Auscultation

Auscultation
By the time you listen, you should know what to hear If you dont hear what you expect, explain it Dont leave the bedside till you know what you are hearing Never auscultate from the wrong side of the bed

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

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

Characteristics of a functional murmur

Short and soft SEM Normal S1 and S2 Normal cardiac impulse No evidence for any hemodynamic abnormality

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

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

Assessing Murmurs
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 bedside

Functional Murmur: short and soft SEM Normal S1 and S2 Normal cardiac impulse No evidence for hemodynamic abnormality

Innocent Murmurs
Common in asymptomatic adults Characterized by
Grade I II @ LSB Systolic ejection pattern

S1 S2 Normal intensity & splitting of second sound (S2) No other abnormal sounds or murmurs No evidence of LVH, and no with Valsalva

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
S1 S2 S1

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

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

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

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

Auscultation
Mitral Area (LLSB)
Listen for intensity of S1
Soft-LV dysfunction, first degree heart block, preclosure 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

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

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

AuscultationTiming of A2 to OS Interval
Say Prrr Pada Pata Papa Tuhuh Timing Severity Other seconds of MS HSs 0.06 Severe .07-.08 .08-.09 0.10 .12 Modsevere Mod Mild PK
0.1-0.110

A2-S3
0.12-0.18

Clinical Signs of LV Dysfunction

Hypotension Pulsus alternans Reduced volume carotid LV apical enlargement/displace ment Sustained apex - to S2 Soft S1 Paradoxically split S2 S3 gallop (not S4 = impaired LV compliance) Mitral regurgitation Pulmonary congestion
rales

Clinical Signs of RV Dysfunction

With Pulmonary HPT
Loud P2/palpable PR murmer RV lift

Without Pulmonary HPT

Soft P2 No PR +/- RV lift
TR CV wave murmer Pulsatile liver Edema

Common findings

RV S4 RV S3 JVP A wave + HJR + Kussmauls

Causes of RV Dysfunction
LV failure Pulmonary HPT
1 2

RV infarction Pericardial Disease

tamponade constriction