13.14: Cardiovascular System Abnormal Findings II: Auscultation

Auscultation, an essential part of a heart examination, is done using a stethoscope. It provides crucial information about heart function and possible heart problems. Due to heart problems, abnormal sounds can be heard during systole or diastole. These sounds include S3 and S4 gallops, opening snaps, systolic clicks, and murmurs.

Abnormal Heart Sounds

Gallops:

1. S3 Gallop: An early diastolic sound that suggests heart failure and volume overload. It is best heard with the stethoscope bell at the apex in the fifth intercostal space at the midclavicular line, with the patient lying on their left side.
2. S4 Gallop: A late diastolic sound associated with atrial contraction against a stiff ventricle, common in hypertension and aortic stenosis. It is best heard with the stethoscope bell at the apex in the fifth intercostal space at the midclavicular line, with the patient lying on their left side.

Systolic clicks:

1. Ejection Click: Associated with aortic or pulmonic valve stenosis, observed just after S1. The aortic click can be most clearly heard in the second intercostal space at the right upper sternal border. In contrast, the pulmonic click is most clearly audible at the left upper sternal border in the same intercostal space.
2. Mid-Systolic Click: Associated with mitral valve prolapse, often followed by a late systolic murmur, best heard at the apex in the fifth intercostal space at the midclavicular line.

Opening snaps:

1. A high-frequency sound that occurs shortly after S2 is typically associated with mitral stenosis. It is best heard at the apex and indicates the sudden opening of a stiff mitral valve.

Heart Murmurs

Heart murmurs result from turbulent blood flow and are classified by timing in the cardiac cycle, intensity, pitch, and quality. Key types include systolic, diastolic, and continuous murmurs.

Systolic Murmurs: Occur between S1 and S2. Examples include:

1. Aortic Stenosis: A rough, harsh murmur, most audible at the right upper edge of the sternum in the second intercostal space, extends towards the carotid arteries.
2. Mitral Regurgitation: A high-pitched, blowing murmur best heard at the apex in the fifth intercostal space at the midclavicular line, radiating to the axilla.
3. Ventricular Septal Defect: A loud, harsh murmur is best heard at the left lower sternal border in the third and fourth intercostal spaces.

Diastolic Murmurs: Occur between S2 and S1. Examples include:

1. Aortic Regurgitation: It is characterized by a high-pitched, blowing murmur that is most audible at the left side of the sternum in the third intercostal space.
2. Mitral Stenosis: It is characterized by a low-pitched, rumbling murmur accompanied by an opening snap, heard at the heart's apex located in the fifth intercostal space along the midclavicular line, especially when the patient is in a left lateral decubitus position.

Continuous Murmurs: Heard throughout the cardiac cycle and indicate conditions such as:

1. Patent Ductus Arteriosus: A continuous, machine-like murmur best heard at the left infraclavicular area in the second intercostal space.