Physical Exam: Heart

I. Assess the heart through the anterior thorax (front chest)
II. Inspection and palpation

• Client in supine position or with head elevated at 45 degrees
• Anatomical landmarks of the heart: 

1. Second Right Intercostal Space - Aortic Area
2. Second Left Intercostal Space - Pulmonic Area 
3. Third Left Intercostal Space - Erb's Point
4. Fourth Left Intercostal Space - Tricuspid Area
5. Fifth Left Intercostal Space - Mitral (Apical) Area
6. Epigastric Area at tip of sternum

• Apical Impulse:

1. 4-5th Left intercostal space, midclavicular line
2. may or may not be seen
3. normally a short, gentle tap

III. Auscultation

• Client takes 3 positions: sitting, supine, left lateral recumbent
• Use stethoscope to auscultate heart sounds
• S1 - closing of the mitral valve; after long diastolic pause; before short systolic pause; heard best at apex
• S2 - closing of aortic valve; after short systolic pause; before long diastolic pause; heard best over aorta (second right intercostal space)
• Pulse deficit
• Murmurs

1. Grading system
2. Asymptomatic or symptomatic
3. Thrill
4. Systolic murmur occurs between S1 and S2
5. Diastolic occurs between S2 and S1

Classifying Heart Murmurs by Intensity

• Grade I: Difficult to hear, even with stethoscope
• Grade II: Quiet, heard with stethoscope
• Grade III: Moderately loud, no thrill
• Grade IV: Loud, may have a thrill
• Grade V: Very loud, heard with a stethoscope partially off chest; has thrill
• Grade VI: Can be heard with a stethoscope off the chest; has thrill