Heart sound auscultation sites Name af area Erb point careioloey) Loeaton + alte parasternal intercostal space Patholesy Diastolic murmurs: aortic resurstationculmonicreaursitation ‘Systlc murmurs: HOCM ‘ante area Pulmonte ares Mitra area _2°4right parasternal intercostal space + 209i parasternalintercostal space ‘+ SP leftintercortal spaceln th midctavcula line oriesenosi orticregugtation CCozttatonof the aorta Pulmonary stenos's Pulmonary regurgitation 280 Mitral stenosi Mitral regurgitation Mitral valve orotanse (MVP) “Weuspid area + sPlet parasteralinercostal space “Teuspldstenois TrcuspregurgtationNormal heart sounds * The first ($1) and second (S2) heart sounds are physiological sounds heard in allhealthy individuals. + The third ($3) and fourth (54) heart sounds may be physiological (particularly n young adults, pregnant women, and the elderly) or pathological ‘Normal heart sounds sound onin Location Fatheartsound + Closure ofthe mil vate ana + Heat bestn he ital area crac p09) ea tspidvahe Seconthent + Casroofthezrtevae(A2}and + AU:Heardst nthe aot oreo at thee per et iuimenary val 2) strat border) © Ad:cloureof the aortic vale louder) © P2:cosur ofthe pulmonary vae (softer) + Pz:Heard bestinthe pulmonary resion Timing + Attheonset ofsstole + Heard ust beorethe carotid pulsations Duringthe transition from systoteto diastole + Heardimmeciatly ter the carotid pulsation + Seealso"Sptingof52°Extra heart sounds! ‘xtra heart sounds (gallons) Sound | Origin “Timing Occurrence Tried | * Ducto rani ventilating and sudden + Early iastoicsound that isheardimmediatey ater S2 ‘+ Physolesica: younginiviuals (- the mitralaran wlth the patietlvingina le {ater poston deceleration of lod when he verre | Veneer sop ts toiawesty$2 sean close succession 0 yar of age ales, or ere] aches eteelin rezemblng he cadence ofthe word Kentucky” (en TUCK) 20 Pregrant women + Heardbestwth the bellofthestethoscopein | auscultation ©) + Pathological = ‘the itral area withthe paietina etateral © Chronicmitralesursitation postion «+ oticreguation + Hear faire © «© Dilatodcardamyopathy « Thyrorueess Founh | + Dvetolstedoetleconracionofthest'a + Lateclasl pent soura hess icles bore St «+ Phyloleeea avancesage E) heart (auc) agisthigh ventricular oressure |, 51 apy follows 4 resembling the cadence of he word + Pathologaif palpable wm | = “Tennesse (Termes SEE) on auscitaton. «© Vontriularhypertrophy (23, Q + Heard best withthe bellofthestethscopein fpertenson sortie stenosis imonsle) © lechemiceardionropathy © Acute myocardalinfrctionChanges In intensity ™ Increased or decreased intensity (loudness) of the heart sounds may indicate certain pathologies. © Mitral stenosis ©) © Tachycarala © Hyperdynamic states (eg, left-to-right shunts ©) © Short PRinterval eg. AVRT) + Softsi © Severe mitralstenosis ©) ©. Conditions that impair the transmission of heart sounds to the chest wall: COPD, pneumothorax. pericardial fusion, obestty © LeBe S} © Prolonged PR interval eg, first-degree heart blocks) + Variable intensity ©. Atrial fibrillation © AV dissociation 2 Auscultatory alternans: severe LV fallure, large pericardial effusion‘S2intensity + Loud A2:arterialhypertension, coarctation of the aorta + Loud p2: pulmonary hypertension ©), atrial septal defects" Splitting of heart sounds!" If the aortic and pulmonary valves do not close simultaneously, an apparent spitting of $2 canbe heard upon auscultation.) Solttingotheeresounds Typeotslt Deseition causes somes + Occurs whenthe dose ofthe ticuspd valves delayed (eg. due toan RBBB) resuting | + Conductioncsorders inthesoundo tricuspid val oso heard shorty after mia aie lure) + Hemodnamiccause Physiological | + Thesoundof aortic valve dsure (2) precedes thesound of pulmonary valeclosure(P2) | + Espedally pronounced amon youns ‘Solit ‘during inspiration individuals it 2 © reprton ~ fallin intrathoracic presse ncesseinvenousreturato theishtside a ofthe haart — prolonged rsh verrcular systole —~ delved closure cfP2 «Peeling boosh sulrenarycrculsen ~ shortened lftvantclsrsetla— prematurea2 + Anexageerated pysoloscl spt hich ismare pronounced ring ispcaton(A2 + Pulmona ion widest a recedes P2) + Pulmonary valestenos's © + Caused by any conton that ereses ght venta fein or deereates left eu ventiular preload «Increased right ventricular afterload —- prolonged right ventricular systole + Massive pulmonary emboli© Increased right ventricular afterload — prolanged right ventricular systole ‘Massive pulmonary embolism © Decreased left ventricular preload ~ shortened lft ventricular systole + Severe mitral regurgitation + Wolf-Parkinson White syndrome + Constricivepericardts + Docsnet change ith respiration and tends tobewide.Le.thespltisalo audbleduring | + Atrialseptaldetect(ASD) Foxed slit expiation S) + Severe RV allure a + Lefeto right shunt in ASD ~ RV vslume overnad ~ deayin the closure ofthe pulmansry valve pardoc + Audible during expiration but not inspiration + Aorticstenosis reconical © Exprtion:A2 isheardatterP2 during exiration due to delayed cosureaf the serie. Lf unde branch block soli valve (pt reversal) | sfebundle branch block + HOCM (lV outow tractobstruction) reversed © Inspiration: theclosureof the pulmonary valves ako delayed resulting in 2nd P2 ‘split occurring simultaneously (i... a paradoxical decrease inthe split during inspiration) . Ey troctaton of tein sentido 1 Wolf Parkinson White snaome) a ‘Absent split + Nosalitngof52 + Severe sorte stenass(geritri) ©) ‘VSO with Elesnmengar syndrome pediatric) ©Etolosy + rlysystole sound + Aartestancse dliele ‘Heard best with the diaphragm of a stethoscope at the aorticregion with the patient ‘immediately after $4) {tated lain forward Mirtvaive ‘Mirae plas ro tele aa drng sole + Midst somna) Minaivaie prolapse click ‘Heard best withthe diaphragm of astethascope atthe mitra region withthe patfentin * prolapse leflstrl esiion ©) Mitvave peningofa soffit ave + Eaydstalcsond + Mirlstenss a Heardbesththeelofasettosopeatthemiareianviththpatertinale | medal aferS2) lateral position Machaizalvave | + StandS2sound acl «Goings witha normal Stand | + Prosthetic ve clicks: ‘Heard best with the diaphragm of astethoscope & Peckardalitin | * Sratchingsound due oon betwee the vera and parietal paws ©] Syst or dstteseund : aa Heardbest veh stra borde durin xian wth teat sting ove andletirgormad Perwraatinace | + Suen cesaton of ensign rig pera ack + Dimtacsona Conscive ‘Heard best at the left sternal border + pericarditis‘+ Murmurs are blowing or whooshing sounds that occur as a result of turbulent blood flow, ‘+ They are described according to the location. radlation, timing, Intensity, configuration frequency, and response to dynamlcmaneuvers. «+ For specific auscultatory findings in valvular heart disease, see "Auscultation in valvular defects” ‘+ For specific auscultatory ndings of heart defects, see “Congenital heart detects” Functional and pathological murmurs ‘Murmurs may be functional or pathological Difference berween functional and pathological murmurs crea Funetional heart murmur {physiological or innocent) ae Etology | Anelecton murmur ue tolnereasadar turbulent Hood few seree norm serteandopulmonaryvalves, | + Causady structural defect (aiular eg,dueto a hyperdynmic circulation iseaseor heart defects) ‘+ Mest commonly eccursinchilren and young adults + Cardiac pathology mustberuled out , 1 Softgrace «3/6wlthout ahr) + Tiel grace» 9/6 tensity + Toil maybepresent Tings + Most commonly midsysioicor continuous + Stoic diastolic or continaous Position “+ Postion-dependent: varies in intensity rcssppears + Rarely disappears ‘changeTiming of heart murmurs! Murmur Timing =) Occurrence Functional Pathological systole + During vantreuar contraction (a, occurs + Children anti murmur | withoraterS1 and before S2) + pregnanoy + steno + Conbecassifed as: + During states of excitement or strenuousaciviy Palmore © Early systole murmur . + ences © Midsysttle murmur ©) nee Mil © Latesystoticmurmur i a + regurgitation + Tryrotoxtosis Theaspld © Holesystoic murmur] + Benes + regurgitation + Artriovenousfstula + v0 + Stiimarmur CCourctatonot © Most common innocent murmurin children ©) + thezorts © Grade 1-3 midsystolle murmur heard best tthe left midsteral border or + Hoo between the et ower sternal border andthe apex © Louder when the patients susine an sfter when thepatent suprght © Unknown etiolonyDiastolic | * During ventricular relaxation (te, occursvwtth + Does not occur phystologially ‘Mitral rag | rater andbeforest) + stenosis + Canbedassined ast otic © Exrydastole + repurptation | Miseacttle Trews > Late diastolic + steno « Holodiasteic Pulmonary + eugtation Continuous | + During systole snd taste + Hyperdymamic state + PDA rmureeur + Cervical venoushur Arteriovenous © Common benign findinsinchildrendue to turbulent fowininternalugular veins | + fistulas Heard best the infreclaviclar and susracavicuar regions (mere common on the rights} © Becomes softer or isappears with lon ofthe ead compression of the Jugularvein or inthe supine position © May atiate tothe 1 and 2°¢1¢5 ©“Maneuvers and their effect on murmurs Maneuver Valsalva maneuverstancing ‘Sauating/ ing down quickiasng the legs ©) Effect oncardiac parameters 1 RV preload LW pred Noeffecton Vafterload | RV preload lV preload 4 lWaftedoad 1 RV preload 11 preload Nosftecton LV afterload (teroodt marincrease with sasatins) Effect on murmurs + Intensity of murmurs arising from theriehtsdeof theheart + {Intensity of murmurs asing fom the eft ide ofthe hear {see“Exceptions to maneuvers” below! +t ntensty of MVP with eary midsole cick and hypertrophic careiomponathy (HCM) + {Intensity of murmurs asing fom the eft side ofthe hea {see “Exceptions to maneuvers” below) + Intensity ofall murmurs see" Exceptions to maneuvers" below) + {Intensity of MVP wit Ite systole ce and HCM murmurs + Tetzlogy of Fallot: The severity of te spl andthe asadated murmurs decrease with swatting, 1+ MVP: cickoceuslaterinsystole sande + NoeectonRV preload + Intensity of murmurs resulting rom backward flow of bled in thee side ofthe heart fez. eee + Noeffecton LV preload sort regurgitation, mitral regurgitation, VSD, MVP) Dates + LInteityof murmurs azrociated with forward fl of Hoodinthe let side ofthe her le, iva stenosis, aortiestenors HEM) + MPs elckoceurssterinsystole + Noattce + Intense ofmurmurs ator near the ari valve (esate steals sorte eguration, ‘Sting and ening frward ‘coarctation ofthe aorta, HOCM)+ Nostiet on RY preload ‘intensity of murmurs resulting from backwardfow of bloodin the lft sdeoftheheart (ee. Hand grip) + NoetfectontV pretoad sorte equation, mitral reguritation VSO, MVP) “Wottsoas _LIntensty of murmurs asocates wit forward lowofbloedin the tse ofthe hears. ner sterene sorte steness, HM) Muck oceurs later insystole . . + Noetect, “Intensity of mumursat or near the antic vale (eg, aortstenoss orticreguttaton, Siting on lenine forward courclationof he 2rta,HOCM) + Noetfect ‘Iovansty of murmurs ator nar the mia valve (eg, mitral stenosis, mitral regurgitation, lying down inthe lateral wo position