THE HEART To bring the left ventricular outflow tract closer to the chest

Review of Anatomy of the Heart wall and improve detection of aortic regurgitation, have the
patient sit up, lean forward, and exhale.
Relation of Auscultatory Findings to the Chest Wall
The locations on the chest wall where you auscultate heart
sounds and murmurs help identify the valve or chamber
where they originate.

INSPECTION
Careful inspection of the anterior chest may reveal the
location of the apical impulse or PMI, or less commonly, the
ventricular movements of a left-sided S3 or S4. Shine a
tangential light across the chest wall over the cardiac apex
to make these movements more visible.

Techniques of Examination

PALPATION
Begin with general palpation of the chest wall. In women,
keeping the right chest draped, gently lift the breast with
your left hand or ask the woman to do this to assist you.

Heaves, Lifts, Thrills; S1 and S2, S3 and S4

Using the techniques below, palpate in the 2nd right
interspace, the 2nd left interspace, along the sternal
Positioning the Patient
border, and at the apex for heaves, lifts, thrills, impulses
For the cardiac examination, stand at the patient’s right
from the RV, and the four heart sounds.
side.
The patient should be supine, with the upper body and
o To palpate heaves and lifts, use your palm
head of the bed or examining table raised to about 30°.
and/or hold your finger pads flat or obliquely
To assess the PMI and extra heart sounds such as S3 or
against the chest. Heaves and lifts are sustained
S4, ask the patient to turn to the left side, termed the left
impulses that rhythmically lift your fingers, usually
lateral decubitus position—this brings the ventricular apex
produced by an enlarged right or left ventricle or
closer to the chest wall.
atrium and occasionally by ventricular aneurysms.
L. Bickley et al., Bates’ Guide to Physical Examina:on and History Taking, 12th ed., 2017
Trans by: Maine 11.17.24
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 o For thrills, press the ball of your hand (the Aortic Area—The Right 2nd Interspace
padded area of your palm near the wrist) firmly on This interspace overlies the aortic outflow tract. Search for
the chest to check for a buzzing or vibratory pulsations and palpable heart sounds.
sensation caused by underlying turbulent flow. If § A pulsation here suggests a dilated or aneurysmal
present, auscultate the same area for murmurs. aorta. A palpable S2 can accompany systemic
o Palpate impulses from the RV in the right hypertension.
ventricular area, normally at the lower left sternal
border and in the subxiphoid area. PERCUSSION
o To palpate S1 and S2, using firm pressure, place Palpation has replaced percussion when estimating
your right hand on the chest wall. With your left cardiac size. If you cannot pal- pate the apical impulse,
index and middle fingers, palpate the carotid percussion may be your only option, but has limited
upstroke to identify S1 and S2 just before and just correlation with the cardiac borders. Starting well to the left
after the upstroke. With practice, you will succeed on the chest, percuss from resonance toward cardiac
in palpating S1 and S2. For S3 and S4, apply dullness in the 3rd, 4th, 5th, and, possibly, 6th interspaces.
lighter pressure at the cardiac apex to detect the
presence of any extra movements. AUSCULTATION
Know Your Stethoscope!
Left Ventricular Area – The Apical Impulse or Point of It is important to understand the uses of both the
Maximal Impuls diaphragm and the bell.
The apical impulse represents the brief early pulsation of § The diaphragm
the left ventricle as it moves anteriorly during contraction o Better for picking up the relatively high-
and contacts the chest wall. In most examinations the pitched sounds of S1 and S2, the
apical impulse is the PMI; however, pathologic conditions murmurs of aortic and mitral
such as right ventricular hypertrophy, a dilated pulmonary regurgitation, and pericardial friction
artery, or an aortic aneurysm may produce a pulsation that rubs. Listen throughout the precordium
is more prominent than the apex beat. with the diaphragm, pressing it firmly
against the chest.
Right Ventricular Area—The Left Sternal Border in the § The bell
3rd, 4th, and 5th Interspaces o More sensitive to the low-pitched
With the patient supine and the head elevated to 30°, ask sounds of S3 and S4 and the murmur of
the patient to exhale and briefly stop breathing, then place mitral stenosis. Apply the bell lightly,
the tips of your curved fingers in the left 3rd, 4th, and 5th with just enough pressure to produce an
interspaces to palpate for the systolic impulse of the RV. air seal with its full rim. Use the bell at
If there is a palpable impulse, assess its location, the apex, then move medially along the
amplitude, and duration. In thin individuals, you may lower sternal border. Resting the heel of
detect a brief systolic tap, especially when stroke volume your hand on the chest like a fulcrum
is increased by conditions such as anxiety. may help you to maintain light pressure.
§ A sustained left parasternal movement beginning at
S1 points to pressure overload from pulmonary
hypertension and pulmonic stenosis or the chronic
ventricular volume over- load of an atrial septal defect.
A sustained movement later in systole can be seen in
mitral regurgitation.

Pulmonic Area—The Left 2nd Interspace

This interspace overlies the pulmonary artery. As the
patient holds expiration, inspect and palpate for
pulmonary artery pulsations and transmitted heart sounds,
especially if patients are excited or examined after
exercise.
§ A prominent pulsation here often accompanies
dilatation or increased flow in the pulmonary artery. A
palpable S2 points to increased pulmonary artery
pressure from pulmonary hypertension.

L. Bickley et al., Bates’ Guide to Physical Examina:on and History Taking, 12th ed., 2017
Trans by: Maine 11.17.24
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L. Bickley et al., Bates’ Guide to Physical Examina:on and History Taking, 12th ed., 2017
Trans by: Maine 11.17.24
3