space and fifth.

[9:03]Now it is in the fifth space. The next thing is then marking for mid clavicular line.

[9:08]The mid clavicular line is the area between the acromion and suprasternal notch, this is the point. I'll just be drying an arbitrary line.

[9:25]An arbitrary line here. Here I have palpated that apex. Now I can say that apex beat is almost at the site of mid clavicular line in the fifth intercostal space. And then I need to comment on the character.

[9:42]There can be heaving character, there can be tapping character, in heaving that may be ill sustained or sustained and you guys can read these things from your books obviously.

[9:52]Then what next? Then I have to palpate for the heart sounds.

[9:58]I'll be placing my hand in a kind of a Z-like manner. First I'll be placing my hand like that.

[10:07]Then step next, I'll be placing that way. And then step next, I'll be placing that way. So what kind of heart sounds I am preparing here? Obviously the added heart sound here is S3 and S4.

[10:19]Here I am looking for palpable P2. So this is what, this is why you try to palpate this is where you try to palpate for this heart sounds.

[10:30]And many a time if you will not appreciate what kind of heart sound it is, although I'll not be continually placing my thumb on the carotid as I'll be examining ahead.

[10:40]But you just need to keep it in your memory that you are supposed to place your thumb. How it's gonna help you?

[10:50]Whenever you are palpating for thrill, whenever you are auscultating for murmurs, this can help you that if you can you are palpating a certain murmur.

[11:03]And exactly at the same time you are able to appreciate the pulse, it would be suggesting that it is systolic in character and same way it can help you a little bit, it can guide you related to the heart sound as well.

[11:15]So you are supposed to place your thumb over the carotids for the rest of examination. So after completion of that heart sounds and this maneuver,

[11:25]Now I am assessing for palpable thrill. For palpable thrill, my hands are supposed to be placed at the same place.

[11:34]So during that palpation of heart sounds you can do both things at the same time. Usually the systolic thrills are palpable. Diastolic thrills are rarely palpable.

[11:45]And when palpable thrill is there, it suggests that the intensity of the murmur is grade four and above.

[11:51]So here you can find and appreciate systolic thrill, usually secondary to mitral regurgitation murmur.

[12:00]Sometimes across the sternum you can palpate the thrill and then it is suggestive of ventricular septal defect. So these different sort of thrills you can appreciate and palpate.

[12:09]Then you look for, then you look for this para-sternal heave. So that's the way. You are supposed to be at the level of the precardium and you would be looking for that para-sternal heave.

[12:20]And then you look for that epigastric heave in that way, so your hand will keep moving like that. If there is right ventricular hypertrophy, so usually the right ventricular hypertrophy leads to epigastric heave first and then you can appreciate lately that parasternal heave as well.

[12:38]And finally, you can palpate sometime pericardial rub as well. Palpation of the pericardial rub, fourth inter usually third to fourth intercostal space lateral to the sternal border. You place your hand like that and this part with this part.

[12:51]As you slightly press more firmly, this pericardial surface scratch with each other and you can appreciate that drop. So that's all about palpation.

[13:03]Moving next to the auscultation part. In exam, a command may be given separately for purely auscultation, sometime for that palpation and accordingly you would just be doing that part.

[13:17]But here obviously we are examining the whole precardium. In auscultation, what we are going to do, we'll be auscultating for heart sounds, as you understand well that there is first heart sound and second heart sound.

[13:28]So we'll be commenting on the intensity as well as on the split of heart sound. Heart sound as far as the first heart sound is concerned, remember one thing.

[13:37]Because this is a common mistake on part of students that they forget that they cannot comment on the intensity of first heart sound, second heart sound while they are auscultating at the apex.

[13:50]You can comment on the intensity of second heart sound only when you would be auscultating the base of the heart. So remember this rule.

[14:00]I am placing my diaphragm where I am supposed to place my diaphragm. Obviously, as I already know that here the apex beat is lying, so I'll be placing my diaphragm at exactly the same area.

[14:10]I'll be auscultating for heart sounds, then I'll be auscultating for additional heart sounds. Then I'll be auscultating for murmurs.

[14:18]And would be looking for their radiation and finally I'll be trying to auscultate for pericardial rub.

[14:24]So there are four things you are supposed to do. So by placing, I'm not placing it inside here, but remember you are supposed to place it in ears.

[14:32]So I'm just placing like that so that I can guide you appropriately. First I am going to place my diaphragm here at the apical area and as I already highlighted that place your thumb like that. Auscultate for first heart sound.

[14:50]Then what next? At tricuspid area as well. We'll be trying to auscultate it. Sometime the heart sounds which are of low intensity.

[15:00]You cannot appreciate with this diaphragm. So if somebody has got bell, I do not have bell here. But if somebody has got bell, then he should use that bell as well.

[15:12]For the heart sounds which are sometime low intensity that can be very helpful just like a diastolic murmur you auscultate in the setting of mitral stenosis.

[15:22]So we are using bell here. We are using diaphragm here. Auscultating then here as well.

[15:30]And then what next? After completion of that auscultation, after completion of his auscultation at the apex, I am moving to this area. This is the aortic one area. This is aortic two area. It is in the third intercostal space lateral to the sternal border.

[15:44]I am auscultating now at aortic two area. Then this is the pulmonary area and this is the aortic one area.

[15:51]The first I am completing the auscultation for heart sounds or additional heart sounds at all these areas. My next step gonna be auscultation for the murmurs and that's very very important.

[16:04]In exam, if you will be given a case, more than 90% of the time, the findings are there. Patient would usually be having some murmur. So there is a protocol that how you auscultate for these murmurs.

[16:17]So I'm starting here once again and I'm auscultating for murmurs at the mitral area. Remember, it's not a complex scenario.

[16:26]The murmurs are not many. There are essentially two diastolic and two systolic murmurs.

[16:33]At the apex, mitral area, there is one murmur known as mitral uh due to mitral stenosis or sometime even due to a tumor plop like sound in the setting of atrial mixoma can be seen.

[16:47]It's sort of a diastolic murmur which you auscultate here.

[16:51]Or you may appreciate systolic murmur that is a murmur of mitral regurgitation. So I'll be auscultating here.

[17:00]And will be trying to appreciate for this murmurs. If I am not able to appreciate any murmur, should I stop there? No.

[17:07]I would always be asking the patient to move towards that side laterally. Thoda sa aap is taraf ko side lenge aise. Bas itni kaafi hai. Theek hai?

[17:17]Now what I am doing here, I am auscultating for purely for mitral stenosis murmur because this low pitch murmur can sometime solely be auscultated at left lateral position.

[17:32]That you can appreciate better in that position. I'll be again asking the patient. Seedhe ho jaiye. Theek hai? Seedhe ho jaiye. Again I'll be asking the patient to move towards same uh state position. He should preferably be at 45 degree.

[17:42]Then I'll be moving to the tricuspid area. Same way I'll be auscultating for murmur of tricuspid regurgitation and tricuspid stenosis here. Obviously a diastolic murmur or and additionally a systolic murmur.

[17:57]Now I am going to do few things here. Whenever you are auscultating for this murmurs, you are supposed to look for radiations as well.

[18:04]But for this particular matter, one thing should always be in your mind. We have seen candidates looking for radiation when there is no murmur.

[18:15]So please do not get into that practice. Only if you are able to appreciate anything that sounds like a murmur, you are supposed to look for its radiation.

[18:25]If murmur is not there, then there is no fun to look for radiation. However, you are supposed to ask the patient to move left laterally. That is because the low intensity murmur of mitral stenosis can be better appreciated in the left lateral position.

[18:41]But not for radiations. Radiation will only check if we are able to appreciate anything that sounds like a murmur. We are not very sure whether this is diastolic or systolic.

[18:49]As we'll be looking for radiations, that will help us and that will guide us that what kind of murmur it is. So where are the radiations?

[18:57]From that area, my thumb is supposedly here at the carotids. That is helping me to understand that it is systolic murmur if it is coming with the pulses.

[19:07]And if alternating with the pulse it is diastolic. So I am moving towards that direction. So murmur of mitral regurgitation.

[19:15]If there is anterior mitral valve reflect problem, the radiation will be towards that axilla. If there is posterior mitral valve reflect problem, the radiation is towards the base of the heart.

[19:28]So I have to check for radiation in that direction as well. And then I have to check radiation across the sternum as well. Now this is for the VSD.

[19:33]So these are the three places where you are supposed to look for radiations. Then what next? Then I'll be auscultating this area tricuspid and then I'll be going down. I'll be looking for radiation of tricuspid regurgitation towards that area.

[19:49]Additionally, what kind of maneuvers I'm going to do here? I would be asking the patient. I would be asking the patient to breathe in. Breathe in deeply.

[20:00]And then I'll be asking the patient to breathe out deeply. As he'll be exhaling air, and my diaphragm is placed here, the murmurs of left side of heart means the mitral area or and the aortic area, they are supposed to increase somewhat in intensity.

[20:22]So sometime a murmur is very uh low in intensity.

[20:27]As I'll be asking the patient to breathe, exhale out and while meanwhile auscultating, I can appreciate those murmurs the better way.

[20:36]But remember again the golden rule, do not place your diaphragm on tricuspid area while asking the patient to breathe out.

[20:45]While asking the patient to breathe out, you are always supposed to place your diaphragm on mitral area or aortic area.

[20:53]And while asking the patient to breathe in, you are always supposed to ask the patient to place your diaphragm on the tricuspid and pulmonary area.

[21:03]Breathing in tricuspid pulmonary area, breathing out aortic and mitral area. So they increase in intensity. So that way, I have checked for these radiation three radiations. Tricuspid downward.

[21:16]Now I am going towards the base of the heart. The examination of base of the heart is always better in sitting position. Just for purpose of ease, I am just auscultating at the 45 degree that you can do.

[21:33]But when you would be asking the patient to lean forward, sometime the murmurs at the base, which you can cannot appreciate at that 45 degree, can be appreciated simply with this change of positioning.

[21:45]You can better appreciate those murmurs. And again, while auscultating these murmurs, thumb would be placed at the carotids. I am auscultating the aortic area.

[21:57]So where I would be checking for radiation? If I am able to hear something that sounds like a murmur, I would be checking for radiation downwards. This is for aortic regurgitation.

[22:06]Then what next? I'd be checking for radiation towards the neck. That is for murmur of aortic stenosis. And then if there is here, there is pulmonary stenosis, then I would be checking for radiation towards that point as well.

[22:24]Now many a time you are not knowing whether this is pulmonary stenosis or aortic stenosis, then these radiations help. Radiation jet is towards neck, aortic stenosis.

[22:31]Jet is towards this point, then this is pulmonary stenosis. In sitting position I would be asking the patient that way, placing diaphragm that way, I would be asking the patient to breathe in deeply.

[22:48]And I'll be placing my diaphragm on the pulmonary area. So that way, sound can accentuate and you can hear it well. After completion of these, this examination of murmurs, after checking for radiation at seven different areas, as I have highlighted you, after always assessing for that murmur of mitral stenosis in left lateral position additionally, then we move towards this remaining part and that is auscultation for the pericardial rub.

[23:25]As we palpated it, so you really will place it at the third to fourth intercostal space, left sternal border and you are supposed to press a little firmly and with that firm application, usually that sounds increase in intensity, that pericardial rub increase in intensity.

[23:46]So that way, you can auscultate that pericardial rub. So that's the complete examination. But uh just reaching to that point doesn't mean you are all over with your examination.

[23:57]Here always follow the two things, standardized protocols, say thanks to the patient.

[24:02]Bahut shukriya ji. Aapne muayane ki izazat di. And then after saying thanks always recover the exposed parts. So that's how you complete your examination. Thank you.