các cấu trúc của tim trong mối quan hệ với các dấu hiệu bề mặt của ngực (xem hình 5,7) là cần thiết. Nó là tốt thực hành để lắng nghe ít nhất là năm khu vực của thành ngực để loại trừ sự hiện diện của một tiếng thổi tim, đó là: 1 đỉnh (khu vực hai lá), 2 cạnh sternal thấp hơn bên trái, | 76 EXAMINATION OF THE NEWBORN FIGURE Palpating the chest to detect a heave TABLE Audible heart sounds Heart sound Where What First Apex Closure of mitral and tricuspid valves Second Second intercostal Closure of aortic and pulmonary space valves the structures of the heart in relation to the surface markings of the chest see Figure is needed. It is good practice to listen to at least five areas of the chest wall to exclude the presence of a heart murmur these are 1 the apex mitral area 2 lower left sternal edge at the fourth intercostal space tricuspid area 3 left of the sternum in the second intercostal space pulmonary area 4 right of the sternum in the second intercostal space aortic area and 5 midscapular area posteriorly coarctation area . When listening for a murmur it is useful to palpate the brachial pulse simultaneously in order to determine whether a murmur is systolic or diastolic in timing and at what point in the cycle it NEONATAL EXAMINATION 77 Superior vena cava Aortic valve Tricuspid valve Left ventricle Right ventricle Pulmonary artery Pulmonary valve Mitral valve FIGURE Position of the structures of the heart in relation to the surface markings of the chest occurs. If it occurs during the systolic phase of the cardiac cycle it occurs between the lub and the dub see heart sounds p. 77 . A diastolic murmur is audible between the dub and the next lub of the heart sounds. An ejection systolic murmur starts just after the onset of systole and is maximal halfway through it. A pansystolic murmur extends throughout systole starting at the same time as the first heart sound and is accentuated slightly in mid-systole. It may extend slightly into diastole. An early diastolic murmur starts early on in diastole and is decrescendo. A mid-diastolic murmur starts later in diastole and is loudest in mid-diastole. A presystolic murmur occurs late in diastole. The loudness of the murmur which is graded from one to six should also be documented as .
