Electrocardiogram

Palpation of the heart
• Ask the patient if they have any chest discomfort or pain
Determine the location and character of the apex beat. It is normally located in the fifth intercostal
space at the midclavicular line. The apex may be:
–– impalpable: obesity, dextrocardia, situs inversus…
–– displaced, suggesting volume overload (mitral or aortic regurgitation)
–– heaving, suggesting pressure overload and left ventricular hypertrophy (aortic stenosis)
–– ‘tapping’, suggesting mitral stenosis
• Place the flat of your hands over either side of the sternum and feel for any heaves and thrills.
Heaves result from right ventricular hypertrophy (cor pulmonale) and thrills from transmitted
murmurs.

Auscultation of the heart
• Listen for heart sounds, additional sounds, murmurs, and pericardial rub. Using the stethoscope’s diaphragm, listen in the:
–– aortic area -right second intercostal space near the sternum
–– pulmonary area-left second intercostal space near the sternum
–– tricuspid area-left third, fourth, and fifth intercostal spaces near the sternum
–– mitral area (use the stethoscope’s bell)-left fifth intercostal space in the mid-clavicular line
• Manoeuvres and points to remember:
–– ask the patient to bend forward and to hold his breath at end-expiration. Using the stethoscope’s
diaphragm, listen at the left sternal edge in the fourth intercostal space for the middiastolic
murmur of aortic regurgitation
–– ask the patient to turn onto his left side and to hold his breath at end-expiration. Using the
stethoscope’s bell, listen in the mitral area for the mid-diastolic murmur of mitral stenosis
–– listen over the carotid arteries for any bruits and the radiation of the murmur of aortic
stenosis
–– listen in the left axilla for the radiation of the murmur of mitral regurgitation

For any murmur, determine its
location and radiation, and its
duration (early, mid, late, ‘pan’
or throughout) and timing
(diastolic, systolic) in relation to
the cardiac cycle. This is best done
by palpating the carotid or
brachial artery to determine the
start of systole. Grade the murmur
on a scale of I to VI according to its
intensity

• https://youtu.be/FtXNnmifbhE