As described previously, the heart should be listened to at several locations because the different valves are not equally audible everywhere. In addition to this the heart must be listened to with the diaphragm (high sounds: 1st and 2nd sound) and the bell (low sounds: 3rd and 4th sound) side of the stethoscope. Placing the patient in the left semi-prone position brings the heart closer to the thorax walk and makes the sounds located at the tricuspid and mitral orifice clear. That is why parts of the heart examination are still performed in this position.
1. In supine position using the diaphragm side:
- left parasternal 3rd ICS (Erb)
- right parasternal 2nd ICS (aortic orifice)
- left parasternal 2nd ICS (pulmonary orifice)
- left parasternal 4th/5th ICS (tricuspid orifice)
- left midclavicular 4th/5th ICS (apex, mitral orifice)
2. In supine position using the bell side:
- left parasternal 4th/5th ICS (tricuspid orifice)
- left midclavicular 4th/5th ICS (apex, mitral orifice)
3. In left semi-prone position using the diaphragm side:
- left midclavicular 4th/5th ICS (apex, mitral orifice)
4. In left semi-prone position using the bell side:
- left midclavicular 4th/5th ICS (apex, mitral orifice)
1. In supine position using the diaphragm side
- left parasternal 3rd ICS (Erb) [Figure 15]
Figure 15: Erb’s point (diaphragm)
- right parasternal 2nd ICS (aortic orifice) [Figure 16]
Figure 16: right parasternal 2nd ICS (diaphragm)
- left parasternal 2nd ICS (pulmonary orifice) [Figure 17]
Figure 17: left parasternal 2nd ICS (diaphragm)
- left parasternal 4th/5th ICS (tricuspid orifice) [Figure 18]
Figure 18: left parasternal 4th/5th ICS
- left midclavicular 4th/5th ICS (apex, mitral orifice) [Figure 19]
Figure 19: Apex (diaphragm)
2. In supine position using the bell side
- left parasternal 4th/5th ICS (tricuspid orifice) [Figure 20]
Figure 20: parasternal left 4th/5th ICS (bell)
- left midclavicular 4th/5th ICS (apex, mitral orifice) [Figure 21]
Figure 21: Apex (bell)
3. In left semi-prone position using the diaphragm side
- left midclavicular 4th/5th ICS (apex, mitral orifice) [Figure 22]
Figure 22: Apex, semi-prone position (diaphragm)
4. In left semi-prone position using the bell side
- left midclavicular 4th/5th ICS (apex, mitral orifice) [Figure 23]
Figure 23: Apex, semi-prone position (beel)
During the examination always note:
- heart rhythm (combine with palpation of carotid artery and radial artery)
- heart rate (combine with palpation of carotid artery and radial artery)
- loudness of 1st and 2nd sound
- splitting of sounds
- extra sounds
- murmurs
- phase in which the murmur occurs
- duration
- point of maximum intensity
- radiation
- intensity, change in intensity
- quality.