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 patient’s 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.

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 try to feel right ventricular pulsations.

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.

AUSCULTATION

Stetoskope

• The diaphragm. The 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 technique—an observation that may help to identify them. In contrast, high-pitched 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.