Examination of the heart

To examine the heart, stand at the patient's right side. Have the patient remain supine with the upper body raised to about 30 degrees. Inspect the precordium, noting any pulsations, heaves or retractions. There are none here. Look for the apical impulse, which when visible, is normally seen in the left-fifth interspace at or medial to the mid-clavicular line. Using your fingertips, palpate for pulsations or heart sounds in the right-second interspace, left-second interspace, and left-third interspace. Next, palpate for the systolic impulse of the right ventricle. While keeping one finger in the third interspace, place additional fingertips in the fourth and fifth interspaces.

If an impulse is palpable, note its location, duration and amplitude. If the patient's chest has an increased antroposterior diameter, palpate for the right ventricular impulse high in the epigastric area where it may be easier to feel. Finally, palpate the apical impulse. If it is not visible, feel for its location with your palm and fingers. When you find it, assess it with your fingertips. Observe its location, diameter, amplitude and duration. Identify its location by the interspaces in which you feel the apical impulse and by its distance in centimeters from the mid-sternal or mid-clavicular line.

Measure the diameter of the impulse in centimeters. Feel for the amplitude of the apical impulse. It is usually small and feels like a gentle tap. To estimate the duration of the apical impulse, feel it as you listen to the heart sounds with a stethoscope. The normal impulse may last through the first two-thirds of systole, but not longer. Please turn over to your left side. If you can't feel the apical impulse, ask the patient to roll partly onto his left side and try again. Now I'd like to tap on your chest to see the size of your heart.

If you still can't feel the apical impulse, estimate heart size by percussion. Starting on the far left of the chest, percuss toward the left border of cardiac dullness in the third, fourth, fifth and possibly sixth interspaces. Normally, percussion reveals pulmonary resonance laterally and cardiac dullness medially.