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Health History

1. Current Health Status

- chest pain
angina myocardial infarction post-myocardial syndrome
pericarditis dissecting aortic aneurysm pulmonary artery hypertension
pneumothorax pneumonia rib fracture
esophageal reflux esophageal spasm esophageal rupture

- shortness of breath
- syncope
- swelling of ankles or feet
- heart palpitations
- fatigue

2. Past Health History

- congenital heart disease
- rheumatic fever
- heart murmur
- high blood pressure, high cholesterol, diabetes mellitus
- confusion
- fatigue
- dental work

3. Family History

4. Personal Habits

- smoking
- alcohol
- sleep & rest
- exercise
- nutrition
- stress & coping

Techniques of Examination

The patient should be supine with upper body elevated at a 15-30E angle. The room must be quiet, warm, and have good lighting. You should stand to the right of the patient being examined. Inspection and Palpation of the Heart

    Inspection and palpation reinforce each other and are time saving when done together.

    Tangential lighting helps you detect pulsations.

    The ball of the hand (at the base of the fingers) is the most sensitive at detecting thrills.

    The finger pads are more sensitive in detecting pulsations.

Inspect and Palpate for:

    Pulsations- these are more visible when patients are thin. A thick chest wall or increased AP diameter can obscure them. Pulsations may indicate increased blood volume or pressure.

    Lift or heaves- these are forceful cardiac contractions that cause a slight to vigorous movement of sternum and ribs.

    Thrills- these are the vibrations of loud cardiac murmurs. They feel like the throat of a purring cat. Thrills occur with turbulent blood flow.

You should inspect and palpate at the following areas:

1. Aortic Area (second interspace to the right of the sternum).

    a pulsation could indicate an aortic aneurysm.
    a thrill could indicate aortic stenosis.
2. Pulmonic Area (second interspace to the left of the sternum).

    a pulsation could indicate pulmonary hypertension.
    a thrill could indicate pulmonic stenosis.

3. ERB's Point (third interspace to the left of the sternum).

    findings similar to that of aortic and pulmonic areas.
4. Tricuspid Area (Right Ventricular Area) (4-5th interspace; lower half of the sternum).

    a sustained systolic lift could indicate right ventricular enlargement.

    a systolic thrill could indicate a ventricular septal defect.

    in patients with anemia, anxiety, hyperthyroidism, fever, pregnancy, or increased cardiac output, a brief pulsation may be felt.

5. Mitral Area (Left Ventricular Area) (5th intercostal space at the midclavicular line). This is where you can find the Apical Pulse and usually can find the Point of Maximum Intensity (PMI).

    identify the PMI by location, diameter, amplitude, duration, and rate. To help identify it, have patient exhale completely and hold breath or have the patient lean forward. Normal is a light tap, 1-2 cm in diameter at the 5th interspace at the left midclavicular line. PMI could be displaced down and to the left with ventricular hypertrophy, pregnancy, and CHF.

    normally seen in less than half the population.

    increased pulsation could indicate increased cardiac output, anemia, anxiety, fever, or pregnancy.

    a thrill could indicate mitral regurgitation, or mitral stenosis.

6. Epigastric Area (below xyphoid process).

    increased aortic pulsation could indicate AAA, and aortic regurgitation or right ventricular pulsation of right ventricular enlargement.

7. Ectopic Area (2-3rd interspace at the LMCL)

    increased pulsations in this area seen in patients with MI's or coronary heart disease.

8. Sternoclavicular Area (top of sternum at junction of clavicles

    pulsation of aortic arch may be felt in a thin client.

Auscultation of the Heart

1. Aortic Area 2nd right interspace close to the sternum.
2. Pulmonic Area 2nd left interspace.
3. ERB's Point 3rd left interspace.
4. Tricuspid Area 5th left interspace close to the sternum.
5. Mitral Area (Apical) 5th left interspace medial to the MCL

1. With your stethoscope, identify the first and second heart sounds (S1 and S2).

    at the aortic and pulmonic areas (base). S2 is normally louder than S1. S2 is considered the dub of 'lub-DUB.' S2 is caused by the closure of the aortic and pulmonic valves.

    at the tricuspid and mitral area (apex) S1 is often, but not always louder than S2. S1 is considered the lub of 'LUB-dub.' S1 is caused by the closure of the mitral and tricuspid valves.

    S1 is synchronous with the onset of the apical impulse.

2. Identify the heart rate.



3. Identify the rhythm.

    if it is irregular, try to identify the pattern.

    Do early beats appear on a regular rhythm?

    Does the irregularity vary consistently with respiration?

    Is rhythm totally irregular?

4. Listen to S1 first, then S2 at the previously mentioned areas using the diaphragm and then the bell.

    note its intensity.

    are there any splitting sounds check during inspiration where S2 usually splits at pulmonic and ERB's point.

    a thick chest wall or increased AP diameter may make S2 inaudible.

    Alterations in S1

      a. S1 is accentuated in exercise, anemia, hyperthyroidism, and mitral stenosis.

      b. S1 is diminished in first degree heart block.

      c. S1 split is most audible in tricuspid area (T-lub-dub).

    Alterations in S2

      a. Normal physiological splitting of S2 is best heard at pulmonic area. It occurs on inspiration (lub-T-dub, lub-dub).

      b. Splitting of S2 can indicate pulmonic stenosis, atrial septal defect, right ventricular failure, and left bundle branch block (lub-T-dub).

5. Listen for S3 (ventricular gallop).

    a physiologic S3 is frequently heard in children and in pregnant women.

    it occurs early in diastole during rapid ventricular filling. It is heard best at the apex in the left lateral decubitus position.

    it is heard best using the bell.

    a pathologic S3 occurs in people over the age of 40. Cause is usually myocardial failure.

    sounds like lub-dub-dee (or 'Kentucky').

6. Listen for an S4 (atrial gallop).

    it occurs before S1

    it is low pitched and best heard with the bell.

    often normal in older adults.

    it is heard best at the apex in the left lateral decubitus position.

    it may be caused by coronary artery disease, hypertension, myocardiopathy, or aortic stenosis.

    sounds like dee-lub-dub (or 'Tennessee').

7. Listen for murmurs.

CHECK TIMING. Are they systolic or diastolic?

(systolic murmurs may be benign. Diastolic murmurs are never benign).

LOCATION OF MAXIMAL INTENSITY. Where is the murmur best heard?

FREQUENCY (pitch).
This varies from low-pitched, caused by slow velocity of blood flow, to high pitched, caused by a rapid velocity of blood flow.

INTENSITY. the loudness of a murmur is described on a scale of 1 to 6:

Grade Intensity/ Sounds
1 very faint, easily missed
2 quiet, barely audible
3 moderately loud but easily heard. Same intensity as S1 or S2.
4 loud but usually no thrill present
5 very loud- thrill present
6 heard with stethoscope off of chest. Thrill present.

RADIATION. some murmurs radiate in the direction of the blood stream by which they are produced. Listen over neck, back, shoulders, and left axilla.


musical blowing harsh rumbling

    aortic murmurs are heard best in full expiration with patient leaning forward.

    mitral murmurs are heard best after exercise in left side lying position.

Assessment of Extra Heart Sounds

    - ejection click

    - opening snap

    - midsystolic click

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