Approaching the Patient
The patient is approached from the right side. Lighting should be available to cast tangential shadows on the skin of the right side of the neck so that internal and external jugular veins can be inspected while simultaneously listening to the heart. The room should be made as quiet as possible. Room temperature should be appropriately comfortable for the patient's state of dress.
Proper auscultation should not be done through clothing. The patient should be positioned, and the examination bed or table should be adjusted to allow sequential examination of the patient in the sitting, recumbent and left lateral d ecubitus positions. Sitting positions include upright, reclining back at approximately a 45 degree angle, and any other angle that optimizes neck vein inspection. Additional patient positions during dynamic auscultation may include standing and squatting, face down on the bed, and leaning forward while standing or sitting.
Inspection should precede auscultation (the visual clues to heart disease will be discussed separately). As one listens to the patient it may be useful to close the eyes temporarily to improve auditory concentration. During the rest of the time the eyes should be trained on the right side of the neck where the internal jugular pulsations are best seen.
Palpation of the right carotid pulse can be performed from the patient's right side by using the examiner's left thumb. The left carotid pulse is palpated with the examiner's right index and middle fingers.
Auscultation should be systematic with a consistent approach from patient to patient. One goal of the experienced examiner (while remaining methodical) is to identify memorable auscultatory features that are unique to the patient (much the same way that one recognizes the voice of a long lost acquaintance on the phone).
A systematic approach requires that heart sounds should be identified first and murmurs should initially be ignored. The number of heart sounds per cardiac cycle is readily determined. Triple rhythms (more than two heart sounds per cycle) are thus identified early in the cardiac assessment. Respiratory splitting of sounds heard along the left sternal border is also identified and characterized early in the exam.
Hearing should be selectively tuned for one auscultatory feature at a time. The rationale is the same as when listening to an orchestra. After an intitial overall impression of sound, it is necessary to selectively tune in to an individual instrument to truly appreciate it.
The listening sequence can begin at the point of maximal impulse at the cardiac apex. The stethoscope is then walked up and down the left sternal border finishing at the right upper sternal area. The neck, clavicles and other parts of the chest are also an integral part of the auscultatory exam.
In order to detect both high and low frequency heart sounds and murmurs - the examiner must incorporate both the bell and the diaphragm into the sequential approach.
Identifying the Heart Sounds
The first and second heart sounds actually sound quite different. The first sound is longer and lower pitched (hence: Lub). The second sound is shorter and higher pitched (Dup). The loudness of heart sounds changes with location. The second heart sound is louder at the base. The first heart sound is louder at the apex. This is made most obvious by putting the patient in the left lateral decubitus position, finding the point of maximal impulse, putting the diaphragm there first and then comparing the loudness by listening back and forth between the apex and the base.
When listening at the upper right sternal border in the normal child or adult - the first heart sound is never louder than the second heart sound.
At slow heart rates systole is noticeably shorter than diastole. Consequently, the second heart sound follows the shorter pause, while the first heart sound follows the longer pause.
Palpating the carotid pulse while listening to the heart sounds can also be useful for timing systole. The palpable carotid upstroke is called the percussion wave. The normal precussion wave is felt early in systole just after hearing the first heart sound.
Palpating the point of maximal impulse at the apex can also be useful in the normal patient for timing systole. The normal apical impulse is brief, and is palpated in early systole immediately after the first heart sound. However, there are abnormal apical findings that can be misleading for timing purposes if unrecognized. For example, patients with (now rarely found) constrictive pericarditis may have apical systolic retraction and diastolic expansion .
The contents and links on this page were last verified on July 6, 2006.
This information is intended for use by doctors and other healthcare professionals.
Daniel Shindler M.D., F.A.C.C.
Professor of Medicine
UMDNJ - Robert Wood Johnson Medical School
Director, Echocardiography Laboratory
Robert Wood Johnson University Hospital