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School of Medicine.
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of Medicine and VA Medical Center, San Diego, California 920930611.
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Cardiovascular Exam
The major elements of the cardiac exam include observation, palpation and, most
importantly, auscultation (percussion is omitted). As with all other areas of the
physical exam, establishing adequate exposure and a quiet environment are critical.
Initially, the patient should rest supine with the upper body elevated 30 to 45
degrees. Most exam tables have an adjustable top. If not, use 2 or 3 pillows.
Remember that although assessment of pulse and blood pressure are discussed in
the vital signs section they are actually important elements of the cardiac exam.
The evaluation of the cardiovascular system focuses on the heart, but should also
include an assessment for disease in the arterial system throughout the body.
Atherosclerosis, the most common cardiovascular ailment in the western world, is
a systemic disease. As such, appropriate evaluation requires a broad assessment.
Observation &
Jugular Venous
Pressure

Palpation of Assessment of
Gowning Palpation Auscultation the abdominal lower
aorta
extremities

Observation: Assessment for distention of the right Internal Jugular vein (IJ) is a
difficult skill. Its importance lies in the fact that the IJ is in straight-line
communication with the right atrium. The IJ can therefore function as a
manometer, with distention indicating elevation of Central Venous Pressure (CVP).
This in turn is an important marker of intravascular volume status and related
cardiac function. The focus here is on simply determining whether or not Jugular
Venous Distention (JVD) is present. A discussion of the a, c and v waves that make
up the jugular venous pulsations can be found elsewhere. These are quite difficult
to detect for even the most seasoned physician.
Why is JVD so hard to assess? The IJ lies deep to skin and soft tissues, which can
provide quite a bit of cover. Additionally, this blood vessel is under much lower
pressure then the adjacent, pulsating carotid artery. It therefore takes a sharp eye to
identify the relatively weak, transmitted venous impulses. A few things to
remember:
1. Think anatomically. The right IJ runs between the two heads (sternal and
clavicular) of the sternocleidomastoid muscle (SCM) and up in front of the

ear. This muscle can be identified by asking the patient to turn their head to
the left and into your hand while you provide resistance to the movement.
The two heads form the sides of a small triangle, with the clavicle making
up the bottom edge. You should be able to feel a shallow defect formed by
the borders of these landmarks. Note, you are trying to identify impulses
originating from the IJ and transmitted to the overlying skin in this area. You
can't actually see the IJ. The External Jugular (EJ) runs in an oblique
direction across the sternocleidomastoid and, in contrast to the IJ, can
usually be directly visualized. If the EJ is not readily apparent, have the
patient look to the left and valsalva. This usually makes it quite obvious. EJ
distention is not always a reliable indicator of elevated CVP as valves,
designed to prevent the retrograde flow of blood, can exist within this vessel
causing it to appear engorged even when CVP is normal. It also makes
several turns prior to connecting with the central venous system and is thus
not in a direct line with the right atrium.

2. Take your time. Look at the area in question for several minutes while the
patient's head is turned to the left. The carotid artery is adjacent to the IJ,
lying just medial to it. If you are unsure whether a pulsation is caused by the
carotid or the IJ, place your hand on the patient's radial artery and use this as
a reference. The carotid impulse coincides with the palpated radial artery
pulsation and is characterized by a single upstroke timed with systole. The
venous impulse (at least when the patient is in sinus rhythm and there is no
tricuspid regurgitation) has three components, each associated with the
aforementioned a, c and v waves. When these are transmitted to the skin,
they create a series of flickers that are visible diffusely within the overlying
skin. In contrast, the carotid causes a single up and down pulsation.
Furthermore, the carotid is palpable. The IJ is not and can, in fact, be
obliterated by applying pressure in the area where it emerges above the
clavicle.
3. Search along the entire projected course of the IJ as the top of the pressure
wave (which is the point that you are trying to identify) may be higher then
where you are looking. In fact, if the patient's CVP is markedly elevated,
you may not be able to identify the top of the wave unless they are
positioned with their trunk elevated at 45 degrees or more (else their will be
no identifiable "top" of the column as the entire IJ will be engorged). After
you've found the top of the wave, see what effect sitting straight up and
lying down flat have on the height of the column. Sitting should cause it to
appear at a lower point in the neck, while lying has the opposite effect.
Realize that these maneuvers do not change the actual value of the central
venous pressure. They simply alter the position of the top of the pulsations
in relation to other structures in the neck and chest.
4. Shine a pen light tangentially across the neck. This sometimes helps to
accentuate the pulsations.
5. If you are still uncertain, apply gentle pressure to the right upper quadrant of
the abdomen for 5 to 10 seconds. This elicits Hepato-Jugular Reflux which,
in pathologic states, will cause blood that has pooled in the liver to flow in a
retrograde fashion and fill out the IJ, making the transmitted pulsations more
apparent. Make sure that you are looking in the right area when you push as
the best time to detect any change in the height of this column of blood is
immediately after you apply hepatic pressure.
6. Once you identify JVD, try to estimate how high in cm the top of the
column is above the Angle of Louis. The angle is the site of the joint which
connects the manubrium with the rest of the sternum. First identify the
supra-sternal notch, a concavity at the top of the manubrium. Then walk
your fingers downward until you detect a subtle change in the angle of the
bone, which is approximately 4 to 5 cm below the notch. This is roughly at

the level of the 2nd intercostal space. The vertical distance from the top of
the column to this angle is added to 5cm, the rough vertical distance from
the angle to the right atrium with the patient lying at a 45 degree angle. The
sum is an estimate of the CVP. However, if you can simply determine with
some accuracy whether JVD is present or not, you will be way ahead of he
game! Normal is 7-9 cm.

Bony Structures of the Chest

Finding the Angle of Louis: The wooden Q-tips highlight the different slopes of
the sternum and manubrium.
The point at which the Q-tips cross is the Angle of Louis.

Determining the CVP

Video of patient with markedly elevated
central venous pressure.
Video simulation and discussion of
central venous pressure.

Take some time to look across the left chest and try to identify the transmitted
impulse caused by ventricular contraction, which may be apparent when
contractions are particularly vigorous.
Thoughts On "Gown Management" & Appropriately/Respectfully Touching
Your Patients:
There are several sources of tension relating to the physical exam in general, which
are really brought to the fore during the chest examine. These include:
Area to be examined must be reasonably exposed - yet patient kept as
covered as possible
The need to Palpate sensitive areas in order to perform accurate exam requires touching people w/whom you've little acquaintance - awkward,
particularly if opposite gender
As newcomers to medicine, you're particularly aware that this aspect of the
exam is "unnatural" & hence very sensitive.. which is a good thing!

Keys to performing a sensitive yet thorough exam:

Explain what you're doing (& why) before doing it acknowledge
"elephant in the room"!
Expose the minimum amount of skin necessary - this requires "artful" use of
gown & drapes (males & females)
Examining heart & lungs of female patients:
o Ask pt to remove bra prior (you can't hear the heart well thru fabric)
o Expose left side of chest to extent needed
o Enlist patient's assistance, asking them to raise their breast to a
position that enhances your ability to listen to and palpate the heart
Don't rush, act in a callous fashion, or cause pain
PLEASE... don't examine body parts thru gown as:
o It reflects Poor technique
o You'll miss things
o You'll lose points on scored exams (OSCE, CPX, USMLE)!
Palpation: The palm of your right hand is placed across the patient's left chest so
that it covers the area over the heart. The heel should rest along the sternal border
with the extended fingers lying below the left nipple. Focus on several things:
Palpation of the Precordium to Determine the Location of the PMI

1. Can you feel a Point of Maximum Impulse (PMI) related to contraction at

the apex of the underlying left ventricle? If so, where is it located? After
identifying the rough position with the palm of your hand, try to pin down
the precise location with the tip of your index finger. The normal sized and
functioning ventricle will generate a penny sized impulse that is best felt in
the mid-clavicular line, roughly at the 5th intercostal space. If the ventricle
becomes dilated, most commonly as the result of past infarcts and always
associated with ventricular dysfunction, the PMI is displaced laterally. In
cases of significant enlargement, the PMI will be located near the axilla.
Occasionally, the PMI will not localize to any one area, which does not
necessarily indicate ventricular enlargement or dysfunction. Obesity and
COPD may also limit your ability to identify its precise location. Palpating
while the patient is in the left lateral decubitus position can make the PMI
more obvious.
2. What is the duration of the impulse? In the setting of hypertension or any
other state of chronic pressure overload, the ventricle hypertrophies and the
PMI becomes sustained (i.e. you feel the impulse for a longer period of
time). This is actually pretty subjective and can be tough to detect. Note that
hypertrophy and dilatation are not synonymous. They can exist separately or
in conjunction with one another.
3. How vigorous is the transmitted impulse? Processes associated with
ventricular hypercontractility (e.g. compensated mitral regurgitation or
aortic insufficiency that result in exceptionally large stroke volumes)
generate an impulse of unusual vigor.

4. Do you feel a thrill, a vibratory sensation produced by turbulent blood flow

that is usually secondary to valvular abnormalities? The feeling is similar to
that produced when you squeeze on a garden hose, partially obstructing the
flow of water. The location of the thrill will depend on the involved valve
(e.g. thrills caused by aortic stenosis are best felt toward the right upper
sternal border). If a loud murmur is detected during auscultation, you may
then go back and reassess for the presence of a thrill. In general, thrills are
an uncommon finding.
*Palpation of the precordium of a female patient is best done by placing the
palm of your right hand directly beneath the patient's left breast such that the
edge of your index finger rests against the inferior surface of the breast.
Make sure that you tell that patient what you are about to do (and why)
before actually performing this maneuver. Remember that with age tissue
turgor often declines, causing the breasts to hang below the level of the
heart.
5. Carotid Artery Palpation: This is of greatest value during the assessment of
aortic valvular and out flow tract disease (see below) and should thus be
performed after auscultation so that you know whether or not these
problems exist prior to palpation. However, for the sake of completeness it
will be described here. The carotids can be located by sliding the second and
third finger of either hand along the side of the trachea at the level of the
thyroid cartilage (i.e. adams apple). The carotid pulsation is palpable just
lateral to the groove formed by the trachea and the surrounding soft tissue.
The quantity of subcutaneous fat will dictate how firmly you need to push.
The pulsations should be easily palpable. Diminution may be caused by
atherosclerosis, aortic stenosis, or severely impaired ventricular
performance. Do not push on both sides simultaneously as this may
compromise cerebral blood flow.

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

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!

Adult Stethoscope

Combination Adult & Pediatric

Stethoscope

Adult Stethoscope: Diaphragm

and Bell Incorporated Into Single
Side.

Newborn Stethoscope

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.
Univeristy of Utah, Review of Cardiac Physiology
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 insufficiency).

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 yourself:
1. Does it occur during systole or diastole?
2. 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.
3. 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.
4. What is the relationship of the murmur to S1 and S2 (i.e. when does it
start and stop)?
5. 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.
b. 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!
The Auscultation Assistant is an excellent heart sound simulation site developed at
UCLA. Press the "Back" button to return to this page.
Blaufuss Multimedia Heart Sounds Tutorial. Press the "Back" button to return to
this page.
This University of Washington site also provides a variety of simulated heart
sounds. Press the "Back" button to return to this page.
In addition, there is an excellent heart sound tutorial CD ROM called, The
Physiological Origins of Heart Sounds and Murmurs available at the OLR.

c. Identifying the Most Common Murmurs:

d. 1. Systolic Murmurs: In the adult population, these generally represent
either aortic stenosis or mitral regurgitation. To distinguish between them,
remember the following:
e. Murmurs of Aortic Stenosis (AS):
1. 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).
2. 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.

3. Are better heard when the patient sits up and exhales.

4. 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.
5. 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.
6. 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):

7. Sound the same throughout systole.
8. 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.
9. Get louder as you move your stethescope towards the axilla.
10.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.
11. 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):

12.Is best heard along the left para-sternal border, as this is the direction
of the regurgitant flow.
13.Becomes softer towards the end of diastole (a.k.a. decrescendo).
14.Can be accentuated by having the patient sit up, lean forward and
exhale while you listen.
15.Occasionally accompanies aortic stenosis, so listen carefully for
regurgitation in patients with AS.
16.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):
17.Heard best towards the axilla
18.Can be accentuated by having the patient role onto their left side
while you listen with the bell of your sthethescope.

19.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 Center.
A few final comments about auscultation:
1. 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 heart.
2. 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 coexistent 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.
3. Patients with COPD (emphysema) often have very soft heart sounds.
Air trapping and subsequent lung hyperinflation results in a posteriorinferior 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.
4. 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 finding.

5. 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!
6. Don't get frustrated! Auscultation is a difficult skill to "master" and
we are all continually refining our techniques. Take your time. Make
sure the room is quiet. Be patient. Ask for help frequently. Read about
particular murmurs and their pathophysiology when you encounter
them. A number of the more subtle findings (e.g. an S3 or S4) can be
very difficult to identify when the patient is tachycardic, a not
uncommon scenario as this is one of the compensatory mechanisms
for dealing with the dysfunction that has generated these findings in
the first place. Re-examination after the patient has made clinical
improvement may be more revealing.
In general, many of the above techniques are not used when examining every
patient. If the exam is normal, it would be neither efficient nor revealing to put a
patient through all of these maneuvers. The goal is to have a "bag of skills" at your
disposal that you can reach into and employ to better define abnormalities when
they present themselves.