Cardiac examination
In medicine, the cardiac examination, also precordial exam, is performed as part of a physical examination, or when a patient presents with chest pain suggestive of a cardiovascular pathology. It would typically be modified depending on the indication and integrated with other examinations especially the respiratory examination. Like all medical examinations, the cardiac examination follows the standard structure of inspection, palpation and auscultation. Positioning. The patient is positioned in the supine position tilted up at 45 degrees if the patient can tolerate this. The head should rest on a pillow and the arms by their sides. The level  of the jugular venous pressure (JVP) should only be commented on in this position as flatter or steeper angles lead to artificially elevated or reduced level respectively. Also, left ventricular failure leads to pulmonary edema which increases and may impede breathing if the patient is laid flat. Lighting should be adjusted so that it is not obscured by the examiner who will approach from the right hand side of the patient as is medical custom. The torso and neck should be fully exposed and access should be available to the legs. Inspection. General Inspection: Inspect the hands for: Inspect the  head for: Then inspect the precordium for: Palpation. The pulses should be palpated, first the radial pulse commenting on rate and rhythm then the brachial pulse commenting on character and finally the carotid pulse again for character. The pulses may be: Palpation of the precordium. The valve areas are palpated for abnormal pulsations (palpable heart murmurs known as "thrills") and precordial movements (known as "heaves"). Heaves are best felt with the heel of the hand at the sternal border. Palpation of the apex beat. The apex beat is found approximately in the fifth left intercostal space in the mid-clavicular  line. It can be impalpable for a variety of reasons including obesity, emphysema, effusion and rarely dextrocardia. The apex beat is assessed for size, amplitude, location, impulse and duration. There are specific terms to describe the sensation such as tapping, heaving and thrusting. Often the apex beat is felt diffusely over a large area, in this case the most inferior and lateral position it can be felt in should be described as well as the location of the largest amplitude. Finally the sacrum and ankles are checked for pitting edema which is caused by right ventricular failure in isolation or  as part of congestive cardiac failure. Auscultation. One should comment on Completion of examination. To complete the exam blood pressure should be checked, an ECG recorded, funduscopy performed to assess for Roth spots or papilledema. A full peripheral circulation exam should be performed.