Auscultation
AuscultationAuscultation
• 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
AuscultationAuscultation
• 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
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
AuscultationAuscultation
Characteristics of a “functional” murmurCharacteristics of a
“functional” murmur
• Short and soft SEM
• Normal S1 and S2
• Normal cardiac impulse
• No evidence for any hemodynamic abnormality
AuscultationAuscultation
• 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
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
AuscultationAuscultation
Assessing Murmurs Assessing Murmurs
Grading of Murmurs:Grade 1 - only a staff man can
hearGrade 2 - audible to a residentGrade 3 - audible to a medical
studentGrade 4 - associated with a
thrill or palpable heart soundGrade 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 MurmursInnocent 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)
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
AuscultationAuscultation
“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
AuscultationAuscultation
“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
AuscultationAuscultation
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
AuscultationAuscultation
Left Sternal Border
• Listen for early diastolic murmurs (AR/PR)
• Press firmly with diaphragm
• Listen upright with forced expiration
• Listen on hands and knees
AuscultationAuscultation
“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
AuscultationAuscultation
“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
AuscultationAuscultation
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
Auscultation-Timing of A2 to OS Interval
Say Timing seconds
Severity of MS
Other HS’s
Prrr 0.06 Severe
Pada .07-.08 Mod-severe
Pata .08-.09 Mod
Papa 0.10 Mild PK 0.1-0.110
Tu-huh
.12 A2-S3 0.12-0.18
Clinical Signs of LV Dysfunction
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
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