1. Auscultation of The Heart Dr. R
Auscultation of The Heart Dr. R. Tandon Sitaram Bhartia Institute, New Delhi

2. First Sound (S1) Due to closure of MV/TV
Accentuated, diminished or variable intensity
Wide split – Rt. BBB.

3. First Sound (S1) Accentuated : Loud M1 Tachycardia Short PR interval
Mitral stenosis
VSD, PDA.
LVH
Loud T1 : ASD, TAPVC
Tricuspid Stenosis

4. First Sound (S1) Diminished :- S2 > S1 at apex.  LV contractility
1° AVB AR

5. First Sound (S1)
Variable Intensity
Comp. AVB
Atrial fibrillation.

6. Second Sound Normal :- Two components A2 & P2 A2 louder than P2
Insp.; split S2; A2-P2
Exp. : Single S2
A2 all over the precordium
P ULSB

8. Second Sound Abnormalities : A2 or P2
Intensity : Increased or decreased
Timing : Early or late

11. Second Sound Splitting :- Normal. W&V - PS, PAPVC - IAS, MR, VSD
W&F - ASD, TAPVC, Rt. BB, WPW(A)
Single - A2 or P2 or A2 + P2
Paradox - AS, PDA, LVF, Lt. BB, WPW (B)

12. Third Sound (S3) End of early diast. filling.
Dull, 50 to 100 msec after S2.
Normal in children and young adults
Abnormal above 40 yrs.
Left or right sided.

13. Fourth Sound Abnormal if audible. Rt. / Lt. sided
Rt. / Lt. atrial hypertension (high RV/LV edp).
Audible intermittently in comp. AVB.
Acute MR - S4+.

14. Systolic Clicks (x) Loud sharp sounds Ejet. or Non-eject.
Eject – Aortic, pulmonary – single.
Non-eject - MV / TV prolapse - single or multiple.

15. Systolic Clicks Aortic : Constant, early Heard all over the precard
Bicuspid AoV.
Dilated Asc, Ao
Syst. hypertension, aneurysms
Fallot’s physiology, PTA.
Disapear - fibrosis, calcification.

16. Systolic Clicks Pulmonary :- PS or PAH at ULSB. PS - Valvar PS
- Audible in expirat. only
-  severity - closer to SI
PAH - PVOD - Constant

17. Systolic Clicks Non-Ejection : MVPS Single or multiple.
Mid systolic but can be early - radiates to base and neck
Late murmur ±

18. A2 P2 S1 X
Syst. m.

19. Opening Snap Mitral, diast. sound 40-120 msec after A2
A2-OS interval - severity
Disappears in immobile valves
Tricuspid OS drowned in MSm.

21. Murmur Systolic - Pansystolic. Ejection systolic
Diastolic * Semilunar valves
- Regurgitant m.
Early diastolic m.
* Atriovent. Valves
- Functional m.
- Obstructive m.
Delayed diast. (Middiast.)
Late diast. (Presyst.)
Continuous

25. S1 X A2
ES. m.
AR. m.

26. S1 X
A2 P2
ES. m.
PR m.

27. S1 X
A2 P2
ES. m.
PR. m.

28. S1x S2
S1 x
Cont. m.

29. S1x S2 S1
Cont. m.

32. Auscultation
Clinical Utility :-
Murmurs present.
Murmurs absent.

33. Auscultation Clinical Utility :- Murmurs absent Myocardial disease
- Primary – DCM, RCM, HCM
- Secondary to CAD
Pericardial disease
Utility of S3, S4, S2, S1

34. Auscultation Clinical Utility :- Murmurs present Cong. Ht. Dis.
Rh. Ht. Dis.
PMD - DCM – MR/TR
HOCM - Outflow m.
- MR. m.
Post M.I. - MR / VSD.

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