Heart

Frontal section of the heart.

Views of the heart. A, Anterior.

B, Posterior.

Anterior cross section showing the valves and chambers of the heart.

Blood flow through the heart. A, Systole.

B, Diastole.

Events of the cardiac cycle, showing venous pressure waves, electrocardiogram (ECG; the graphic representing the electrical activity during the cardiac cycle), and heart sounds in systole and diastole. PCG, Phonocardiogram.

Cardiac conduction.

Chest Pain

Inspection

In most adults, the apical impulse is visible at about the midclavicular line in the fifth left intercostal space.

But it it easily obscured by obesity, large breasts, or muscularity.
In the adult, the apical impulse should be most visible when the patient is in the upright position.

Palpation

Apex, up the left sternal border, base, down the right sternal border, into the epigastrium or axillae if the circumstance dictates
Apical impulse
- Point of maximal impulse (PMI)
  - The point at which the apical impulse is most readily seen or felt
- Heave or lift
  - The apical impulse is more vigorous than expected
  - A lift along the left sternal boarder is most likely the result of the right ventricular hypertrophy
- Thrill
  - A palpable rushing vibration over the base of the heart at the second intercostal space
Carotid artery

Palpation of the apical pulse.

Sequence for palpation of the precordium.

A, Apex.

B, Left sternal border.

C, Base.

Palpation of the carotid artery to time events felt over the precordium.

Percussion

Percussion is of limited value in defining the borders of the heart or determining its size because the shape of the chest is relatively rigid and can make the more malleable heart conform.
To estimate heart size by percussion, begin tapping at the anterior axillary line.
Left ventricular size is better judged by the location of the apical impulse.
The right ventricle tends to enlarge in the anteroposterior diameter rather than laterally, thus diminishing the value of percussion of the right heart boarder.

Auscultation

Auscultation should be performed in, but not be limited to, each of the five cardiac areas, using first the diaphragm and then the bell of the stethoscope.
Use firm pressure with the diaphragm (best for higher frequency sounds) and light pressure with the bell (best with low-frequency sounds).
Normal heart sounds are best heard at over areas where blood flows after it passes through a valve.

Areas for auscultation of the heart.

Aortic valve area: Second right intercostal space at the right sternal border
Pulmonic valve area: Second left intercostal space at the left sternal border
Second pulmonic area: Third left intercostal space at the left sternal border
Tricuspid area: Fourth left intercostal space along the lower left sternal border
Mitral (or apical) area: Apex of the heart in the fifth left intercostal space at the midclavicular line

Creative Teaching!

Special thanks to Anna Wilson, who used this video a while ago to teach about the cardiac cycle and shared this with us!

Heart sounds.

University of Washington Department of Medicine
S1 marks the beginning of systole. S1 coincides with the rise (upswing) of the carotid pulse. Listen for S1 while you palpate the carotid pulse.
- Splitting of S1 is not usually heard because the sound of the tricuspid valve closing is too faint to hear
S2 marks the initiation of diastole and closure of the aortic and pulmonic valves.
- Splitting of S2 is an expected event because pressures are higher and depolarization occurs earlier on the left side of the heart
S3 = Ken-TUCK-y
- The early diastolic gallop rhythm
S4 = TEN-nes-see
- A loud S4 always suggests pathology and deserves additional evaluation