1. Auscultation

2. 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

3. 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

4. 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

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

6. 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

7. 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

8. 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

9. Innocent Murmurs Common in asymptomatic adults Characterized by
Grade I – 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
S S2

10. 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
S S S1

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. Auscultation- Timing of A2 to OS Interval

19. 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

20. 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 S TR  CV wave
RV S murmer
 JVP A wave Pulsatile liver
+ HJR Edema
+ Kussmaul’s

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