4 cardiac areas: APTM
(All Patients Take Meds)
(AParTMent 2245)
Aortic: 2nd intercostal space, R sternal border
Pulmonic: 2nd intercostal space, L sternal border
Tricuspid: Left lower sternal border
Mitral: 5th intercostal space, R mid clavicular line (Cardiac Apex)
Preparation
Wash hands
Position: supine
Draping: male - uncover to upper abdo; female - uncover as needed
Inspection
General
Precordial scars
Chest wall abnormalities: pectus excavatum, pectus carinatum
Apex beat
5th (sometimes 4th) intercostal space, mid-clavicular line
Pulsations
Inspect for pulsations in areas corresponding to ascending aorta, pulmonary artery, R ventricle, L ventricle
Ascending aorta: RSB
Aortic arch: heads of clavicles
Pulmonary artery: 2nd intercostal space on LSB
R ventricle: sternum, LSB, sub-xiphoid area
Palpation
Apex beat (most lateral impulse felt in precordium)
Supine
At 5th intercostal space, mid-clavicular line
Normal impulse just after S1
If not felt, try L lateral decubitus
Description (LADS)
Location: 4-5th intercostal space, mid clavicular line
Amplitude: brief outward motion in early systole; gentle tap
Duration: normal = < ⅔ of systole
(time with auscultation or palpation of radial pulse)
Size: normal = 2-3 cm (size of quarter)
Precordium
Palpate A, P, T(RV) and M(LV) areas with pads of fingers
Thrills: palpable vibrations
Indicate underlying murmur
Heaves/lifts = diffuse movements
LSB, with heel of hand
Produced by enlarged heart structures
Cardiac apex
Feel for multiple impulses per beat
Auscultation
Listen at all 4 areas
S1 and S2
S1 = closure of AV valves (M & T)
S2 = closure of semilunar valves (A & P)
Physiologic split S2 (best heard at pulmonic area)
Normal splitting of S2 on inspiration (delays P2 component)
Extra heart sounds (best heard with bell at apex, L decubitus position)
S3
Low frequency diastolic heart sound; heard in early-mid diastole
S4
Low frequency diastolic heart sound, heard in late diastole
Murmurs
Describe:
Timing: (systolic vs diastolic)
Time with radial pulse
Systolic murmur heard while feeling pulse
Location (where loudest)
Shape: Crescendo, decrescendo, midsystolic, holosystolic
Intensity grade
1: very faint, not heard in all positions
2: quiet, but heard immediately after placing stethoscope on chest
3: moderately loud
4: loud, palpable thrill
5: very loud, heard with stethoscope partially off chest
6: extremely loud, heard with stethoscope not contacting chest
Associated features
Pitch: high or low
Character: blowing, harsh
Radiation: to neck, axilla, back
Systolic murmurs (Between S1 and S2)
Blood ejected from ventricles
AV valves don’t shut properly (MR/TR)
Semilunar valves don’t open properly (AS/PS)
Midsystolic - most common
Can to innocent, physiologic (pregnancy) or pathologic (AS)
Holosystolic (pansystolic) - pathologic
Blood flow from high to low pressure, through valve/structure that should be closed
Ie: MR, VSD
Diastolic murmurs (between S2 and S1)
Blood fills the ventricles
AV valves don’t open properly (TS/MS)
Semilunar valves don’t shut properly (AR/PR)
Mid-late diastolic
Turbulent flow through stenotic valve (MS)
Early diastolic
Regurgitant flow through incompetent semilunar valve (AR)
Post encounter questions:
What might an S3 indicate?
CHF, severe mitral regurg
What might an S4 indicate?
LVH, MI
List a cause of a systolic murmur.
MR/TR/AS/PS/VSD
List a cause of a diastolic murmur.
TS/MS/AR/PR
Murmurs
Rational Clinical Exam update (2009)