hi there my name is Nico and this is Michael and we're medical students at the University of Michigan in this video we'll be discussing and demonstrating a cardiac auscultation cardiac auscultation is a really useful tool for getting a general picture of your patients heart health to do the auscultation we'll use a stethoscope this is a tool that you see a lot of times with health care professionals that help us listen to the sounds of the body like the heart lungs and the GI when you listen to the heart there are some sounds that you focus on the healthy heart sounds are the s-1 and s2 or the lub dub that dr. Fox mentioned in the videos earlier there are some other heart sounds that we want to pay attention to that should be absent in normal patients but we want to detect in case anything's wrong these will be sounds like murmurs or clicks there are others named s3 and s4 so before doing the demonstration I wanted to introduce a mnemonic that we use to find the different valves of the heart and that is apartment M so that's going to be ap TM and you order pulmonary tricuspid and mitral so to get the demonstrated started I'm gonna have Michael remove his shirt and then we'll begin looking for the valves so as you'll recall from the lesson your heart kind of sits in your anterior chest but more on the left side and the valves have a certain anatomical location however when we auscultate we're not actually going to be listening to the anatomical locations of the valves but rather where the sound travels to in the chest cavity so as I mentioned the mnemonic we use is a PTM so we're going to start with the aortic valve so the aortic valve is going to be in the second intercostal space on the right sternal border so that's going to be right around here and the way that I know that is I look for the sternal or jugular notch on the sternum which is at the top of the manubrium and I travel down to what is the sternal angle the sternal angle is where the body of the stern and the manubrium of the sternum meat so I add the sternal angle I move immediately to the patient's right side so it's the left in the video and that is where I'll be able to auscultate the aortic pulse or the Artic valve sound so the Aortic valve as you know closes at the end of systole and that's going to make so as a result the s2 is going to be stronger so you're gonna hear more of a dub lub dub so that's that the aortic valve the pulmonary valve is going to be at the same height but on the opposite side so now we're on the left the patient left second intercostal sternal border and so once again I look for the jugular notch and I travel down to the sternal angle and it's gonna be immediate I'm immediately on the left so once again that's an s2 heavy heart sound and it's gonna be look dub lip dub now I'm gonna look for the tricuspid valve and so I always remember tricuspid is tricuspid so it's the right AV valve but you're gonna listen to it on the left side of the chest so here's my sternal angle okay and here's the pulmonary the tricuspid valve is gonna be at the fourth or fifth intercostal so just about a few inches below that right around here okay and if I were to put these in I would obstacle tape right around here okay and so again this the tricuspid valve is an AV valve so it's going to be s1 heavy or lub-dub lub-dub so that's kind of subtle up here we said it's a dub dub here it's lub dub so that takes some practice to distinguish but if you end up in a clinical setting you'll be able to sit down to detect it so once again here we found our tricuspid valve at the fourth or fifth intercostal space on the left sternal border and now the final one is the mitral valve or the bicuspid of the left or the left AV valve and so that's going to be at the same height for right about the fifth intercostal space but at the midclavicular line so here is your clavicle right and so right about halfway where it is between the sternum and the acromion is the mid area so on males you can actually use the nipple as the landmark so it's going to be immediately inferior to it right about here so I would place my stethoscope here and I would be listening to the mitral valve and once again that's going to be s1 heavy so lub dub so just to review apartment M is going to be the aortic valve at the second intercostal on the right side the sternal border the pulmonary on the left side of the sternal border at the second intercostal space the tricuspid valve at the fourth or fifth intercostal space on the right on the left sternal border and the mitral valve at the fifth intercostal space on the midclavicular line and one final clinical tidbit that we use is right around where the mitral valve sound is is the point of maximum impulse or the PMI and we use this clinically when detecting kind of how hard the heart is working so if I were to palpate here on him or on myself I would be able to feel where my heart kind of rotates into my chest and that's going to be clinically useful to see how hard the heart is working so if you've just exercised or if you're in the middle of exercise you'll feel your heart really beating into your chest there and if you can't you can lean forward or to your left and you'll hear it more so and so while you're sitting down watching lectures it'll be pretty soft compared to when you're exercising so if you have a patient who's just sitting in your office and it's pretty strong that can be clinically relevant so this has been an introduction to the heart sounds and where to locate them on the chest cavity and the point of maximum impulse