CARDIAC EXAMINATION

Surface Projections of
the Heart

 For most of the cardiac examination,

the patient should be supine with the
upper body raised by elevating the
head of the bed or table to about 30.
Two other positions are also needed:
(1) turning to the left side, and (2)
leaning forward.
The examiner should stand at the
patients right side.

INSPECTION AND
PALPATION

Detection of
cardiac activity
through the chest
wall can be
appreciated by
inspection or
palpation or both.
Different parts of
the hand may be
optimal to detect
precordial events

The palm of your right hand is placed

across the patient's left chest so that it
covers the area over the heart. The heel
should rest along the sternal border
with the extended fingers lying below
the left nipple. Focus on several things:
Palpation of the Precordium to
Determine the Location of the PMI

The Apical Impulse or Point of Maximal

Impulse (PMI)
Left Ventricular Area

The Left Sternal Border in the 3rd, 4th, and

5th Interspaces
Right Ventricular Area.

The diastolic movements of

right-sided third and fourth
heart sounds may be felt
occasionally.
Feel for them in the 4th and
5th left interspaces.
In patients with an increased
anteroposterior (AP) diameter,
palpation of the right ventricle
in the epigastric or subxiphoid
area is also useful.
With your hand flattened,
press your index finger just
under the rib cage and up
toward the left shoulder and

AUSCULTATION

Stetoskope

diaphragm is better for

picking up the relatively
highpitched sounds of S1 and
S2, the murmurs of aortic and
mitral regurgitation, and
pericardial friction rubs.
Listen throughout the
precordium with the
diaphragm, pressing it firmly
against the chest.
The bell. The bell is more
sensitive to the low-pitched
sounds of S3 and S4 and the
murmur of mitral stenosis.
Apply the bell lightly, with just
enough pressure to produce
an air seal with its full rim.
Use the bell at the apex, then
move medially along the lower
sternal border. Resting the
heel of your hand on the chest
like a fulcrum may help you to
maintain light pressure.

Auscultation of the Heart

By the diaphragm of stethescope,
place it firmly over the 2nd right
intercostal space, the region of
the aortic valve.
Then move it to the other side of
the sternum and listen in the 2nd
left intercostal space, the location
of the pulmonic valve.
Move down along the sternum
and listen over the left 4th
intercostal space, the region of
the tricuspid valve.
And finally, position the
diaphragm over the 4th
intercostal space, left
midclavicular line to examine the
mitral area.

Listening for Extra Heart Sounds

Pressing the bell firmly on the chest
makes it function more like the
diaphragm by stretching the underlying
skin. Low-pitched sounds such as S3
and S4 may disappear with this
techniquean observation that may
help to identify them. In contrast, highpitched sounds such as a midsystolic
click, an ejection sound, or an opening
snap, will persist or get louder.
Listen to the entire precordium with the
patient supine. For new patients and
patients needing a complete cardiac
examination, use two other important
positions to listen for mitral stenosis
and aortic regurgitation.
Ask the patient to roll partly onto the
left side into the left lateral decubitus
position, bringing the left ventricle
close to the chest wall. Place the bell of
your stethoscope lightly on the apical
impulse

Don't get frustrated!

Auscultation is a difficult skill to "master" and we are all continually refining our techniques.
Take your time.
Make sure the room is quiet.
Be patient.
Ask for help frequently.