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A Technique for Cardiac
Auscultation
Chapter 6
Ara G. Tilkian, MD, FACC
Instructor
Patricia L. Thomas, MBA, RCIS
Outline
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How to Proceed
Patient Position
Inspection and Palpation
Palpating Thrills
Inching
Respiration
Cardiac Auscultation of the Bony Chest
Evaluation of Heart Sounds Summarized
Evaluation of Heart Murmurs Summarized
How to Proceed
• Quiet room
• Block out all other visual & auditory
perceptions
• Closing your eyes may help
• Concentrating on one cardiac event at a
time
Patient Position
• Recumbent, comfortable & relaxed
• Examination from patient’s right side
• Murmurs & gallop rhythms are louder in the
recumbent position
• In this position venous return to the heart is
increased & can be further augmented by raising
the patient’s legs
• Patient’s left side mitral murmurs & thrills are best
heard because the apex is closer to the chest wall
• Sitting or standing sounds & pulsations may
disappears
Inspection & Palpation
• PMI- point of maximal impulse
• Rate of Rise: The Carotid Pulse-peak of pulsation
– A normal ROR feels like a sharp tap
– Abnormal ROR like a nudge or a weak tap
• Pulsus Alternans
– Regular rhythm with alternating strong and weak ventricular
contractions
– Alternation of S2
• Brachioradial Delay & Apical-Carotid Delay
– Indicates aortic stenosis
– Brach: Right Brachial and Right Radial artery
– Apical: PMI & Right Carotid Artery
Palpating Thrills
• Palpable murmurs-low-pitched vibrations
associated with heart murmurs
• Best felt with palms of the hand
• The thrill of AS radiates toward the right
neck
• The thrill of PS radiates toward the left neck
• Look for jerking carotids & for venous
pulsations
“Inching”
• Listen to first heart sound (intensity, variability,
localization
• Listen to second heart sound (It is split?)
• Does it vary with respiration? Is P2 loud?
• Listen for a third heart sound
• Listen for any abnormal sounds such as S4 or a
click
• Listen for systolic murmurs then for diastolic
murmurs
Respiration
• Inspiration causes right-sided cardiac events to be
louder and delays left-sided events by a few
seconds because of
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Decreased intrapleural pressure
Increased venous return to the right heart
Prolongation of RV systole
Delay in PV closure
Increase in pulmonary capacity
Delay in venous return to the LA
Shortening of LV systole
Early closure of the AV
Respiration cont…
• In normal individuals:
– The two components of S2 can usually be
identified at the end of deep inspiration
– S2 becomes one sound during expiration
Evaluation of Heart Sounds Summarized
• Are both S1 and S2 present?
• Is each normal?
• If not, is S1 loud, weak, or absent? Can both
components of S1 be recognized?
• Is S2 loud, weak, or absent? Is there normal
splitting of S2 on inspiration? Is the splitting of S2
reversed (widest on expiration)?
• Are there more than two heart sounds? Is the extra
sound systole or diastolic? Is it closer to S1 or S2
and at what interval? What is its quality? Does it
vary with respiration?
• Is there a murmur?
THE END
OF
CHAPTER 6
Tilkian, Ara MD Understanding Heart Sounds and Murmurs,
Fourth Edition, W.B. Sunders Company. 2002, pp. 49-57.