1. Current Health Status- chest pain
- shortness of breath
2. Past Health History- congenital heart disease
- rheumatic fever
- heart murmur
- high blood pressure, high cholesterol, diabetes mellitus
- dental work
3. Family History
4. Personal Habits- smoking
- sleep & rest
- stress & coping
Techniques of ExaminationThe 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
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:
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.
1. Aortic Area (second interspace to the right of the sternum).
a thrill could indicate aortic stenosis.
a thrill could indicate pulmonic stenosis.
3. ERB's Point (third interspace to the left of the sternum).
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.
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.
8. Sternoclavicular Area (top of sternum at junction of clavicles
Auscultation of the Heart
1. With your stethoscope, identify the first and second heart sounds (S1 and S2).
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.
Do early beats appear on a regular rhythm?
Does the irregularity vary consistently with respiration?
Is rhythm totally irregular?
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
b. S1 is diminished in first degree heart block.
c. S1 split is most audible in tricuspid area (T-lub-dub).
Alterations in S2
b. Splitting of S2 can indicate pulmonic stenosis, atrial septal defect, right ventricular failure, and left bundle branch block (lub-T-dub).
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').
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?
INTENSITY. the loudness of a murmur is described on a scale of 1 to 6:
RADIATION. some murmurs radiate in the direction of the blood stream by which they are produced. Listen over neck, back, shoulders, and left axilla.
mitral murmurs are heard best after exercise in left side lying position.
Assessment of Extra Heart Sounds
- opening snap
- midsystolic click