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Feel the patient's heart. Listen in the other 3 auscultation spots. Repeat steps 2 and 3, this time using the bell of your stethoscope. Ask the patient to lie on his/her left side and ensure proper draping. Leave the examination room and allow the patient to get dressed.
Also known as palpation, place your right hand over the patient's left pectoral. The heel of your hand should be against the sternal border and your fingers should lie just below the nipple. You hand should lay flat against the chest, fingers extended. Make sure you tell the patient what you are going to do before you begin, and explain the purpose. While palpating, be aware of the following: Can you feel a point of maximum impulse (PMI), which indicates the location of the left ventricle? Try to pinpoint its exact location, which is usually near the mid-clavicular line. If the ventricle is normal-sized and functioning, it should be about the size of a penny. If it is enlarged, it may be located closer to the armpit. What is the duration of the impulse? If the patient suffers from hypertension, the impulse will last longer. This is subtle and largely a subjective assessment, however. How strong is the impulse? Do you feel a vibration (or thrill)? If a valve is partially obstructed, you may detect this. If you notice a murmur during auscultation, then check again for a thrill. After auscultating the apex, it is important to listen to the following areas with your stethoscope:  The left side of the patient's sternum, at the bottom (in the 5th intercostal space). This is the best place to auscultate the tricuspid valve.  The left side of the patient's sternum, near the top (in the 2nd intercostal space). This is the best place to auscultate the pulmonic valve.  The right side of the patient's sternum, near the top (in the 2nd intercostal space). This is the best place to auscultate the aortic valve.  Note that listening to the heart's apex is the best spot to assess the mitral valve. The bell is the auscultatory part of the stethoscope with the smaller circumference and concave surface. It is sensitive to abnormal heart sounds called murmurs.  The bell should be applied lightly over the skin to increase sensitivity to murmurs. Pinch the sides of the bell with your thumb and index finger. Rest the heel of your hand against the patient’s chest to ensure that the bell is placed lightly. The bell should create an air-tight seal with the skin to easily hear abnormal heart sounds. This position amplifies the apex’s heart sounds. Place the bell lightly on the apex and listen for murmurs.  Ask the patient to sit up, lean forward, exhale completely and suspend breathing. This maneuver accentuates murmurs.  Both of these maneuvers are "specialty techniques" used to better assess for any heart pathology or murmurs. Do not discuss your physical examination findings with the patient still undressed.