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Medicine Lecture 17,18
Medicine Lecture 17,18
Technique
• Place fingertips over apex (1) to assess for
position and character
• Place heel of hand over left sternal edge (2) for a
• parasternal heave or ‘lift’
• Assess for thrills in all areas, including the aortic
and pulmonary areas (3)
Normal position is the 5th or 6th intercostal space,
at the mid-clavicular line.
Common abnormalities of the apex beat
• Volume overload, such as mitral or aortic
regurgitation: displaced,thrusting
• Pressure overload, such as aortic stenosis,
hypertension: discrete,heaving
• Dyskinetic, such as left ventricular aneurysm:
displaced, incoordinate
Other abnormalities
• Palpable S1 (tapping apex beat: mitral
stenosis)
• Palpable P2 (severe pulmonary hypertension)
• Left parasternal heave or ‘lift’ felt by heel of
hand (right ventricular hypertrophy)
• Palpable thrill (aortic stenosis)
Auscultation of the heart
• Use the diaphragm to examine at the apex,
lower left sternal edge (tricuspid area) and
upper left (pulmonary area) and right (aortic
area) sternal edges
• Use the bell to examine low-pitched noises,
particularly at the apex for the mid-diastolic
murmur of mitral stenosis
• Time the sounds and murmurs by feeling the
carotid pulse; the first heart sound (S1) just
precedes the upstroke of the pulse and the
second heart sound (S2) is out of step with it
• Systolic murmurs are synchronous with the
pulse
• Listen for radiation of systolic murmurs, over
the base of the neck (aortic stenosis) and in
the axilla (mitral incompetence)
• Listen over the left sternal border with the
patient sitting forward (aortic incompetence),
then at the apex with the patient rolled on to
the left side (mitral stenosis)
• Myocardial cells constitute 75% of the heart
mass but only about 25% of the cell number