The Cardiac Exam: Auscultation

Normal

Abnormal

? Diastolic

 

? Systolic

 

? Miscellaneous

Introduction

Auscultation is an essential part of even a cursory cardiac exam.  Listening to the heart you can gather information about the  1) rate and rhythm, 2) value functioning (e.g. stenosis, regurgitation/insufficiency), and 3) anatomical defects (e.g. atrial septal defects, ventricular septal defect (VSD), hypertrophy).?

 

In describing and documenting a murmur, you should be able to characterize 4 properties of an “abnormal” heart sound:

    1. The location of the heart sound on the chest (i.e. where is it heard loudest and where you can hear the sound at all).
    2. The timing of the heart sound (i.e. early diastolic, pan systolic, etc.)
    3. The grade or intensity of the heart sound (i.e.1-6 (see table below))
    4. The quality and shape of the heart sound (i.e. musical crescendo, harsh snap, etc.)

Where to place your stethoscope

Picture of 4 typical cardiac ausculation area on the chest.As with palpation of the heart, auscultation should proceed in a logical manner over 4 general areas on the anterior chest, beginning with the patient in the supine position.  The 4 percordial areas are examined with diaphragm, including:

  1. Aortic region (between the 2nd and 3rd intercostal spaces at the right sternal border) (RUSB – right upper sternal border).
  2. Pulmonic region (between the 2nd and 3rd intercostal spaces at the left sternal border) (LUSB – left upper sternal border).
  3. Tricuspid region (between the 3rd, 4th, 5th, and 6th intercostal spaces at the left sternal border) (LLSB – left lower sternal border).
  4. Mitral region (near the apex of the heard between the 5th and 6th intercostal spaces in the mid-clavicular line) (apex of the heart).

After this initial examination in the supine positions, several additional maneuvers should be accomplished in the thorough cardiac exam, as follows:

  1. Instruct the patient to turn onto their left side (left decubitus position) and listen with the bell of the stethoscope at the apex for mitral stenosis (low pitched diastolic murmur).
  2. Instruct the patient to sit upright and re-examine the 4 percordial regions, again with the diaphragm of the stethoscope.
  3. Instruct the patient to lean forward, exhale, and hold their breath.  Listen with the diaphragm between the second and third intercostal spaces at the right sternal (aortic) and left sternal (pulmonic) areas for aortic regurgitation.

Murmurs

Murmur Grades

Grade

Volume

Thrill

1/6

very faint, only heard in ideal circumstances

No

2/6

loud enough to be generally heard

No

3/6

louder then grade 2

No

4/6

louder then grade 3

Yes

5/6

heard with stethoscope partially off chest

Yes

6/6

heard with stethoscope entirely off chest

Yes


 

Murmur Descriptions

Description

Possible Diagnosis

Systolic ejection murmur

Normal, pulmonic, or aortic stenosis

Early diastolic murmur

Aortic regurgitation

Ejection Sound

Aortic valve disease

Pansystolic murmur

Tricuspid or mitral
regurgitation

Late diastolic murmur

Tricuspid or mitral stenosis

Systolic click with late systolic murmur

Mitral valve prolapse

Opening snap with diastolic rumble murmur

Mitral stenosis

S3

Normal in children and occurs in heart failure

S4

Physiological and in various diseases

Heart Sounds

To listen to the heart sounds below simple click on the appropriate sound.  You will proceed to another screen which will provide a written description of the sound.  The sound should play repeatedly in the background.  You can also save the sound onto your hard drive a then play using any external software program you desire. All sounds are in *.wav format.  Depending on the connection you have to the internet, some sounds may take up to 20-30 seconds to load (sound files are 125 kb or less).

The list of cardiac auscultation sounds include:

More information about heart sounds can be obtained by reviewing the relevant section of the Year 2 CWRU School of Medicine syllabus, especially the lecture entitled Normal Heart Sounds.

 

Additional, high quality, heart sounds can be found at the following external sites:

Biosignetics Corporation (Digital Stethoscope Company) Case Studies (free clinical cases with heart sounds) (http://www.bsignetics.com/case_studies_productPM.htm).

 

Boston Children’s Hospital Cardiovascular Program Multimedia Library (http://www.childrenshospital.org/cfapps/mml/index.cfm) (outstanding reference for pediatric cardiac heart sounds, also includes EKGs, echocardiograms, cardiac catheterization images, and gross pathology).

?(10 December 2006)
david.kaelber@case.edu-- Copyright 1999-2006-- Unauthorized use prohibited