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Sumber: A Practical Guide to Clinical Medicine - University of California

Auscultation: The following anatomic pictures will aid you in understanding the principles of cardiac

Good Exam Options When Ausculting Female Patients

Bad Exam Options When Ausculting Female or Male Patients

1. Become comfortable with your stethescope. There are multiple brands on the market, each of
which incorporates its own version of a bell (low pitched sounds) and diaphragm (higher
pitched sounds). Some have the diaphragm and bell on opposite sides of the head piece.
Others have the bell and diaprhragm built into a single side, with the bell engaged by applying
light pressure and the diaphragm engaged by pushing more firmly. Adult, pediatric, and
newborn sizes also exist. And some combine adult and pediatric scopes into a single unit.
Take the time to read the instructions for your particular model so that you are familiar with
how to use it correctly. Several sample stethescopes are pictured below. It's worth mentioning
that almost any commercially available scope will do the job. The most important "part" is
what sits betwen the ear pieces!
2. Engage the diaphragm of your stethescope and place it firmly over the 2nd right intercostal
space, the region of the aortic valve. Then move it to the other side of the sternum and listen
in the 2nd left intercostal space, the location of the pulmonic valve. Move down along the
sternum and listen over the left 4th intercostal space, the region of the tricuspid valve. And
finally, position the diaphragm over the 4th intercostal space, left midclavicular line to
examine the mitral area. These locations are rough approximations and are generally
determined by visual estimation. In each area, listen specifically for S1 and then S2. S1 will
be loudest over the left 4th intercostal space (mitral/tricuspid valve areas) and S2 along the
2nd R and L intercostal spaces (aortic/pulomonic valve regions). Note that the time between
S1 and S2 is shorter then that between S2 and S1. This should help you to decide which sound
is produced by the closure of the mitral/tricuspid and which by the aortic/pulmonic valves and
therefore when systole and diastole occur. Compare the relative intensities of S1 and S2 in
these different areas.

Auscultation of the Heart

3. In younger patients, you should also be able to detect physiologic splitting of S2. That is, S2
is made up of 2 components, aortic (A2) and pulmonic (P2) valve closure. On inspiration,
venous return to the heart is augmented and pulmonic valve closure is delayed, allowing you
to hear first A2 and then P2. On expiration, the two sounds occur closer together and are
detected as a single S2. Ask the patient to take a deep breath and hold it, giving you a bit
more time to identify this phenomenon. The two components of S1 (mitral and tricuspid valve
closure) occur so close together that splitting is not appreciated.

4. You may find it helpful to tap out S1 and S2 with your fingers as you listen, accentuating the
location of systole and diastole and lending a visual component to this exercise. While most
clinicians begin asucultation in the aortic area and then move across the precordium, it may
actually make more sense to begin laterally (i.e. in the mitral area) and then progress towards
the right and up as this follows the direction of blood flow. Try both ways and see which feels
more comfortable.
5. Listen for extra heart sounds (a.k.a. gallops). While present in normal subjects up to the ages
of 20-30, they represent pathology in older patients. An S3 is most commonly associated with
left ventricular failure and is caused by blood from the left atrium slamming into an already
overfilled ventricle during early diastolic filling. The S4 is a sound created by blood trying to
enter a stiff, non-compliant left ventricle during atrial contraction. It's most frequently
associated with left ventricular hypertrophy that is the result of long standing hypertension.
Either sound can be detected by gently laying the bell of the stethoscope over the apex of the
left ventricle (roughly at the 4th intercostal space, mid-clavicular line) and listening for low
pitched "extra sounds" that either follow S2 (i.e. an S3) or precede S1 (i.e. an S4). These
sounds are quite soft, so it may take a while before you're able to detect them. Positioning the
patient on their left side while you listen may improve the yield of this exam. The presence of
both an S3 and S4 simultaneously is referred to as a summation gallop.

Listening for Extra Heart Sounds

6. Murmurs: These are sounds that occur during systole or diastole as a result of turbulent blood
flow. and fall into 2 broad groups:
1. Leaking backwards across a valve that is supposed to be closed. These are referred to
as regurgitant or insufficiency murmurs (e.g. mitral regurgitation, aortic
2. Flow disturbance across a valve that will not open fully/normally. These valves suffer
from varying degrees of stenosis (e.g. aortic stenosis).

It's worth mentioning that sometimes "flow murmurs" can occur, resulting from high output
across structurally normal valves. In addition, some valves with insignificant degrees of
pathology (e.g. aortic sclerosis - where the valve leaflets are slightly calcified yet function
normally) generate murmurs. Distinguishing which murmurs are clinically relevant takes
thought and practice. Ive added a description of some helpful features below.

Traditionally, students are taught that auscultation is performed over the 4 areas of the
precordium that roughly correspond to the "location" of the 4 valves of the heart (i.e. aortic
valve area ='s the 2nd Right Intercostal Space, pulmonic valve area ='s the 2nd LICS,
tricuspid valve area ='s 4th LICS, and mitral valve area ='s 4th LICS in the midclavicular
line). This leads to some misperceptions. Valves are not strictly located in these areas nor are
the sounds created by valvular pathology restricted to those spaces. So, while it might be OK
to listen in only 4 places when conducting the normal exam, it is actually quite helpful to
listen in many more when any abnormal sounds are detected. If you hear a murmur, ask

c. Does it occur during systole or diastole?

d. What is the quality of the sound (i.e. does it get louder and then softer; does it
maintain the same intensity throughout; does it start loud and become soft)? It
sometimes helps to draw a pictoral representation of the sound.
e. What is the quantity of the sound? The rating system for murmurs is as follows:
 1/6... Can only be heard with careful listening
 2/6... Readily audible as soon as the stethescope is applied to the chest
 3/6... Louder then 2/6
 4/6... As loud as 3/6 but accompanied by a thrill
 5/6... Audible even when only the edge of the stethescope touches the chest
 6/6.. Audible to the naked ear
Most murmurs are between 1/6 and 3/6. Louder generally (but not always)
indicates greater pathology.
f. What is the relationship of the murmur to S1 and S2 (i.e. when does it start and stop)?
g. What happens when you march your stethescope from the 2nd RICS (the aortic area)
out towards the axilla (the mitral area)? Where is it loudest and in what directions
does it radiate? By moving in small increments (i.e. listening in 8 or 10 places along
the chest wall) you will be more likely to detect changes in the character of a
particular murmur and thus have a better chance of determining which valve is
affected and by what type of lesion.
7. Auscultation over the carotid arteries (see under aortic stenosis for additional information): In
the absence of murmurs suggestive of aortic valvular disease, you can listen for carotid bruits
(sounds created by turbulent flow within the blood vessel) at this point in the exam. Place the
diaphragm gently over each carotid and listen for a soft, high pitched "shshing" sound. It's
helpful if the patient can hold their breath as you listen so that you are not distracted by
transmitted tracheal sounds. The meaning of a bruit remains somewhat controversial. I was
taught that bruits represented turbulent flow associated with intrinsic atherosclerotic disease...
and that the disappearance of a bruit which was previously present was a sign that the lesion
was progressing (i.e. further encroachment on the lumen of the vessel). However, a number of
studies provide evidence that atherosclerotic disease is frequently absent when a bruit is
present as well as the reverse situation. This is actually of clinical importance because recent
data suggest that it may be beneficial to surgically repair carotid disease in patients who have
significant stenosis yet have not experienced any symptoms (e.g. Transient ischemic attacks
or strokes. Surgery in these settings has already proven to be beneficial). Thus, it is becoming
increasingly important to determine the best way of identifying asymptomatic carotid artery
disease... and carotid auscultation may, in fact, not be the mechanism of choice!
8. Identifying the Most Common Murmurs:
9. 1. Systolic Murmurs: In the adult population, these generally represent either aortic stenosis
or mitral regurgitation. To distinguish between them, remember the following:
10. Murmurs of Aortic Stenosis (AS):
. Tend to be loudest along the upper sternal borders and get softer as you move down
and out towards the axilla. There is, however, a phenomenon referred to at the
gallavardin Effect which can cause murmurs of AS to sound as loud towards the
axilla as they do over the aortic region. When this occurs, the shape of the sound
should be similar in both regions, helping you to distinguish it from MR (see below).
a. Have a growling, harsh quality (i.e. get louder and then softer.. also referred to as a
crescendo decrescendo, systolic ejection, or diamond shaped murmur). When the
stenosis becomes more severe, the point at which the murmur is loudest (i.e. its peak
intensity) occurs later in systole, as it takes longer to generate the higher ventricular
pressure required to push blood through the tight orifice.
b. Are better heard when the patient sits up and exhales.
c. Are heard in the carotid arteries and over the right clavicle. Radiation to the clavicle
can be appreciated by simply resting the diaphragm on the right clavicle. To assess
for transmission to the carotids, have the patient hold their breath while you listen
over each artery using the diaphragm of your stethescope. Carotid bruits can be
confused with the radiating murmur of aortic stenosis. In general, carotid bruits are
softer. Also, murmurs associated with aortic pathology should be audible in both
carotids and get louder as you move down the vessel, towards the chest. In settings
where carotid pathology coexists with aortic stenosis, a loud transmitted murmur
associated with a valvular lesion may overwhelm any sound caused by intrinsic
carotid disease, masking it completely.
d. Carotid upstrokes refer to the quantity and timing of blood flow into the carotids from
the left ventricle. They can be affected by aortic stenosis and must be assessed
whenever you hear a murmur that could be consistent with AS. This is done by
placing your fingers on the carotid artery as described above while you
simultaneously listen over the chest. There should be no delay between the onset of
the murmur, which marks the beginning of systole, and when you feel the pulsation in
the carotid. In the setting of critical (i.e. very severe) aortic stenosis, small amounts of
blood will be ejected into the carotid and there will be a lag between when you hear
the murmur and feel the impulse. This is referred to as diminished and delayed
upstrokes (a.k.a. parvus et tardus), as opposed to the full and prompt inflow which
occurs in the absence of disease. Mild or moderate stenosis does not alter the
character of carotid in-flow.
e. Sub-Aortic stenosis is a relatively rare condition where the obstruction of flow from
the left ventricle into the aorta is caused by an in-growth of septal tissue in the region
below the aortic valve known as the aortic outflow tract. It causes a crescendo-
decrescendo murmur that sounds just like aortic stenosis. As opposed to AS,
however, the murmur is louder along the left lower sternal border and out towards the
apex. This makes anatomic sense as the obstruction is located near this region. It also
does not radiate loudly to the carotids as the point of obstruction is further from these
vessels in comparison with the aortic valve. You may also be able to palpate a
bisferiens pulse in the carotid artery (see under aortic insufficiency). Furthermore, the
murmur will get softer if the ventricle is filled with more blood as filling pushes the
abnormal septum away from the opposite wall, decreasing the amount of obstruction.
Conversely, it gets louder if filling is decreased. This phenomenon can actually be
detected on physical exam and is a useful way of distinguishing between AS and sub-
aortic obstruction. Ask the patient to valsalva while you listen. This decreases venous
return and makes the murmur louder (and will have the opposite effect on a murmur
of AS). Then, again while listening, squat down with the patient. This maneuver
increases venous return, causing the murmur to become softer. Standing will cause
the opposite to occur. You need to listen for 20 seconds or so after each change in
position to really appreciate any difference. Because the degree of obstruction can
vary with ventricular filling, sub-aortic stenosis is referred to as a dynamic outflow
tract obstruction. In aortic stenosis, the degree of obstruction that exists at any given
point in time is fixed.

Murmurs of Mitral Regurgitation (MR):

f. Sound the same throughout systole.

g. Generally do not have the harsh quality associated with aortic stenosis. In fact, they
sound a bit like the "shshing" noise produced when you pucker your lips and blow
through clenched teeth.
h. Get louder as you move your stethescope towards the axilla.
i. Will get even louder if you roll the patient onto their left side while keeping your
stethescope over the mitral area of the chest wall and listening as they move. This
maneuver brings the chamber receiving the regurgitant volume, the left atrium, closer
to your stethescope, accentuating the murmur.
j. Get louder if afterload is suddenly increased, which can be accomplished by having
the patient close their hands tightly. MR is also affected by the volume of blood
returning to the heart. Squatting increases venous return, causing a louder sound.
Standing decreases venous return, thereby diminishing the intensity of the murmur.

Sometimes murmurs of aortic stenosis and mitral regurgitation co-exist, which can be difficult
to sort out on exam. Moving your stethescope back and forth between the mitral and aortic
areas will allow for direct comparison, which may help you decide if more then one type of
lesion is present or if the quality of the murmur is the same in both locations, changing only in
intensity (i.e. consistent with a one valve problem).

2. Diastolic Murmurs: Tend to be softer and therefore much more difficult to hear then those
occurring during systole. This makes physiologic sense as diastolic murmurs are not
generated by high pressure ventricular contractions. In adults they may represent either aortic
regurgitation or mitral stenosis, neither of which is too common. While systolic murmurs are
often obvious, you will probably not be able to detect diastolic murmurs on your own until
you have had them pointed out by a more experienced examiner.

Aortic Regurgitation (AR); a.k.a. Aortic Insufficiency (AI):

k. Is best heard along the left para-sternal border, as this is the direction of the
regurgitant flow.
l. Becomes softer towards the end of diastole (a.k.a. decrescendo).
m. Can be accentuated by having the patient sit up, lean forward and exhale while you
n. Occasionally accompanies aortic stenosis, so listen carefully for regurgitation in
patients with AS.
o. Will cause the carotid upstrokes to feel extraordinarily full as significant regurgitation
increases ventricular pre-load, resulting in ejection of an augmented stroke volume.
AI can also produce a double peaked pulsation in the carotids known as a bisferiens
pulse, which is quite difficult to appreciate. Feeling your own carotid impulse at the
same time that you're palpating the patient's may accentuate this finding. In cases of
co-existent AS and AI, a bisferiens pulse suggests that the AI is the dominant
problem. It may also be present with sub-aortic stenosis (see above), helping to
distinguish it from AS.

Mitral Stenosis (MS):

p. Heard best towards the axilla

q. Can be accentuated by having the patient role onto their left side while you listen with
the bell of your sthethescope.
r. Associated with a soft, low pitched sound preceding the murmur, called the opening
snap. This is the noise caused by the calcified valve "snapping" open. It can, however,
be pretty hard to detect.

Auscultation, an ordered approach:

Try to focus on each sound individually and in a systematic fashion. Ask yourself: Do I hear
S1? Do I hear S2? What is their relative intensities in each of the major valvular areas? Is S2
split physiologically? Are there extra sounds before S1or after S2 (i.e. an S4 or S3)? Is there a
murmur during systole? Is there a murmur during diastole? If a murmur is present, how loud
is it? What is its character? Where does it radiate? Are there any maneuvers which affect its
intensity? Remember that these sounds are created by mechanical events in the heart. As you
listen, remind yourself what is happening to produce each of them. By linking auscultatory
findings with physiology, you can build a case in your mind for a particular lesion.

Interrelationship of Cardiac Events & Sounds

This diagram courtesy of Dr. Wilbur Lew, Department of Medicine, San Diego VA Medical

A few final comments about auscultation:

19. Pulmonic valve murmurs are rare in the adult population and, even when present, are
difficult to hear due to the relatively low pressures generated by the right side of the
20. Tricuspid regurgitation (TR) is relatively common, most frequently associated with
elevated left sided pressures which are then transmitted to the right side of the heart
(though a number of other processes can cause TR as well). In this setting, both mitral
and tricuspid regurgitation often co-exist. The murmur of MR is generally louder then
that of TR, again due to the higher pressures on the left side of the heart. It can
therefore be difficult to sort out if there is co-existent TR when MR is present. Try to
listen along both the low left and right sternal borders (areas where the tricuspid valve
is best assessed) and compare this to the mitral area. Move your stethoscope slowly
across the precordium and note if there is any change in the character/intensity of the
murmur. TR murmurs are also accentuated by inhalation, which increases venous
return and therefore flow across the valve.
21. Patients with COPD (emphysema) often have very soft heart sounds. Air trapping and
subsequent lung hyperinflation results in a posterior-inferior rotation of the heart
away from the chest wall and causes the interposition of lung between the chest wall
and heart. In this setting, heart sounds can be accentuated by having the patient lean
forward and fully exhale prior to listening. Furthermore, in any patient with
particularly "noisy" breath sounds, it may be helpful to ask them to hold their breath
(if they're able) while you examine the heart.
22. Rubs: These are uncommon sounds produced when the parietal and visceral
pericardium become inflamed, generating a creaky-scratchy noise as they rub
together. The classic rub is actually made up of three sounds, associated with atrial
contraction, ventricular contraction, and ventricular filling. In reality, its rare to hear
all 3 components (more commonly, 2 are apparent). They can be accentuated by
listening when the patient sits up, leans forward and exhales, bringing the two layers
in closer communication. I feel compelled to mention this finding only because a
common short hand for reporting the results of the cardiac exam comments on the
absence of "gallops, murmurs, or rubs," implying (incorrectly) that rubs are a frequent
23. If a patient has an abnormal heart sound due to a structural defect that has been
quantified by echocardiography, make sure that you compare your findings to those
identified during the study. This is a great way of learning!