Tangential light source

image Skin-marking pencil

image Stethoscope with bell and diaphragm

image Centimeter ruler


Inspect precordium
Have patient supine, and keep light source tangential.
imageApical 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

image 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. 114, methodically move from apex to left sternal border, base, right sternal border, epigastrium, axillae.

Locate sensation in terms of its intercostal space and relationship to midsternal, midclavicular, axillary lines.

EXPECTED:Gentle, brief impulse, palpable within radius of 1 cm or less, although often not felt.

UNEXPECTED:Heave or lift, loss of thrust, displacement to right or left; thrill.
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. Approach each of the five precordial areas shown in figure on p. 115 systematically, 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.  

image Rate and rhythm
Assess overall rate and rhythm.

EXPECTED:Rate 60 to 90 beats per minute, regular rhythm.

UNEXPECTED:Bradycardia, tachycardia, dysrhythmia.

image 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. 116.

UNEXPECTED:Extra sounds or murmurs.

image 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. 116.
imageSplitting EXPECTED:S2 splitting—greatest at peak of inspiration—varying from easily heard to nondetectable.

image 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.

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Mar 25, 2017 | Posted by in PHYSIOLOGY | Comments Off on Heart

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