Auscultation and Demonstration of Heart Sounds OS 213

Nelson Abelardo, MD Exam 01

01 Oct 2019 Trans B05

OUTLINE  Aortic sounds can be heard from apex to aorta, pulmonic from
I. Introduction RV to PA, etc.
II. Stethoscope
III. Auscultation
A. General Formatting
IV. Heart Sounds
V. Murmurs
Note from the TG: Dr. Abelardo skipped a lot of his slides during
this lecture due to time constraints and proceeded to teach the
topic from memory. This trans is based mainly on the 2022 block B
trans to retain a structured organization. We supplemented this
with info and tips from Dr. Abelardo’s lecture.
I. INTRODUCTION
Does Cardiac Auscultation Still Have a Role in Practice
 Ascendancy of advanced technology
 Imbalance between cost effective clinical skills and high cost Figure 1. Parts of the Stethoscope.
technology
 Neglect and apathy regarding teaching and application of clinical III. AUSCULTATION
skills because of lack of emphasis on cardiac auscultaiton  The most widely used method of screening for valvular heart
resulting in low percentage of students in demonstrating disease.
proficiency in these skills  Listening to the heart has come to epitomize the art of bedside
 Detrimental to practitioners as well as patients especially in diagnosis.
areas where advanced diagnostic facilities are lacking or  Auscultation of heart sounds and murmurs is an important skill
unavailable in the physical examination that leads directly to important
clinical diagnoses.
The Imperative  Heart sounds and murmurs that originate in the four valves
 Fascination with technology and the wide availability of radiate widely.
sophisticated equipment have contributed to the devaluation of  Use anatomical location rather than valve area to describe
the hands-on approach to medicine, thus eroding the doctor- where murmurs and sounds are best heard
patient relationship. Example: NOT “at the mitral valve area” BUT “at the 4th
 The need for cost containment predicates and impels the intercostal, left mid-clavicular line”
teaching and implementation of clinical skills, not only for the
sake of controlling costs but also evaluate treatment decisions
and justify expensive testing procedures.
 Good health care professionals must balance health costs, time
liability, outcomes and risks with clinical skills in decision
making, diagnosis and treatment.
Traditional Methods in Cardiac Auscultation
 Identification of heart sounds relying on audiovisual aids like CD
ROMs, tape recorded or videotaped sounds
Verbal description of sounds and murmurs like rough,
smooth, blowing, musical, train wheel, and sea gull have
been used
 Drawbacks include:
Different subjects may have different notions of these
descriptions
They are descriptions and not transliterations
Verbal descriptions may be lengthy and rely on rote memory
and recall of specific sound is difficult
Figure 2. Auscultation Points
II. STETHOSCOPE
 Parts of a Stethoscope Table 1. Auscultatory Points & Their Corresponding Locations.
Earpiece AREA LOCATION
Binaurals Aortic valve 2nd ICS R Parasternal border
Tubing Pulmonic valve 2nd ICS L Parasternal border
Chestpiece Tricuspid valve 4th ICS L Parasternal border
 Bell – more sensitive to low-pitched (low velocity) sounds of S3 Mitral (bicuspid) 5th ICS L Midclavicular line
and the murmur of mitral stenosis valve
 Diaphragm – better for picking up the relatively high pitched ICS – intercostal space; R – right; L – left
(high velocity) sounds of S1 and S2, the murmurs of aortic and
mitral regurgitation and pericardial fiction rub.  Mnemonics:
 Heart sounds in auscultatory areas follow the direction of blood  Always Pray To Mary
flow.  Apartment (APTM) 2245

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OS 213: Auscultation and Demonstration of Heart Sounds Exam 01 - Trans B05

IV. HEART SOUNDS normal finding in patients <40 y/o [University of Washington Department of
Medicine]
Rate
 Bradycardic: HR < 60 bpm  S4 – low frequency sound heard right before the next S1
 Normal Heart Rate: 60-100 bpm Late diastolic
 Tachycardic: HR > 100 bpm Known as the atrial gallop
‘Tennessee’ cardiophonetic
Rhythm/Regularity corresponds to atrial kick (contraction of atria during
 Regular: your normal lub-dub ventricular diastole)
 Irregular: anything else Seen in patients with stiffened left ventricles, resulting from
Regularly irregular: if the irregularity has a pattern conditions such as hypertension, aortic stenosis, ischemic or
Irregularly irregular: if there is no definable pattern hypertrophic cardiomyopathy [University of Washington Department of
Medicine]
Identifying Heart Sounds
 Keep your left index and middle fingers on the right carotid artery V. MURMUR
in the lower third of the neck to facilitate correct identification of  Heart sounds caused by turbulence in blood flow
S1 and S2  Heard loudest in the area of the lesion
S1: just before the carotid upstroke
S2: follows the carotid upstroke Murmur vs Click
 The period between S1 and S2 is systole (shorter interval), and  Click – is a “tick”; could be S3 or S4
the period between S2 and the next S1 is diastole (longer  Murmur – more prominent; “boogsh”, “fwooo”
interval)
Stenosis vs Regurgitation
 Note that S1 and S2 are heard over all auscultatory areas
 Stenosis – open valve has pathologically narrowed; blocked
opening
Low pitch since blood is forced into a small opening
 Regurgitation – closed valve is “leaky” and allows backflow of
blood (pathologic)
High pitch from turbulence
Systolic murmur vs Diastolic murmur
 Systolic murmur - after S1; falls between S1 and S2
 Diastolic murmur – after S2; falls between S2 and the next S1
Characteristic murmurs
 Aortic regurgitation – passive blowing, diastolic murmur since
there is a passive flow of blood; gentle sound
 Mitral stenosis – “angry cat-like purring” or active “growling”
diastolic murmur since there is an active flow of blood; harsh
Figure 2. Schematic showing systole and diastole seperated by S1 and S2. sound
 PDA – continuous (systolic and diastolic) “factory-like” murmur
 Be sure to compare the intensities of S1 and S2 as you move
your stethoscope through the different auscultatory points
o Go either from top (base) to bottom (apex*) or bottom to top
(inching method)
*the mitral auscultatory area is usually the point where the apex
beat is found
 At the base:
S2 is louder than S1
S2 may be split with respiration
 Increased flow to the right side increases the flow to the
pulmonic valve. Hence, the pulmonic valve is thus open
wider so it takes a longer time to close.
 At the apex:
S1 is louder than S2
S1 may be split with respiration
 Increased flow to the right side increases the flow to the
tricuspid valve. Hence, the tricuspid valve is thus open
wider so it takes a longer time to close.
S3 and S4
 S3 – low frequency sound heard right after the previous S2 that Figure 3. Description of murmurs
is closer to the previous S2 than to the next S1 Holosystolic = sound is heard in whole of systole
Early diastolic
Known as the ventricular gallop END OF TRANS
‘Kentucky’ cardiophonetic
REFERENCES
corresponds to ventricular filling (splashing of blood on heart
2022 Exam 1 Trans B07
walls)
Dr. Abelardo’s lecture
Results from increased atrial pressure leading to increased
https://upload.wikimedia.org/wikipedia/commons/thumb/9/93/Stethosco
flow rates, as seen in congestive heart failure, but may be a pe.svg/2000px-Stethoscope.svg.png
https://depts.washington.edu/physdx/heart/tech2.html

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OS 213: Auscultation and Demonstration of Heart Sounds Exam 01 - Trans B05

SUMMARY

Stethoscope: Bell vs Diaphragm

BELL DIAPHRAGM
 More sensitive to low-pitched (low velocity) sounds  More sensitive to relatively high pitched (high velocity) sounds
 S3  S1 and S2
 Murmur of mitral stenosis  Murmurs of
aortic and mitral regurgitation
pericardial fiction rub

Auscultation Points
Heart sounds
AREA LOCATION
HEART
Aortic valve 2nd ICS R Parasternal border CHARACTERISTICS
SOUND
Pulmonic valve 2nd ICS L Parasternal border S1  “Lub”
Tricuspid valve 4th ICS L Parasternal border  At the apex, louder than S2
Mitral (bicuspid) valve 5th ICS L Midclavicular line  Shorter interval after; systole
ICS – intercostal space; R–right; L – left S2  “Dub”
Mnemonics:  At the base, louder than S1
 Always Pray To Mary  Longer interval after; diastole
 Apartment (APTM) 2245 S3  low frequency sound heard right after the
previous S2
 early diastolic
 ventricular gallop; Kentucky
S4  low frequency sound heard right before the
next S1
 late diastolic
 atrial gallop; Tennessee

Murmur
 Prominent “boogsh” or “fwooo” sounds; differentiated from S3 and S4 which are Clicks
 Stenosis – low pitched active harsh growling sound due to narrowed valve
 Regurgitation – high pitched passive gentle blowing sound due to a leaky valve
 Systolic murmur – between S1 and S2
 Diastolic murmur – between S2 and S1

HEART CONDITION ‘BEATBOX’ TIMING QUALITY/PITCH SHAPE

Mitral/Tricuspid WoooshDUB Holosystolic (chronic)/ High pitch Holosystolic
Regurgitation Early systolic (acute)
Aortic/Pulmonic Stenosis Lub-WOOSHhh DUB Mid-systolic Low pitch Crescendo

Mitral/Tricuspid Stenosis LUB-Durruuhh Mid-Diastolic Coarse rumbling Holodiastolic with a gap

(meaning no entry of
blood)
Aortic/Pulmonic LUB-fwooohh Early Diastolic Blowing, high pitch Decrescendo
Regurgitation

Patent Ductus Arteriosus SHOOSHwoosh Continuous Machine-like

Disclaimer: minor variations with regards to timing between mitral and tricuspid, and aortic and pulmonic; vary on area on auscultation

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