CARDIAC EXAMINATION

dr. Yosef Purwoko, M.Kes, Sp.PD

Surface Projections of 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 patients
right side.
INSPECTION AND PALPATION
Detection of cardiac
activity through the
chest wall can be
appreciated by
inspection or palpation
or both.
Different parts of the
hand may be optimal to
detect precordial events
The palm of your right hand is placed across the
patient's left chest so that it covers the area over
the heart. The heel should rest along the sternal
border with the extended fingers lying below the
left nipple. Focus on several things:
Palpation of the Precordium to Determine the
Location of the PMI
The Apical Impulse or Point of Maximal Impulse (PMI)
Left Ventricular Area
The Left Sternal Border in the 3rd, 4th, and 5th Interspaces
Right Ventricular Area.

The diastolic movements of right-sided

third and fourth heart sounds may be felt
occasionally.
Feel for them in the 4th and 5th left
interspaces.

In patients with an increased

anteroposterior (AP) diameter, palpation of
the right ventricle in the epigastric or
subxiphoid area is also useful.
With your hand flattened, press your index
finger just under the rib cage and up
toward the left shoulder and try to feel
right ventricular pulsations.
AUSCULTATION
Stetoskope
 The diaphragm. The diaphragm is better
for picking up the relatively highpitched
sounds of S1 and S2, the murmurs of
aortic and mitral regurgitation, and
pericardial friction rubs.
Listen throughout the precordium with
the diaphragm, pressing it firmly against
the chest.

The bell. The bell is more sensitive to the

low-pitched sounds of S3 and S4 and the
murmur of mitral stenosis.
Apply the bell lightly, with just enough
pressure to produce an air seal with its
full rim. Use the bell at the apex, then
move medially along the lower sternal
border. Resting the heel of your hand on
the chest like a fulcrum may help you to
maintain light pressure.
Auscultation of the Heart

By the diaphragm of
stethescope, place it firmly over
the 2nd right intercostal space,
the region of the aortic valve.
Then move it to the other side of
the sternum and listen in the 2nd
left intercostal space, the
location of the pulmonic valve.
Move down along the sternum
and listen over the left 4th
intercostal space, the region of
the tricuspid valve.
And finally, position the
diaphragm over the 4th
intercostal space, left
midclavicular line to examine the
mitral area.
Listening for Extra Heart Sounds
Pressing the bell firmly on the chest
makes it function more like the
diaphragm by stretching the underlying
skin. Low-pitched sounds such as S3 and
S4 may disappear with this technique
an observation that may help to identify
them. In contrast, high-pitched sounds
such as a midsystolic click, an ejection
sound, or an opening snap, will persist or
get louder.
Listen to the entire precordium with the
patient supine. For new patients and
patients needing a complete cardiac
examination, use two other important
positions to listen for mitral stenosis and
aortic regurgitation.
Ask the patient to roll partly onto the
left side into the left lateral decubitus
position, bringing the left ventricle close
to the chest wall. Place the bell of your
stethoscope lightly on the apical impulse
 Don't get frustrated!

Auscultation is a difficult skill to

"master" and we are all continually
refining our techniques.

Take your time.

Make sure the room is quiet.
Be patient.
Ask for help frequently.