10 Basic Rules
on
Cardiac Auscultation
Antonio Guijarro-Morales, MD
Head of Clinical Cardiology
Hospital Universitario San Cecilio
Granada - Spain
1 - The First Heart Sound
is simultaneous to the carotid pulse.
Its identification is the
first obligate step
on cardiac auscultation.
2 - The Second Heart Sound
must be analyzed,
with the membrane of the stethoscope,
at the pulmonary area,
where its two components are best identified.
Observe its respiratory
variations and splitting.
3 - The Third Heart Sound
is usually best heard
at cardiac apex,
in the partial left lateral
decubitus position,
with the bell of the stethoscope.
4 - The Fourth Heart Sound
is best heard with the bell of the stethoscope,
at cardiac apex (left origin)
or tricuspid area (right origin).
5 - In Systole we can hear
early systolic ejection sounds
(aortic or pulmonary stenosis),
nonejection mid- to late- systolic clicks
(prolapse, extracardiac),
and also
holosystolic (mitral or tricuspid regurgitations
or interventricular communication),
protomesosystolic ejection
(innocent or aortic or pulmonary stenosis)
and mesotelesystolic (prolapse)
murmurs.
6 - In Diastole we may hear
opening snaps (mitral or tricuspid stenosis),
protodiastolic murmurs (aortic regurgitation
or hypertensive pulmonary regurgitation),
mesodiastolic rumbles
(organic or functional mitral
or tricuspid stenosis)
and
presystolic murmurs
(mitral or tricuspide stenosis
in sinusal rythm).
7 - Frequently, but not always,the
double and triple murmurs
are due to combined valve injuries.
The pericardial friction rub
usually is triple-phased,
with scratching quality.
8 - The continuous murmurs
begin in systole and continue into the diastole,
without interruption
through the timing of second heart sound.
They are due to
arteriovenous shunts and venous hum.
9 - The areas of auscultation
indicate zones where sounds and murmurs
are heard with preference,
but do not exclude to auscultate
all around the thorax.
10- The best profit
of the cardiac auscultation is obtained
studying the appearance or modification
of sounds and murmurs
by means of the appropriate
postural, respiratory and functional changes
(Valsalva, exercise, handgrip,
amyl nitrite inhalation, etc).
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