Auscultation

Auscultation By the time you listen, you should know what to hear If you don’t hear what you expect, explain it Don’t leave the bedside till you know what you are hearing Never auscultate from the wrong side of the bed

Auscultation Use the diaphragm for high pitched sounds and murmurs Use the bell for low pitched sounds and murmurs Sequence of auscultation upper right sternal border (URSB) upper left sternal border (ULSB) lower left sternal border (LLSB) apex apex - left lateral decubitus position lower left sternal border (LLSB)- sitting, leaning forward, held expiration

Auscultation Grading of Murmurs: Grade 1 - only a staff man can hear Grade 2 - audible to a resident Grade 3 - audible to a medical student Grade 4 - associated with a thrill or palpable heart sound Grade 5 - audible with the stethoscope partially off the chest Grade 6 - audible at the bed-side

Characteristics of a “functional” murmur Short and soft SEM Normal S1 and S2 Normal cardiac impulse No evidence for any hemodynamic abnormality

Auscultation Use the diaphragm for high pitched sounds and murmurs Use the bell for low pitched sounds and murmurs Sequence of auscultation upper right sternal border (URSB) upper left sternal border (ULSB) lower left sternal border (LLSB) apex apex - left lateral decubitus position lower left sternal border (LLSB)- sitting, leaning forward, held expiration

Auscultation Grading of Murmurs: Grade 1 - only a staff man can hear Grade 2 - audible to a resident Grade 3 - audible to a medical student Grade 4 - associated with a thrill or palpable heart sound Grade 5 - audible with the stethoscope partially off the chest Grade 6 - audible at the bed-side

Assessing Murmurs Functional Murmur: short and soft SEM Grading of Murmurs: Grade 1 - only a staff man can hear Grade 2 - audible to a resident Grade 3 - audible to a medical student Grade 4 - associated with a thrill or palpable heart sound Grade 5 - audible with the stethoscope partially off the chest Grade 6 - audible at the bed-side Functional Murmur: short and soft SEM Normal S1 and S2 Normal cardiac impulse No evidence for hemodynamic abnormality

Innocent Murmurs Common in asymptomatic adults Characterized by Grade I – II @ LSB Systolic ejection pattern Normal intensity & splitting of second sound (S2) No other abnormal sounds or murmurs No evidence of LVH, and no  with Valsalva S1 S2

Common Murmurs and Timing (click on murmur to play) Systolic Murmurs Aortic stenosis Mitral insufficiency Mitral valve prolapse Tricuspid insufficiency Diastolic Murmurs Aortic insufficiency Mitral stenosis S1 S2 S1

Auscultation “Aortic area” 2nd left intercostal space (URSB) compare S1 to S2-S1 should be softer. If the same, think Mitral Stenosis identify ejection murmur-time the peak intensity in relation to systole identify ejection click if present

Auscultation “Pulmonary Area” 2nd right intercostal space (ULSB) listen for split S2 (A2/P2) identify the intensities of A2 and P2 time split S2 with respiration normally widens with inspiration, closes with expiration wide split S2-RBBB, RV volume overload,PS, RV failure wide fixed split = ASD paradoxical split = LBBB, severe AS, severe LV dysfunction, pacemaker

Auscultation Differential diagnosis of split S2 A2/P2 A2/Pericardial knock A2/OS Sometimes 3 components heard A2/P2/OS A2/P2/PK Exclude S3 Lower pitched Heard with bell At apex In left decubitus position

Auscultation Left Sternal Border Listen for early diastolic murmurs (AR/PR) Press firmly with diaphragm Listen upright with forced expiration Listen on hands and knees

Auscultation “Mitral Area” (LLSB) Listen for intensity of S1 Soft-LV dysfunction, first degree heart block, pre-closure with sudden severe AR/MR Loud-MS, sympathetic stimulation Variable- Complete heart block with AV dissociation, Wenkebach Identify splitting of S1 M1/T1, M1/EC(aortic or pulmonary) , M1/Non-EC (MVP), S4/M1

Auscultation “Mitral Area” (LLSB) Identify quality,timing and intensity of systolic murmurs ejection quality vs regurgitant quality pansystolic vs early or mid to late systolic murmer

Auscultation Apex Listen for S3 and S4 Consider differential diagnosis of S3 A2-wide P2, A2-OS, A2-PK, A2-S3 Identify diastolic rumble Determine radiation of murmur e.g.. MR to axilla

Auscultation- Timing of A2 to OS Interval

Clinical Signs of LV Dysfunction Hypotension Pulsus alternans Reduced volume carotid LV apical enlargement/displacement Sustained apex - to S2 Soft S1 Paradoxically split S2 S3 gallop (not S4 = impaired LV compliance) Mitral regurgitation Pulmonary congestion rales

Clinical Signs of RV Dysfunction With Pulmonary HPT Loud P2/palpable PR murmer RV lift Common findings Without Pulmonary HPT Soft P2 No PR +/- RV lift RV S4 TR  CV wave RV S3 murmer  JVP A wave Pulsatile liver + HJR Edema + Kussmaul’s

Causes of RV Dysfunction LV failure Pulmonary HPT 1 2 RV infarction Pericardial Disease tamponade constriction