Thought provoking questions during or following practice:

1. Why is a focused examination of the nails and mouth a part of the cardiac exam? The

nails may reveal splinter hemorrhages indicating endocarditis. The palate may be
arched in cases of Marfans syndrome or demonstrate palatal petechiae in cases of
endocarditis. This is to remind the students to perform a full focused exam of other
organ systems not just the cardiac system when confronted with a cardiac complaint.
2. What is the difference between pectus carinatum and pectus excavatum and what
cardiac etiologies are associated with each? Pectus carinatum is a pigeon chest
associated with Marfans syndrome while Pectus excavatum or caved-in chest is
associated with mitral valve prolapse as well as Marfans syndrome.
3. What is a thrill and a heave? What does it signify? A thrill is a vibratory sensation felt on
the chest wall from underlying vascular turbulence. It signifies a loud murmur and
should prompt the examiner to auscultate closely for a loud murmur. A heave is a
sustained impulse felt on the chest wall indicating an enlarged right or left ventricle or
atrium and occasionally by ventricular aneurysms.
4. For each specialized maneuver state which cardiac etiology is being confirmed. The JVP
is used to assess right arterial pressure. If the top of the column is 3cm above the sternal angle,
then the venous pressure is elevated. If there is neck vein distention at the level of the jaw
margin while the patient is sitting at 90 degrees, the right arterial pressure usually exceeds
15mm of Hg.
The HJR assess for right ventricular failure. Normal response is for the IJ and EJ to demonstrate
transient distention through several cardiac cycles with a return to baseline at the end of compression.
In patients with right ventricular failure or elevated pulmonary wedge pressure, the neck veins remain
dilated throughout the maneuver.

5. What is a split s2? What does it signify?

6. How would you describe a murmur?
a. Timing in cardiac cycle
b. Location
c. Radiation
d. Duration
e. Intensity
f. Pitch
g. Quality
h. Relationship to respiration
i. Relationship to body position
Teaching Points for facilitators
Remind students that specialized maneuvers are performed as confirmatory tests for specific
etiologies. They are not performed on every patient. For exam JVP is examined as a way to
assess right heart function.
Reinforce to the students that a full exam involves inspection, palpation, percussion and
auscultation. Reinforce that students need to examine, if appropriate other organ systems even
though patient may be presenting with a cardiac complaint.
During the auscultation portion of the physical exam lab, prompt the students to explain what
murmur is best heard in each position.
o Left lateral decub-diastolic murmur of mitral stenosis heard with bell of stethoscope
o Upright sitting forward with patient in full exhalation-high-pitched diastolic murmur of
aortic regurgitation

The website www.practicalclinicalskills.com is the basis for this heart sounds lab. Below are the
steps to locating the audio for a variety of normal and abnormal heart sounds. Each section is
introduced with a small case and is followed by discussion questions that should be answered
while examining each of the heart sounds.
Make sure each of these sounds are covered in your small group prior to the physical exam
portion. Feel free, if time permits, to explore other heart sounds or review the anatomy and
description tabs for each of the sounds.
This website should be loaded for you prior to start of session. However, if you would like to
review the lab prior the small group session:
1. Go to website www.practicalclinicalskills.com
2. Click on heart sounds
3. Click on courses

Normal Heart Sounds-S1/S2 unsplit

Case: Ms. Jennifer Alvarez who you had seen last year for her pre-exercise clearance is back for her
routine yearly examination. You listen to her heart and hear the following:
1.
2.
3.
4.

On left side of page will be a list of heat sounds, click on normal heart sounds
Click on #1-First and second heart sounds-normal and unsplit
In the red banner click on Phonocardiogram/Waveform
Using the radiobuttons on the Soundbuilder click first on s1 and allow students to interpret
the sound
5. Continue through the buttons to build s1/s2, s1 systole/s2 diastole
Discussion Questions as you are examining the normal heart sounds
1. (Play S1 in isolation) What sound are you hearing? S1
2. How can you tell the first heart sound from the second? At normal heart rates (below 100)
systole is shorter than diastole so the first heart sound is occurs after a longer pause. The first
heart sound occurs right before the carotid pulse is felt.
3. Where is S1 best heard? The first heart sound is louder at the 5th intercostal space (apex).
4.
5.
6.
7.

What does S1 signify? What is happening anatomically during S1?

(Play S1/S2) What sound(s) do you here now? S1 and S2
What does S2 signify? What is happening anatomically during S2?
Where is the S2 best heard? At the 2nd intercostal space (base)

Normal Heart Sounds-S1/S2 physiologic Splitting

1. On left side of page will be a list of heat sounds, click on normal heart sounds
2. Click on #3-Second Hear Sound-Physiologic Split #1
3. In the red banner click on Phonocardiogram/Waveform
Discussion Questions as you are examining the physiologic split of S2:
1. (Ask while playing audio) What are you hearing? S1 with a Split S2
2. What position do you have the patient lying in to appreciate this sound the best?
3. What part of the stethoscope would you use to hear this sound the best?
4. Where do you place the stethoscope to best hear this sound?
5. What causes a split S2?
6. Why does the S2 change with inspiration and expiration?

S3
Case: A 67 year old man with a history of a myocardial infarction 6 months ago now presents with pedal
edema, orthopnea, decreasing exercise tolerance with dyspnea on walking 2 blocks and you hear the
following heart sounds:
1.
2.
3.
4.
5.
6.

Click on courses
On left side of page will be a list of heat sounds, click on Extra heart sounds-S3/S4
Click on #1-Third Heart Sound Gallop
In the red banner click on Phonocardiogram/Waveform
The soundbuilder radiobuttons will automatically be set to S1 systole and s2 diastole. Hit play.
If the students are having difficulty discerning the sounds feel free to use the sound builder to
separate s1 from s2 and the gallop

Discussion questions as you are examining the S3 gallop:

1. (Ask while playing audio) What heart sounds are you hearing? S1/S2 and S3 gallop (Kentucky)
2. How does the presence of an S3 affect the sound of the S1 and S2? The S1 is decreased in
intensity and the S2 is increased in intensity
3. What is an S3? The third heart sound is caused by a sudden deceleration of blood flow into the
left ventricle from the left atrium.
4. When in the cardiac cycle does an S3 occur? Diastole
5. Where on the chest wall is an S3 best heard? Mitral area, apex of the heart
6. What part of the stethoscope do you use to best hear an S3 and why? The bell because it is a lowpitched sound
7. How is the patient positioned to best hear an S3? Left lateral decubitus position
8. What does the presence of an S3 indicate clinically in a pediatric patient or athlete? It may be
normal
9. What does the presence of an S3 indicate clinically in this hypertensive patient? Congestive heart
failure
S4
A 72 year old woman with long standing hypertension presents for her routine examination. Her blood
pressure is still elevated at 160/94. You hear the following heart sounds:
1.
2.
3.
4.
5.
6.

Click on courses
On left side of page will be a list of heat sounds, click on Extra heart sounds-S3/S4
Click on #2-Fourth Heart Sound Gallop
In the red banner click on Phonocardiogram/Waveform
The soundbuilder radiobuttons will automatically be set to S1 systole and s2 diastole. Hit play.
If the students are having difficulty discerning the sounds feel free to use the sound builder to
separate s1 from s2 and the gallop
7. Feel free to alternate between the S3 (#1) and S4 (#2) sounds on the main extra heart sounds
menu and clicking on the play button overlying the chest wall diagram so that the students can
hear the difference.
Discussion questions as you are examining S4 gallop:
1. (Ask while playing audio) What heart sounds are you hearing? S1/S2 and S4 gallop
2. How does the presence of an S4 affect the sound of the S1 and S2? The S1 is decreased in
intensity and the S2 is increased in intensity
3. What is an S4? A low pitched diastolic gallop heard in pre-systole. It typically occurs about
90msec before S1. It is caused by a forceful atrial contraction against a stiffened ventricle that
cannot expand any further.
4. When in the cardiac cycle does and S4 occur? Diastole

5. Where on the chest wall is an S4 best heard? The 5th intercostal space, midclavicular line just
below the left nipple (apex)
6. What part of the stethoscope do you use to best hear an S4 and why? Bell because it is a lowpitched sound
7. How is the patient positioned to best hear an S4? Left lateral decubitus
8. What does an S4 indicate clinically? The left ventricle is stiffened from hypertrophy of fibrosis.
Innocent (Functional) Murmur
A 32 year old man with sickle cell disease is admitted with an acute painful crisis, his hgb is 7.2gm/dl.
While listening to his heart you hear the following murmur.
1.
2.
3.
4.
5.

Click on courses
On left side of page will be a list of heat sounds, click on Normal heart sounds
Click on #5-Innocent Murmur
In the red banner click on Phonocardiogram/Waveform
The soundbuilder radiobuttons will automatically be set to S1 systole and s2 diastole. Hit
play.

Discussion questions for innocent murmur:

1. What are you hearing? An innocent murmur
2. When does an innocent murmur occur during the cardiac cycle? Functional murmurs
are short early to mid systolic murmurs
3. Where is an innocent murmur best heard? They are well localized to the left sternal
border
4. What is the intensity or grading of functional murmurs? What does this mean? They
are grade less than 2/6. This means they are low intensity and usually audible to
inexperienced listeners. There is no thrill.
5. What maneuvers decrease the intensity of a functional murmur? Innocent murmurs
decrease in intensity when the patient stands, sits up or strains during Valsalva
maneuver.
6. What are some causes of functional murmurs? These murmurs are usually due to
conditions outside the heart- anemia, fever with increased blood flow.
Severe Aortic Stenosis
A 76 year old woman complains of substernal chest pain on walking 3 blocks that lasts for 5 minutes
and then resolves when she stops walking. On listening to her heart in the 2nd right ICS by the sternum
you hear the following.
1.
2.
3.
4.
5.

Click on courses
On left side of page will be a list of heat sounds, click on Systolic Murmurs
Click on #4-Aortic Stenosis-Severe
In the red banner click on Phonocardiogram/Waveform
The soundbuilder radiobuttons will automatically be set to S1 systole and s2 diastole. Hit
play.

Discussion questions for the murmur of aortic stenosis:

1. What are you hearing in regards to heart sounds? S1 is normal. As the disease
progresses the intensity of S2 decreases. An absent S2 as in this case indicates severe
disease.
2. Describe the murmur. This is a late peaking (diamond shaped) systolic murmur.
3. Based on these findings (A diamond shaped midsystolic murmur with an absent S2)
what is the diagnosis? Severe aortic stenosis.

4. What position should the patient be sitting in to best hear the murmur of AS? Seated
leaning forward.
5. Where is this murmur usually heard and where does it tend to radiate? Over the left
sternal border, 2nd intercostal space. The murmur typically radiates to the carotids.
6. What would you find on palpating her PMI? A sustained apical impulse due to LVH.
7. What would you find on palpating her carotids? A small volume impulse and delayed
(pulsus parvus et tardus).
Mitral Regurgitation
A 55 year old man with a past history of cocaine use was told last year he had cardiomegaly on x ray.
He now has the following murmur:
1.
2.
3.
4.
5.

Click on courses
On left side of page will be a list of heat sounds, click on Systolic Murmurs
Click on #5-Mitral Regurgitation
In the red banner click on Phonocardiogram/Waveform
The soundbuilder radiobuttons will automatically be set to S1 systole and s2 diastole. Hit
play.

Discussion questions for the murmur of aortic stenosis:

1. What are you hearing in regards to heart sounds? S1 is normal. S2 is normal.
2. Describe the murmur. This is a rectangular shaped murmur that is heard throughout
systole.
3. Based on these findings (A rectangular shaped holosystolic murmur what is the
diagnosis? Mitral Regurgitation
4. What position should the patient be sitting in to best hear the murmur of AS? Supine
with the diaphragm of the stethoscope
5. Where is this murmur usually heard and where does it tend to radiate? At the apex
(midclavicular line 5th intercostal space) and radiating to the axilla.
6. What would bilateral increased hand grip do to this murmur? Why? The murmur
would increase in intensity by increasing arterial resistance causing more blood to
flow back through the mitral valve.
Mitral Valve Prolapse
A 23 year old woman with a BMI of 22 and a blood pressure of 100/70 complains of intermittent
palpitations. On listening to her heart you hear the following:
1.
2.
3.
4.
5.

Click on courses
On left side of page will be a list of heat sounds, click on Systolic Murmurs
Click on #6-Mitral Valve Prolapse
In the red banner click on Phonocardiogram/Waveform
The soundbuilder radiobuttons will automatically be set to S1 systole and s2 diastole. Hit
play.
6. Feel free to use the soundbuilder to isolate the heart sounds and the midsystolic click.
Discussion questions for mitral valve prolapse:
1. What are you hearing in regards to heart sounds? S1 is normal. S2 is normal. There is
a midsystolic click.
2. Describe the murmur. There is a medium pitched diamond shaped murmur that
begins right after a mid systolic click and runs to the end of systole.
3. Based on these findings (A diamond shaped midsystolic murmur following a
midsystolic click what is the diagnosis? Mitral Valve Prolapse

4. What position should the patient be sitting in to best hear the murmur of AS? Supine
with the diaphragm of the stethoscope.
5. Where is this murmur usually heard and where does it tend to radiate? At the apex.
Midclavicular line 5th intercostal space
6. What do different maneuvers do to the click of MVP? Maneuvers that decrease return
to the heart (standing or straining with valsalva) will cause a smaller left ventricle and
leaflets to prolapse earlier moving the click towards S1. The murmur always follows
the click.
7. What maneuvers would increase the intensity of the murmur? Why? The murmur
would increase in intensity with handgrip and moving from squatting to standing.
The intensity of the murmur depends on afterload. Afterload is the end load against
which the heart contracts to eject blood. Afterload is the aortic pressure the left
ventricular muscle must overcome to eject blood. Squatting to standing makes the
murmur louder because increased sympathetic tone preserves afterload and
ventricular contractions are more vigorous intensifying the sound.
Aortic Regurgitation
A 46 year old IV drug user is admitted with a fever of 103F. You listen to his heart and hear the
following:
1.
2.
3.
4.
5.

Click on courses
On left side of page will be a list of heat sounds, click on Diastolic Murmurs
Click on #1-Aortic Regurgitation-mild
In the red banner click on Phonocardiogram/Waveform
The soundbuilder radiobuttons will automatically be set to S1 systole and s2 diastole. Hit
play.
1. What are you hearing in regards to heart sounds? S1 is present with absent S2
2. Describe the murmur. There is a high pitched decrescendo murmur occupying the first
half of diastole can be heard starting immediately after the second heart sound.
3. Based on these findings (A high pitched decrescendo murmur what is the diagnosis?
Aortic Regurgitation
4. What position should the patient be sitting in to best hear the murmur of AS? Seated
leaning forward holding his breath after expiration.
5. Where is this murmur usually heard and where does it tend to radiate? At Erbs Pointthe third intercostal space on the left sternal border where S2 is best auscultated.

Hypertrophic Cardiomyopathy (HOCM) (use only if time permits)

A 14 year old boy is concerned because his 20 year old cousin was recently told to stop playing College
Varsity basketball. You listen to his heart and hear the following: Feel free to substitute famous athletes
who have died of HOCM. Go to
http://en.wikipedia.org/wiki/Hypertrophic_cardiomyopathy#Notable_cases prior to the session.
1. Click on courses
2. On left side of page will be a list of heat sounds, click on Systolic Murmurs
3. Click on #7-Hypertrophic Cardiomyopathy
4. In the red banner click on Phonocardiogram/Waveform
5. The soundbuilder radiobuttons will automatically be set to S1 systole and s2 diastole.
Hit play.

Discussion questions for the murmurs of hypertrophic cardiomyopathy:

1. What are you hearing in regards to heart sounds? S1 is normal. S2 is normal. There
may be an S4 due to the stiffness of the left ventricle
2. Describe the murmur. There is a harsh diamond shaped murmur that starts at the
beginning of systole and ends well before the second heart sound. There are actually
2 murmurs, a systolic aortic murmur and a systolic mitral murmur. However, because
they occur at the same time they are heard as one murmur.
3. Based on these findings (A harsh shaped midsystolic murmur in the aortic area with a
diastolic murmur in the mitral area) what is the diagnosis? Hypertrophic
Cardiomyopathy
4. Why are there 2 murmurs in this condition? The first systolic murmur results from the
strong contraction of the stiff left ventricle causes the anterior leaflet to be sucked into
the ventricle, blocking the flow into the aorta and causing an aortic murmur. At the
same time turbulent flow from the left ventricle to the left atrium causes a second
systolic mitral murmur.
5. What position should the patient be sitting in to best hear the murmur of HOCM?
Supine with the diaphragm of the stethoscope and sitting forward.
6. Where is this murmur usually heard and where does it tend to radiate? The
rectangular shaped pansystolic murmur is best heard over the apex while the aortic
midsystolic diamond shaped murmur is best heard and the left sternal border, 2nd
intercostal space.
7. What does handgrip, squatting and leg elevation do to this murmur? What about
Valsalva strain? Why? The murmur would decreases in intensity with handgrip and
moving from squatting to standing. The intensity of the murmur decreases with
increased afterload. Valsalva decreases blood return to the heart therefore decreasing
ventricular volume. This increases the obstruction and increases the murmurs
intensity.
If time permits you can also take the Quick Quiz together as a group.
1. Click on courses
2. On left side of page will be a list of heart sounds, click on Auscultation in
Primary Care
3. Click on Quick Quiz at the bottom of the page