Cardiac Auscultation

Cardiovascualr Exam
Palpation

 Point of Maximal Intensity (PMI)

o Place flat hand over apical area

o Localize PMI with pads of fingers

o May have patient lean forward if unable to detect

o Normally felt at or medial to the left 4th or 5th ICS MCL

Auscultation

 Listening Areas:

o Aortic Area  2nd right ICS close to the sternum

o Pulmonic Area  2nd left ICS

o ERB’s Point  3rd left ICS

o Tricuspid Area  5th left ICS parasternally

o Mitral Area  5th left ICS MCL

 Sounds

o Time between S1 to S2 shorter than S2 to S1

o S1 heard best at the apex

o S2 heard best at the base

o S1 synchronous closure is of mitral and tricuspid valves

o S2 synchronous closure is of aortic and pulmonic valves

 Murmur Timings

o Diastolic

 Aortic and Pulmonic  Regurgitation

 Mitral and Tricuspid  Stenosis

o Systolic
  Aortic and Pulmonic  Stenosis

 Mitral and Tricuspid  Regurgitation

 Left lateral (Decubitus)

o 30-35° left lateral

o Listen when patient is moving into and out of position

o Use the bell

 May attenuate murmurs

 May make S3 and S4 sounds more detectable

 Certain murmurs may be best heard in this position (mitral

stenosis)
 Can make the PMI more obvious

Extra Heart Sounds

 Splitting S2

o Closure of the aortic and pulmonic valves create S2 sound

o Pulmonic valve  (P2) closes slightly after the aortic valve (A2) during
inspiration
o THIS IS A NORMAL FINDING

o Best heard during inspiration at pulmonic and ERB’s point

o Lub-T-dub, Lub-T-dub

 S3

o Comes just after S2 (Ventricular Gallop)

o May sound like an S2 split but the size of the split doesn’t change with
respiration
o It’s fairly normal in children and athletes

o In older individuals it may represent non-specific impairment of

ventricular function
o Ken-tuck-y… ken-tuck-y

 S4

o Just prior to S1

o Usually not normal

 o Active ventricular filling during diastole

o More pronounced when ventricular wall gets more rigid (as with
hypertrophy)

 Timing Cycles

o Pansystolic  goes through the entire systolic interval

o Crescendo  increasing intensity (increase pitch)

o Decrescendo  decreasing intensity (pitch decreases

o Diamond shaped  crescendo – decrescendo

 Rating Systolic Murmurs

o 1. Heard with careful listening

o 2. Readily audible soon as stethoscope is applied to chest

o 3. Louder than 2 without a thrill

o 4. Loud with associated thrill

o 5. Audible even when only the edge of stethoscope

o 6. Audible without stethoscope

Rhythm Abnormalities

 Sinus arrhythmia

o Most common arrhythmia

o Pulse rate accelerates with inspiration

o Pulse rate decfreases with expiration

 More common in children and often found in adults

 Pulse defecit

o Atrial fibrillation + tachycardia

o Radial pulse may not be equal to cardiac pulse

 Bigeminal Pulse

o Two consecutive beats closely coupled with subsequent pause before

next beats
o Second beat may be waker

o Caused by:
  PVC  irregularly irregular

 2nd degree heart block  regularly irregular

Volume Abnormalities

 Pulsus Alterans

o Alternating succession of strong and weak beats due to chaning

systolic pressure
o Regular in rhythm/variable in volume

o Difference in intensity due to ventricular decompensation

 Hyperkinetic Pulse (bounding)

o Quick up stroke with full volume

o Hypertension and anxiety

 Corrigan’s Pulse (water-hammer pulse)

o Brisk pulse with full volume

o Sudden expansion followed by sudden collapse

o Aortic regurgitation