Introduction to Auscultation
Dr Zoltán Pozsonyi
3rd Dep. of Int. Med.
Semmelweis University
History
History
• before: ear on the chest
• Laennec- 1816:
– rolled up piece of paper in case of an obese
female patient with sus...
Auscultation
• very important, simple, effective clinical
technique to evaluate circulatory and
respiratory system
• very ...
Significance
• Nowadays (echo, X-ray, CT, MRI) the
importance of auscultation is smaller
• limited access to imiging modal...
Technique of auscultation
• quiet environment
– ER, other patients, computers; close the
doors

• proper position
– may ne...
Auscultation of the abdomen
• Bowel motility and abdominal complaints
• Searching for renal stenosis (hypertension)
• How ...
Abnormal bowel sounds
• Increased intensity and frequency:
– diarrhea
– intestinal obstruction=obstructive ileus

• Decrea...
Bruits over the abdomen
• Normally there is no bruit
• for stenosis of the renal artery:
– listening for bruits (vascular ...
Bruits
• Atherosclerosis--stenosis
• Carotid artery (part of routine exam.)
–
–
–
–

stenosis=bruits (not always)
ischaemi...
Before auscultation of lungs
• Patients arms crossed in front of the chest
• Diaphragm of the stethoscope
• Ask the patien...
Location of auscultation
Topographic considerations
Posterior view

Anterior view
Lung sounds
inspiration

pause

expiration

pause

• Expiration is longer than expiration
• Normally expiration is less lo...
Lung sounds-normal sounds
Two forms
• Tracheal or bronchial breath sounds
• Origin: turbulent airflow in central airways
•...
Normal sounds
• Vesicular breath sounds
• Origin: distal to the trachea, proximal to
the alveoli
• Normally vesicular soun...
Abnormal sounds
Absent or decreased breath sounds
• Severe asthma bronchiale: decreased
sounds
• Emphysema: decreased soun...
Adventitious breath sounds
• Crackles (rales), discontinuous, non-musical, brief
•
•
•
•
•

sounds
more commonly on inspir...
Crackles- conditions
•
•
•
•
•
•

pneumonia
ARDS
bronchiectasis
early CHF
interstitial lung disease
pulmonary edema
Wheeze
• continuous, high pitched, hissing sounds
• heard normally on expiration but also
sometimes on inspiration
• produ...
Wheeze-Conditions:
•
•
•
•
•

asthma bronchiale
CHF
chronic bronchitis
COPD
pulmonary edema
Stridor
• inspiratory musical wheeze heard loudest
over the trachea during inspiration
• stridor suggests an obstructed tr...
Pleural Rub
• creaking or brushing sounds produced
when the pleural surfaces are inflamed
and rub against each other
• may...
Pleural Rub-condition
• Pleuritis
• Pneumonia with pleuritis
• Postthoracothomy syndrome
Auscultation of the heart
• bare skin; displace gently large left breast
• supine position first
• location
– anatomic ref...
Heart
• Diaphragm: high pitched sounds:
– S1, S2, systolic murmurs (common)

• Bell: low pitched sounds:
– S3, S4, diastol...
What to listen for
• First heart sound (S1: closure of mitr. & tricusp.
valves)
– intensity, splitting (PHT, BB)
• Second ...
Examples
• Expiratory slitting of S2 is abnormal
• Loud P2= pulmonary hypertension
• Systolic click: in mitral valve prolp...
Heart murmur, what should be
described
• timing, shape, loc. of max. intensity,
radiation, intensity, pitch, quality
Timing of a murmur
S1

S2

S1

midsystolic murmur (aortic
stenosis)

pansystolic murmur (mitral
regurg)

late systolic mur...
Timing of a murmur
S1

S2

S1

early diastolic (aortic regurg)

mid-diastolic (mitral stenosis)

late diastolic= praesysto...
Timing of a murmur
• Continuous murmur
• Throughout in diastole and systole
– pericardial friction rubs, patent ductus Bot...
Shape of a murmur
crescendo
decrescendo

crescendodecrescendo
(diamond shaped)
platau murmur
Location of maximal intensity
• The site where it can be heard best
– anatomic pos.

"Traditional areas"
Intensity of a murmur
Grade

Murmur Grades
Volume

Thrill

1/6

very faint, only heard in ideal
circumstances

No

2/6
3/6...
Radiation of a murmur

• radiation from the point of maximal intensity
– for ex.: AS to the carotid arteries (blood flow)
...
Aortic stenosis
S1

S2

S1

Timing: midsystolic
Location: right 2nd intercostal space
Radiation: to the neck, carotid arte...
Mitral regurgitation
S1

S2

S1

Timing: systolic, holosystolic
Location: apex
Radiation: left axilla
Intensity: soft to l...
What else is the stethoscope
good for?
• look like a doctor
• blood pressure measurement
• to transmit infection from pati...
How to choose a stethoscope?
when I was a 3rd y student

•
•
•
•
•
•

good for decades
if you want to be a cardiologist,.....
Introduction to auscultation
Introduction to auscultation
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Introduction to auscultation

  1. 1. Introduction to Auscultation Dr Zoltán Pozsonyi 3rd Dep. of Int. Med. Semmelweis University
  2. 2. History
  3. 3. History • before: ear on the chest • Laennec- 1816: – rolled up piece of paper in case of an obese female patient with suspicion of heart disease • the first single ear stethoscope • later: made of wood and plastic
  4. 4. Auscultation • very important, simple, effective clinical technique to evaluate circulatory and respiratory system • very useful in examination of arteries and abdomen • understanding of underlying pathomechanisms and practice!!
  5. 5. Significance • Nowadays (echo, X-ray, CT, MRI) the importance of auscultation is smaller • limited access to imiging modalities • auscultation is available anywhere
  6. 6. Technique of auscultation • quiet environment – ER, other patients, computers; close the doors • proper position – may need help; ICU • stethoscope on the bare skin – rubbing • proper size of diaphragm of the stethoscope – children; slim, skinny patients
  7. 7. Auscultation of the abdomen • Bowel motility and abdominal complaints • Searching for renal stenosis (hypertension) • How to ... – supine position – place the stethoscope on the abdomen – bowel sounds: • normal sounds: clicks and gurgles 5-30/min • wildly transmitted: one place is enough usually
  8. 8. Abnormal bowel sounds • Increased intensity and frequency: – diarrhea – intestinal obstruction=obstructive ileus • Decreased intensity and frequency, or on sounds at all: – paralytic ileus (dumb abdomen) – peritonitis • Splash in ileus (lot of air and liquid)
  9. 9. Bruits over the abdomen • Normally there is no bruit • for stenosis of the renal artery: – listening for bruits (vascular sound; like heart murmurs) – in each upper quadrant of the epigastrium – costovertebral angels
  10. 10. Bruits • Atherosclerosis--stenosis • Carotid artery (part of routine exam.) – – – – stenosis=bruits (not always) ischaemic stroke, TIA, embolization ask the patient to turn his/her neck back ask the patient to stop breathing momently • Femoral bruits (above the aorta, iliac arteries) – suspicion of insufficient arterial circulation of lower extremities (pain, induced by walking; smoking; HT; DM)
  11. 11. Before auscultation of lungs • Patients arms crossed in front of the chest • Diaphragm of the stethoscope • Ask the patient not to speak and to breathe deeply through the mouth • Hyperventilation should be avoided (collapse) • Always compare the two sides at the identical locations • At least one full breath at each location • In case of suspitous sounds, auscultate nearby
  12. 12. Location of auscultation
  13. 13. Topographic considerations Posterior view Anterior view
  14. 14. Lung sounds inspiration pause expiration pause • Expiration is longer than expiration • Normally expiration is less loud, so at auscultation it seems, these are at the same length
  15. 15. Lung sounds-normal sounds Two forms • Tracheal or bronchial breath sounds • Origin: turbulent airflow in central airways • Turbulence is less in expiration, so expiration is more quiet • Not transmitted through air filled lung, but cab be transmitted in atelectasy • Normally can not be heard • Can be heard in pneumonia, when lung tissue loses air, or in case of large pleural effusions • Loud, high pitched, (like over the trachea, scapula)
  16. 16. Normal sounds • Vesicular breath sounds • Origin: distal to the trachea, proximal to the alveoli • Normally vesicular sounds are over the lung • Soft and low pitched
  17. 17. Abnormal sounds Absent or decreased breath sounds • Severe asthma bronchiale: decreased sounds • Emphysema: decreased sounds • Pneumothorax: absent or decreased sounds • Bronchial: pneumonia, effusion
  18. 18. Adventitious breath sounds • Crackles (rales), discontinuous, non-musical, brief • • • • • sounds more commonly on inspiration. fine (high pitched, soft, very brief) or coarse (low pitched, louder,less brief). Mechanical basis: small airways open during inspiration and collapse during expiration causing the crackling sounds. (fine crackles) Another explanation for crackles is that air bubbles through secretions or incompletely closed airways during expiration (coarse crackles)
  19. 19. Crackles- conditions • • • • • • pneumonia ARDS bronchiectasis early CHF interstitial lung disease pulmonary edema
  20. 20. Wheeze • continuous, high pitched, hissing sounds • heard normally on expiration but also sometimes on inspiration • produced when air flows through airways narrowed by secretions, foreign bodies, or obstructive lesions.
  21. 21. Wheeze-Conditions: • • • • • asthma bronchiale CHF chronic bronchitis COPD pulmonary edema
  22. 22. Stridor • inspiratory musical wheeze heard loudest over the trachea during inspiration • stridor suggests an obstructed trachea or larynx • constitutes a medical emergency that requires immediate attention • foreign body
  23. 23. Pleural Rub • creaking or brushing sounds produced when the pleural surfaces are inflamed and rub against each other • may be discontinuous or continuous sounds • usually localized at a particular place on the chest wall and are heard during both the inspiratory and expiratory phases
  24. 24. Pleural Rub-condition • Pleuritis • Pneumonia with pleuritis • Postthoracothomy syndrome
  25. 25. Auscultation of the heart • bare skin; displace gently large left breast • supine position first • location – anatomic references: sternum, midclavicular line, axillary lines, costal interspace Apex: • timing S1 S1 S2 systole diastole S2 time – hard in case of tachycardia; intensity of heart sounds may help
  26. 26. Heart • Diaphragm: high pitched sounds: – S1, S2, systolic murmurs (common) • Bell: low pitched sounds: – S3, S4, diastolic murmurs (rare) • Throughout the entire praecordium • (stop breathing) • Usually supine position, but: – mitral stenosis – aortic regurgitation
  27. 27. What to listen for • First heart sound (S1: closure of mitr. & tricusp. valves) – intensity, splitting (PHT, BB) • Second heart sound (S2: closure ao. & pulm valves) – intensity, splitting (respiratory cycle) • Comparing intensity of S2 • Systolic extra sound – click, ejection sounds, • Diastolic extra sound – S3, S4, opening snap • Diastolic and systolic murmurs (longer than sounds)
  28. 28. Examples • Expiratory slitting of S2 is abnormal • Loud P2= pulmonary hypertension • Systolic click: in mitral valve prolpase
  29. 29. Heart murmur, what should be described • timing, shape, loc. of max. intensity, radiation, intensity, pitch, quality
  30. 30. Timing of a murmur S1 S2 S1 midsystolic murmur (aortic stenosis) pansystolic murmur (mitral regurg) late systolic murmur (mitral prolaps)
  31. 31. Timing of a murmur S1 S2 S1 early diastolic (aortic regurg) mid-diastolic (mitral stenosis) late diastolic= praesystolic (mitral stenosis)
  32. 32. Timing of a murmur • Continuous murmur • Throughout in diastole and systole – pericardial friction rubs, patent ductus Botalli
  33. 33. Shape of a murmur crescendo decrescendo crescendodecrescendo (diamond shaped) platau murmur
  34. 34. Location of maximal intensity • The site where it can be heard best – anatomic pos. "Traditional areas"
  35. 35. Intensity of a murmur Grade Murmur Grades Volume Thrill 1/6 very faint, only heard in ideal circumstances No 2/6 3/6 4/6 loud enough to be generally heard louder then grade 2 louder then grade 3 No No Yes 5/6 heard with stethoscope partially off chest Yes 6/6 heard with stethoscope entirely off chest Yes
  36. 36. Radiation of a murmur • radiation from the point of maximal intensity – for ex.: AS to the carotid arteries (blood flow) Pitch – high, medium, low Quality – blowing, harsh, rumbling, musical
  37. 37. Aortic stenosis S1 S2 S1 Timing: midsystolic Location: right 2nd intercostal space Radiation: to the neck, carotid arteries Intensity: often loud Pitch: medium Quality: often harsh
  38. 38. Mitral regurgitation S1 S2 S1 Timing: systolic, holosystolic Location: apex Radiation: left axilla Intensity: soft to loud Pitch: medium to loud Quality: blowing
  39. 39. What else is the stethoscope good for? • look like a doctor • blood pressure measurement • to transmit infection from patient to patient – wash it sometimes, not just your hands
  40. 40. How to choose a stethoscope? when I was a 3rd y student • • • • • • good for decades if you want to be a cardiologist,.. price size of the diaphragm digital is not better color
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