1. Jay L. Rubenstone, D.O., F.A.C.C. October 2012
Cardiac Auscultation
Jay L. Rubenstone, D.O., F.A.C.C.
October 2012

2. Techniques of Examination
Order of Exam
Aortic Area
Pulmonic Area
Tricuspid Area
Mitral Area

4. Process of Auscultation
At each auscultatory area:
1. Concentrate on 1st Heart Sound
note Intensity and Splitting
2. Concentrate on 2nd Heart Sound
3. Listen for Extra Sounds in Systole
note Timing, Intensity, Pitch

6. Process of Ascultation
4. Listen for Extra Sounds in Diastole
note timing, intensity, pitch
5. Listen for Systolic Murmurs*
6. Listen for Diastolic Murmurs*
7. Other Heart Sounds

7. Process of Ascultation
*If Systolic or Diastolic Murmur Present, Note:
Location
Radiation
Intensity
Pitch
Quality

8. Auscultation Timing Systolic Diastolic Early Mid Late
Late (or Presystolic)

9. Auscultation Location
Interspace
Centimeters from
Midsternal
Midclavicular
Or Axillary Lines

10. Auscultation Intensity
Grade 1 Very Faint
Grade 2 Quiet, but Heard Immediately
Grade 3 Moderately Loud, Not Associated with a Thrill
Grade 4 Loud, May Be Associated with a Thrill
Grade 5 Very Loud
Grade 6 May be Heard w/stethoscope off chest

11. Auscultation Radiation or Transmission Pitch Quality High, Med, Low
Blowing
Rumbling
Harsh
Muscial

12. Components of S1 Mitral Valve Closure Tricuspid Valve Closure
Best Heard: Apex
Tricuspid Valve Closure
Best heard: Lower Left Sternal Boarder

13. S1 Wide Splitting Single Sound RBBB PVC from Left Ventricle Normal
LBBB
PVC from Right Ventricle
Paced Beats

14. S1 Increased Intensity Short PR Rapid HR Atrial Fibrillation
Mitral Stenosis

15. S 1 Decreased Intensity Mitral Stenosis (Immobile Leaflets)
Opposite of Causes of Increased Intensity

16. S 2 Two Components Aortic Closure A2 Pulmonic Closure P2
Best Heard at the Base

17. S 2 Normal Splitting Best Heard At 2nd Left Intercostal Space
During Inspiration there is Delayed Pulmonic Valve Closure
Due to Increased Capacitance of Pulmonary Bed

18. S 2 Loss of Splitting Inaudible P2-
Adults with Increased Chest Diameter
Congenital (Tetralogy, Pulmonary Atresia Transposition)
Increased Pulmonary Valve Resistance-Pulmonary HTN
Eisenmenger’s Complex-Equal Pulmonary & Systemic Resistances

19. S 2 Persistent Splitting Fixed Splitting RBBB Pure MR
Healthy Adolescents when in Supine Position
Fixed Splitting
Atrial Septal Defect- Due to Delayed Closure of Pulmonic Valve from Increased Right-Sided Flow

20. S 2 Paradoxical Splitting- P2 before A2 Increased Intensity
LBBB
Paced Beats
Increased Intensity
A2 Systemic HTN
Dilated Aortic Root
P2 Pulmonary HTN
Dilated Pulmonary Trunk

22. Early Systolic Sounds Ejection Sound- Usually High Frequency
Aortic Valve- Aortic Stenosis, Bicuspid Aortic Valve
Pulmonary Valve-Pulmonic Stenosis Vary with Respirations
Prosthetic Valves- Mechanical, Not Bioprosthetic

23. Mid-Late Systolic Sounds
Click
High Frequency Sound Found in Mitral Valve Prolapse
Occurs Earlier with Valsalva Maneuver or Squatting to Standing

24. Early Diastolic Sounds
Opening Snap of Mitral Stenosis (MS)
High Frequency-Left Lateral Decubitus Position, Apex
Occurs after S2, before S3
MS More Severe with Short A2-OS Interval
Precordial Knock
Chronic Constrictive Pericarditis
Mitral Regurgitation
Atrial Myxoma
Older Model Prosthetic Mitral Valve

26. Mid Diastolic Sounds S3
Occurs During Rapid Filling of Left Ventricle (LV) related to LV Volume
Low Frequency Best Heard
At the Apex w/Bell
Pt in Left Lateral Decubitus Position
Can Be Normal to Age 40???
Can be Pathognomonic for Congestive Heart Failure

27. Late Diastolic Sounds S4 During Atrial Phase of LV Filling
Consequence of Ventricular Stiffness
Absent in Atrial Fibrillation or Ventricular Pacing
Low Frequency Sound Best Heart
At the Apex
Pt in Left Lateral Decubitus Position
HTN, Aortic Stenosis, Ischemic Heart Disease

28. Diastolic Sounds Right Sided S3, S4 Summation Gallop
Left Lower Sternal Boarder
Intensity Varies with Respiration due to Right Heart Filling (Carvallo’s Sign)
Summation Gallop
Occurrence of an Over Lapping S3 and S4 due to Tachycardia

31. Systolic Murmurs
Acute Mitral Regurgitation (MR) or Tricuspid Regurgitation (TR)
Mid Frequency
Not Classic Murmur
Ventricular-Septal Defect (VSD)
High Frequency (diaphram)
Atrial-Septal Defect (ASD)
Pulmonary Outflow
Not Defect Murmur

32. Systolic Murmurs Obstruction to Ventricular Outflow
Dilatation of Aortic Root or Pulmonary Trunk
Accelerated Flow into Aorta or Pulmonary Trunk
Innocent Murmurs
Some Forms of MR (Papillary Muscle Dysfunction)

33. Systolic Murmurs Aortic Valve Stenosis
Diamond Shaped, Crescendo-Decrescendo
Begins After S1 or with Aortic Ejection Sound
Ends Before S2
2nd Right Intercostal Space, Apex, can radiate to Neck
High Frequency, Harsh
Can be Musical in Quality at the Apex

34. Systolic Murmurs Pulmonic Stenosis
Similar to AS Except Relationship to P2
2nd Left Intercostal Space

35. Normal Systolic Murmurs
Still’s Murmur
Medium Frequency, Vibratory, Originating from Leaflets of Pulmonic Valve
Rapid Ejection into Aortic Root or Pulmonary Trunk
Pregnancy
Anemia
Fever
Thyrotoxicosis

36. Normal Systolic Murmurs
Aortic Sclerosis
Most Common Innocent Murmur

37. Systolic Murmurs Mitral Valve Prolapse
High Frequency, Sometimes Honking, Crescendo Murmur
Usually Extends to S2
Classic Mid-Late Systolic Click
Occurs Earlier with Valsalva & Squatting to Standing

38. Systolic Murmurs Holosystolic Begins with S1, Ends at S2
MR- Radiates to Left Sternal Boarder, Base or Neck, More Commonly Apex to Axilla
TR- Carvallo’s Sign (Inspiratory Variation)
VSD-Across Precordium
Patent Ductus Arteriosis (PDA)- Aorto-Pulmonary Connection

40. Early Diastolic Murmur
Aortic Regurgitation
High Pitched, Decrescendo Murmur
Best heard at
Left Sternal Boarder with the diaphram w/Patient Leaning Forward at End Expiration
Acute, Severe AR Murmur
Can be Short, Soft and Med Pitched
Chronic, Sever AR-
Murmur Usually Long, Loud, Blowing Decrescendo, High Frequency

42. Early Diastolic Murmur
Graham Steell –
Murmur of Pulmonic Regurgitation as a Result of Pulmonary HTN
High Freq, Decrescendo Blowing Murmur Heard throughout Diastole

43. Mid Diastolic Murmur Mitral Stenosis (MS) Follows Opening Snap
Low Pitch Rumble
Best Heard
Apex over LV
Using Bell of Stethoscope
Pt in Left Lateral Decubitus Position

44. Mid Diastolic Murmurs Tricuspid Stenosis
Similar to MS, except increases with Respiration (Carvallo’s Sign)
Best Heard at Left Lower Sternal Edge

45. Mid Diastolic Murmurs Pulmonic Regurgitation
Crescendo-Decrescendo Murmur when Primary Valvular Abnormality and Not Associated with Pumonary HTN

46. Diastolic Murmurs Late or Presystolic Follows Atrial Systole
Implies Sinus Rhythm
Can be present in MS or Complete Heart Block
Austin Flint Murmur of Aortic Regurgitation
Bubbling Quality, Short
Consequence of Aortic Regurgitation impinging on Mitral Valve

47. Diastolic Murmurs Continuous PDA (AortoPulmonary Connection)
Rough Thrill
A-V Fistulas
Hemodialysis Shunt
Aortic Valve Sinus to Right Ventricular Fistula
Coronary Artery Fistulas

48. Diastolic Murmurs Venous Hum Rough in quality not actually a hum
Hepatic
Internal Jugular
During Anemia, Fever, Pregnancy and Thyrotoxicosis

49. Pericardial Friction Rub
Three Phases
Mid Systolic, Mid Diastolic, Pre Systolic
Scratchy, Leathery
Best Heard
With Diaphragm of Stethoscope
Left Sternal Boarder Leaning over at End Expiration
Apposition of Abnormal Visceral and Parietal Pericardium
Confused with Hamman’s Sign in Post Open Heart Surgery (Crunch Sound from Mediastinal Air)

50. Innocent or Normal Murmurs-Systolic
Vibratory Systolic Murmur (Still’s Murmur)
Pulmonic Systolic Murmur (Pulmonary Trunk)*
Mammary Soufflé*
Peripheral Pulmonic Systolic Murmur (Pulmonary Branches)
Supraclavicular or Brachiocephalic Systolic Murmur
Aortic Systolic Murmur
*common in pregnancy

51. Innocent or Normal Murmurs- Continuous
Venous Hum
Continuous Mammary Soufflé

52. Conclusions Consistent Approach to Auscultation
Knowing What to Look For
Follow Through on H&P
Confirm or Eliminate Suspicions
Knowing How to Find It
Proper Utilization of Stethoscope
Location and Quality of Heart Sounds & Murmurs