The Heart

For most of the cardiac examination, the patient should be supine with the upper body raised by elevating the head of the bed or table to about 30°. Two other positions are also needed: (1) turning to the left side, and (2) leaning forward. The examiner should stand at the patient's right side.

The table below summarizes patient positions and a suggested sequence for the examination.

Sequence of the Cardiac Examination

Patient Position

Examination

Accentuated Findings

Supine, with the head elevated 30°

Left lateral decubitus

Supine, with the head elevated 30°

Sitting, leaning forward, after full exhalation

Inspect and palpate the precordium: the 2nd interspaces; the right ventricle; and the left ventricle, including the apical impulse (diameter, location, amplitude, duration).

Palpate the apical impulse if not previously detected. Listen at the apex with the bell of the stethoscope.

Listen at the tricuspid area with the bell.

Listen at all the auscultatory areas with the diaphragm.

Listen along the left sternal border and at the apex.

Low-pitched extra sounds (S 3, opening snap, diastolic rumble of mitral stenosis)

Soft decrescendo diastolic murmur of aortic insufficiency

During the cardiac examination, remember to correlate your findings with the patient's jugular venous pressure and carotid pulse. It is also important to identify both the anatomic location of your findings and their timing in the cardiac cycle.

■ Note the anatomic location of sounds in terms of interspaces and their distance from the midsternal, midclavicular, or axillary lines. The midsternal line ^^ offers the most reliable zero point for measurement, but some feel that the ^ midclavicular line accommodates the different sizes and shapes of patients.

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