Assessment: Heart, Neck and Vessels

A patient with signs or symptoms of heart problems, such as chest pain, may be suffering a life-threatening condition that requires immediate attention. In this situation, act quickly and perform only the portions of the examination that are absolutely necessary. When the patient's condition is stable, perform a more thorough assessment, which can reveal baseline heart function and any risks for heart disease.

  1. Assess patient for symptoms of, and risk factors for, cardiovascular disease. Determine if patient takes cardiovascular medications and understands them.
  2. Assist patient into comfortable semi-Fowler or supine position in quiet room.
  3. Visualize heart's location, and locate anatomic landmarks.
  4. Aortic area is at second intercostal space on patient's right.
  5. Pulmonic area is at second intercostal space on patient's left.
  6. Second pulmonic area is at third intercostal space on left (at Erb's point).
  7. Tricuspid area is at fourth left intercostal space along sternum.
  8. Mitral area is at fifth intercostal space at left midclavicular line.
  9. Epigastric area is at inferior tip of sternum.
  10. Inspect precordium, noting visible pulsations and exaggerated lifts at each landmark, especially apical area. Palpate for pulsations (using proximal halves of four fingers and then with ball of hand) at each landmark.
  11. Palpate Point of Maximal Impulse (PMI) with fingertips along fifth intercostal space in midclavicular line. Note a light, brief pulsation 1 to 2 cm in diameter at apex. Turn patient onto left side, if needed.
  12. Inspect epigastric area, and palpate abdominal aorta. Note a localized strong beat.
  13. Auscultate heart sounds with patient seated and leaning slightly forward, supine, and then in left lateral recumbent position. Lift female patient's left breast, if needed.
  14. Auscultate each anatomic landmark with diaphragm of stethoscope and then bell, using light pressure. Inch stethoscope along. Do not try to hear all heart sounds at once.
  15. Begin at apex or PMI; then move systematically to tricuspid, second pulmonic, pulmonic, and aortic areas. At each site, listen for S1 ("lub") in time with carotid pulse.
  16. Listen for S2 ("dub") at each site. It precedes diastolic phase and is best heard at aortic area. Heart sounds will vary in pitch, loudness, and duration at each site.
  17. Count each combination S1 and S2 ("lub-dub") as one heartbeat. Count for 1 minute.
  18. Assess heart rhythm by noting the time between S1 and S2 (systole) and then the time between S2 and next S1 (diastole). Listen to full cycle at each auscultation area. There should be a distinct pause between S1 and S2.
  19. When irregular heart rhythm occurs, compare apical and radial pulses. Auscultate apical pulse; then immediately palpate radial pulse.
  20. Auscultate for extra heart sounds at each site. If heard, note their pitch, loudness, duration, timing, and location on chest wall.
  21. With bell, listen for low-pitched extra heart sounds, such as S3 and S4, clicks, and rubs. S3 (ventricular gallop) occurs just after S2. It sounds like "lub-dub-ee" or "Ken-tuc-ky." S4 (atrial gallop) occurs just before S1. It sounds like "dee-lub-dub" or "Ten-nes-see."
  22. Listen for clicks as short, high-pitched extra sounds.
  23. With patient leaning forward or lying on left side, listen for friction rubs as squeaky or rubbing sounds. Instruct patient to hold breath as you continue to listen.
  24. Auscultate for heart murmurs over each auscultation site. Determine where murmur is heard best. Note its intensity and pitch (low, medium, or high); use bell for low-pitched sounds.
  25. Assess carotid arteries with patient seated. Inspect neck on both sides for obvious pulsations. Ask patient to turn head slightly away from artery being examined.
  26. Palpate each carotid artery separately with index and middle fingers around medial edge of sternocleidomastoid muscle. Ask patient to raise chin slightly. Note rate, rhythm, and strength; elasticity of artery; and pulse changes with inspiration or expiration.
  27. With bell over each carotid artery, auscultate for blowing sound (bruit) while patient holds breath for a few heartbeats.
  28. To assess venous pressure, have patient recline at 45-degree angle, avoiding neck hyperextension or flexion. Measure distance between angle of Louis and highest point of vein pulsation.
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