Heart

Examination

Technique	Findings
Heart
Inspect precordium
Have patient supine, and keep light source tangential. • Apical impulse	EXPECTED: Visible about midclavicular line in fifth left intercostal space. Sometimes visible only with patient sitting.
	UNEXPECTED: Visible in more than one intercostal space; exaggerated lifts or heaves.
Palpate precordium
• Apical impulse Have patient supine. With warm hands, gently feel precordium, using proximal halves of fingers held together or whole hand, as shown in figure on p. 107. Methodically move from apex to left sternal border, base, right sternal border, epigastrium, axillae.	EXPECTED: Gentle, brief impulse, palpable within radius of ≤1 cm, although often not felt.
	UNEXPECTED: Heave or lift, loss of thrust, displacement to right or left; thrill.
Locate sensation in terms of its intercostal space and relationship to midsternal, midclavicular, axillary lines.
Percuss precordium (optional)
Begin by tapping at anterior axillary line, moving medially along intercostal spaces toward sternal borders until tone changes from resonance to dullness. Mark skin with marking pen.	EXPECTED: No change in tone before right sternal border; on left, loss of resonance generally close to point of maximal impulse at fifth intercostal space. Loss of resonance may outline left border of heart at second to fifth intercostal spaces.
Auscultate heart
Make certain patient is warm and relaxed. Isolate each sound and each pause in cycle, and then inch along with stethoscope. Systematically approach each of the five precordial areas, base to apex or apex to base, using each position shown in figures at right and below. Use diaphragm of stethoscope first, with firm pressure, then bell, with light pressure.


• Rate and rhythm Assess overall rate and rhythm.	EXPECTED: Rate 60-90 beats/min, regular rhythm.
• Rate and rhythm Assess overall rate and rhythm.	UNEXPECTED: Bradycardia, tachycardia, dysrhythmia.
• S₁ Ask patient to breathe comfortably, then hold breath in expiration. Listen for S₁ (best heard toward apex) while palpating carotid pulse. Note intensity, variations, effect of respiration, splitting. Concentrate on systole, then diastole.	EXPECTED: S₁ usually heard as one sound and coincides with rise of carotid pulse. See table on p. 109.
	UNEXPECTED: Extra sounds or murmurs.
• S₂ Ask patient to breathe comfortably as you listen for S₂ (best heard in aortic and pulmonic areas) to become two components during inspiration. Ask patient to inhale and hold breath.	EXPECTED: S₂ to become two components during inspiration. S₂ to become an apparent single sound as breath is exhaled. See table on p. 109.
• Splitting	EXPECTED: S₂ splitting—greatest at peak of inspiration—varying from easily heard to nondetectable.
• S₃ and S₄ If needed, ask patient to raise a leg to increase venous return or to grip your hand vigorously and repeatedly to increase venous return.	EXPECTED: Both S₃ and S₄ quiet and difficult to hear. S₃ has rhythm of Ken-tuc-ky; S₄, Tenn-es-see.
	UNEXPECTED: Increased intensity (and ease of hearing) of either.
• Extra heart sounds	UNEXPECTED: Extra heart sounds—snaps, clicks, friction rubs, murmurs. See table on below.
Assess characteristics of murmurs
Timing and duration, pitch, intensity, pattern, quality, location, radiation, respiratory phase variations.

Heart Sounds According to Auscultatory Area

	Aortic	Pulmonic	Second Pulmonic	Mitral	Tricuspid
Pitch	S₁ < S₂	S₁ < S₂	S₁ < S₂	S₁ > S₂	S₁ = S₂
Loudness	S₁ < S₂	S₁ < S₂	S₁ < S₂^∗	S₁ > S₂^†	S₁ > S₂
Duration	S₁ < S₂	S₁ > S₂	S₁ < S₂	S₁ < S₂	S₁ = S₂
S₂ split	>Inhale	>Inhale	>Inhale	>Inhale^‡	>Inhale
S₂ split	<Exhale	<Exhale	<Exhale	<Exhale	<Exhale
A₂	Loudest	Loud	Decreased
P₂	Decreased	Louder	Loudest