Auscultate the heart in five locations in a systemic fashion,
starting at the apex, move to the lower left sternal
border (include epigastrium), and extend to the base of
the heart.
PMI
epigastrium
left sternal border
second right (aortic)
left (pulmonic) intercostal space
Do this once with the following:
diaphragm (which best facilitates hearing high pitched sounds
including S1 and S2) and repeat with the
bell(which
best facilitates hearing low pitched sounds including S3 and S4).
Give special attention to the intensity of S1 at the apex , to the intensity of S2,
and the splitting of S2 in the left second intercostal space.
Identify any extra sounds in systole or diastole.
Listen to each cardiac event with focus on that event, excluding
all other cardiac sounds, i.e., listen to S1 at all areas determining if it is split,
where it is split.
If splitting changes with respiration and if it is soft or
accentuated, then move and repeat for another cardiac event.
Placing the patient in the left lateral decubitus position will facilitate
hearing diastolic filling sounds and mitral valve related murmers.
Normal:
S1 is louder than S2 in apex.
S1 is softer than S2 at base.
S2 is single over apex.
S2 is normally split
in base and left lower sternal border accentuated by inspiration and becomes single during
expiration.
