- Heart Murmurs
- Continuous [Machinery] Murmurs
- Diastolic Murmurs
- Systolic Murmurs
- Heart Sounds
- Pericardial Friction Rub
How to Cite This Chapter: Ibrahim O, Sibbald M, Szczeklik W, Leśniak W. Heart Auscultation. McMaster Textbook of Internal Medicine. Kraków: Medycyna Praktyczna. //empendium.com/mcmtextbook-sae/chapter/B78.I.1.107.?rfmcm Accessed November 13, 2022.
Last Updated: December 14, 2020
Last Reviewed: April 10, 2021
Chapter Information
McMaster University Editorial Office
Section Editors: Matthew Sibbald
Authors: Omar Ibrahim, Matthew Sibbald
Polish Institute for Evidence Based Medicine Editorial Office
Section Editors: Andrzej Budaj, Wiktoria Leśniak
Authors: Wojciech Szczeklik, Wiktoria Leśniak
South Asia Editorial Office
Section Editor[s]: Jyotirmoy Pal, Nandini Chatterjee
Chapter Editor[s]: Partha Sarathi Karmakar
Main Documents Taken Into Account:
Zipes DP, Libby P, Bonow RO, Mann DL, Tomaselli GF, Braunwald E, eds. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 11th ed. Elsevier; 2019.
Bickley LS, Szilagyi PG. Bates’ Guide to Physical Examination and History-Taking. 11th ed. Wolters Kluwer Health/Lippincott Williams & Wilkins; 2013.
Simel DL, Rennie D, Keitz SA. The Rational Clinical Examination: Evidence-Based Clinical Diagnosis. McGraw-Hill; 2009.
Walker HK, Hall WD, Hurst JW. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd ed. Butterworths; 1990.
There are 4 main areas of auscultation: Fig. 1.15-1. Their central points are:
1] The fifth left intercostal space medial to the midclavicular line [apex]: Mitral valve area [M].
2] The fourth and fifth intercostal spaces near the lower sternal border: Tricuspid valve area [T].
3] The second left intercostal space near the upper sternal border: Pulmonary valve area [P].
4] The second right intercostal space near the upper sternal border: Aortic valve area [A].
Place the patient in a supine position and auscultate the heart. Instruct the patient to breathe steadily. When necessary, ask the patient to stop breathing on inspiration or expiration or to change their body position. Right-sided murmurs are usually louder on inspiration due to increased venous return from negative intrathoracic pressure created by inspiration. Palpate the carotid or radial pulse simultaneously to orient your auscultation to the first heart sound [S1; occurs before pulse upstroke] and the second heart sound [S2; occurs after upstroke].
FiguresTop
Figure 1.15-1. Areas of auscultation of the heart.
Have you ever gone to the doctor and they’ve used a stethoscope to listen to your chest and back? What exactly are they doing, and are they just moving the stethoscope around at random?
Auscultation is a term used to listen to the internal sounds of the body. It is an important part of the physical exam and can help diagnose patients. Let’s now go to Complete Anatomy for more information.
The four standard points of auscultation for the heart are:
- Aortic – on the patients right side of the sternum
- Pulmonary – on the left-hand side of the patients’s sternum
- Tricuspid – in the fourth intercostal space, along the lower-left border of the sternum
- Mitral – in the fifth intercostal space, along the mid-clavicular line
The points of auscultation are an important part of clinical skills for doctors or nurses. Maybe using the mnemonic All Patients Trust Me will help you remember this in the future!
Cardiac auscultation refers to listening to the sounds of the heart with a stethoscope. This short, yet important part of a health exam can tell a lot about the patient’s well-being.
To listen to the different points of auscultation, the doctor will use either a traditional or tunable stethoscope to determine if there are any abnormalities present and if further tests need to be performed. Stethoscope types should be chosen with consideration to the doctor’s needs and the type of patients they will be working with.
Aortic
Typically, the heart creates a “lub-dub” sound, which occurs when blood is being pumped and flowed to and from the heart. These are also referred to as S1 and S2 sounds.
The S1 sound is caused by the closure of the mitral and tricuspid valves. The S2 sound follows, caused by the closure of the aortic and pulmonic valves.
The aortic point is located on the right side of the sternum in the second intercostal space. This is where the doctor will place the stethoscope to listen to the sounds produced by the aortic valve. Here the heart produces the S2 sound, which your doctor will listen for.
Pulmonic
The pulmonic point is left to the sternum in the second intercostal space.
The typical S2 sound, referred to as the “dub” sound, should also be present at the pulmonic auscultation point.
Erb’s Point
Erb’s point is located to the left of the sternum in the third intercostal space and is the approximate center of the heart.
At this point, the doctor will listen for both the S1 and S2 sounds.
Tricuspid
The tricuspid point is left of the sternum in the fourth intercostal space. The tricuspid valve assists blood flow in the right direction while separating the upper and lower chambers of the heart.
Here your doctor can listen to the S1, or “lub”, sound. They can also check for an opening snap, which is a high-frequency sound caused by the opening of the mitral or tricuspid valves, which may indicate a narrowing of the valves.
Mitral
The mitral point is located at the left side of the sternum in the fifth intercostal space.
Here, your doctor will get the clearest resonance of the S1 sound.
Stethoscope Differences
Many stethoscopes now offer tunable diaphragm technology. This helps make finding and listening to auscultation points easier and clearer.
To use, the doctor needs to adjust the pressure applied from the hand to the area of the chest. Light pressure helps with hearing lower frequency sounds, while firm pressure blocks the low sounds and amplifies the higher frequency sounds.
Traditional stethoscope models, which are often used on children, require the doctor to turn over and reposition the chest piece to listen to the different auscultation points. They will first use the flat diaphragm side, followed by the concave bell side.
When the stethoscope is used by a medical professional, it can amplify important cardiac sounds to help determine whether patients may have certain murmurs, heart valve dysfunction, or other abnormalities that require further investigation.