Auscultation, or listening to the heart, is a fundamental part of a medical examination, providing immediate information about cardiac function. Converting the subjective sound heard into an objective, standardized medical record requires precise language. This documentation ensures clear communication among healthcare providers, allowing subtle changes in a patient’s condition to be accurately tracked. The goal is to describe the heart’s rate, rhythm, and the specific characteristics of any sounds heard, relying on established reference points and anatomical locations.
Identifying the Reference Points: S1 and S2
Standardized documentation begins with identifying the two primary sounds, S1 and S2, which act as markers for the cardiac cycle. S1, the “lub” sound, marks the beginning of ventricular contraction (systole) and is generated by the closure of the mitral and tricuspid valves.
S2, the subsequent “dub” sound, signals the end of systole and the start of ventricular relaxation (diastole), resulting from the closure of the aortic and pulmonary valves. Identifying these two sounds is crucial because they define the systolic interval (between S1 and S2) and the diastolic interval (between S2 and the next S1), which provides the necessary framework for timing any abnormal sounds.
Anatomical Mapping: Zones for Auscultation Documentation
To accurately document a heart sound, its location must be fixed to a standardized anatomical zone on the chest wall. The four primary auscultation areas correspond to where the sounds of the heart’s four valves are best transmitted, not the exact physical location of the valves themselves.
The aortic area is documented at the second intercostal space (ICS) just to the right of the sternal border. The pulmonic area is located at the second ICS just to the left of the sternal border. The tricuspid area is typically found at the fourth or fifth ICS along the lower left sternal border. The mitral area is documented at the fifth ICS at the midclavicular line, which is generally where the Point of Maximal Impulse (PMI) is located. Documenting the PMI is important for determining the size of the heart, as displacement can signal underlying pathology.
Documenting Normal Heart Findings: Rate, Rhythm, and Quality
Documentation of a normal heart examination begins with objective, quantitative data. The heart rate is recorded in beats per minute (BPM), and the rhythm is noted as either regular or irregular, with specific descriptors like “irregularly irregular” if no discernible pattern is present. S1 and S2 are documented as being clearly audible and having a normal intensity.
The overall quality is standardized by noting the absence of any additional sounds. A normal finding is documented with a succinct phrase such as “S1 and S2 present, no rubs, gallops, or murmurs noted.” This establishes a baseline for the patient. The absence of a palpable vibration on the chest wall, known as a thrill, is also an important component of normal documentation.
The Language of Abnormal Sounds: Timing, Grading, and Shape
Documenting an abnormal sound, such as a murmur, requires a precise, multi-faceted approach that details its timing, intensity, quality, and configuration.
Timing
The timing must specify when the sound occurs relative to S1 and S2: systolic (between S1 and S2), diastolic (between S2 and the next S1), or continuous (heard throughout the entire cycle). For a systolic sound, further detail is needed, such as whether it is early, mid, late, or holosystolic, meaning it lasts throughout the entire systolic interval.
Grading (Intensity)
The intensity of a murmur is documented using the standardized Levine grading scale, which ranges from Grade I to Grade VI.
- Grade I: Lowest intensity, barely audible even by an expert.
- Grade III: Moderately loud but not associated with a palpable vibration or thrill.
- Grade IV or higher: Loud enough to be associated with a thrill.
- Grade VI: Loudest, heard even with the stethoscope lifted completely off the chest.
Quality and Configuration
The final descriptive elements cover the quality and configuration of the sound. Quality describes the auditory texture, using terms like “blowing,” “harsh,” or “rumbling.” Pitch is documented as low-pitched or high-pitched, which often guides the choice of stethoscope head (bell for low-pitched, diaphragm for high-pitched). Configuration describes the variation in loudness over its duration, such as crescendo (increasing intensity), decrescendo (decreasing intensity), or a crescendo-decrescendo shape (often described as a diamond shape).