3. It is done to see the enlargement of the
dullness of the cardiac region
Left border APEX
Right border RIGHT STERNAL MARGIN
4. Useful in :
Cardiac causes – Cardiomegaly, pericardial
effusion, pulmonary artery
dilatation, dilated
cardiomyopathy, etc.
* See if the dullness extends beyond the
apical impulse as in case of Pericardial
effusion.
5. Useful in :
Respiratory causes : Pleural effusion,
hydropnemothorax,
collapse, fibrosis.
* To find the cause of displaced heart due
to lung conditions
• Presence of diaphragmatic hernia and
eventration of diaphragm can be
suspected.
8. 1. Mitral area – 5th left ICS in mid-clavicular line
(corresponds to apex beat)
2. Tricuspid area – 4th left ICS just lateral to the
lower end of the sternum
3. Aortic area
• First aortic area – 2nd right ICS close to
sternum
• Second aortic area
or ERB’S area – 3rd left ICS close to
sternum
* The early diastolic murmur of AR and pansystolic
murmur of VSD are best heard at ERB’S AREA
9. 4. Pulmonary area – 2nd left ICS close to
sternum
5. Gibson’s area – 2nd left ICS away from
sternum
* The murmur of patent ductus arteriosus is
best heard at gibson’s area
10. Other areas of Auscultation
Carotids
Supraclavicular region
Infraclavicular region
Axillary region
Back – interscapular and infrascapular
regions, bruits in the back
12. Heart sounds
The heart sounds are audible vibrations of
variable intensity, frequency and quality
generated by beating of heart, closure of heart
valves and the resultant blood flow through it.
Four heart sounds
• S1
• S2
• S3
• S4
13. First heart sound (S1)
Produced by closure of AV valves
Best audible at apex
Indicates the beginning of ventricular systole
Split is not normally heard but heard in
phonocardiogram.
14. Factors that affect intensity of
S1
Position of AV valve cusps at the onset of
ventricular systole
Heart rate
Pliability of the valve cusps
* S1 may be normal, soft, loud or variable
intensity.
16. Loud S1
Mitral stenosis
Tricuspid stenosis
Atrial septal defect
Mechanical prosthetic valve
High output states
Short PR interval, tachycardia
Atrial myxoma
In normal children
17. Varying intensity of S1
Atrial fibrillation
Complete heart block
Extra systoles
18. Canon sound(bruit de canon)
Loud S1 heard intermittently in complete heart
block and in interference, dissociation when
the ventricles contract shortly after atria.
Associated with short PR interval
19. Splitting of S1
Components – M1 and T1
Appreciated when
Causes
• Early closure of mitral valve
• Delayed closure of tricuspid valve
• Right bundle branch block
• Pulmonary hypertension
• Left ventricular pacing
• Ectopic beats
• Idioventricular rhythm of left ventricle
20. Reverse splitting of S1
Delayed mitral component
Tricuspid component is heard earlier than
mitral component
Causes
• Right ventricular pacing
• Ectopic beats
• Idioventricular rhythm of right ventricle
21. Second heart sound(S2)
Produced by closure of pulmonary and aortic
valve
Indicates the beginning of diastole
Normal splitting
• Two components – A2 and P2
• A2 louder than P2
• Appreciable during inspiration
22. Abnormalities of aortic
component
Intensity – Accentuated or diminished
Timing – Early or late
Accentuated diminished
• Systemic hypertension
• Aortic regurgitation
• When aortic valve is immobile
as in fibrosis or calcification
• If absent as in aortic valve
atresia
Early Delayed
• VSD
• MR
• Constrictive pericarditis
• When left ventricular ejection
is prolonged as in aortic
valvular or subvalvular stenosis,
PDA with large L R shunt,
AR, left bundle branch block
and LVF
23. Abnormalities of pulmonic
component
Intensity – Accentuated or diminished or
absent
Timing – Delayed
Pulmonary arterial hypertension
Pulmonic stenosis
Pulmonary valvar atresia
• Pulmonic stenosis
• ASD
• Right bundle branch block
• Total anomalous pulmonary venous congestion
• Type A WPW syndrome
24. Abnormalities in splitting of S2
Wide splitting of S2 splitting during expiration
If interval increases during inspiration Wide variable
split
If interval increases in both inspiration and expiration
Wide and fixed second sound
Early A2
Late P2
A2 – P2 interval ≥ 0.03 sec during expiration
25. Wide variable splitting of S2
Pulmonic stenosis due to delay in
P2
Mitral regurgitation
VSD
due to early A2
26. Wide and fixed splitting of S2
ASD
Right bundle branch block
Total anomalous pulmonary venous
connection
* In these conditions, splitting is due to
delay in P2
27. Delay in A2 results in closely split, single or
paradoxically split S2.
In paradoxically split S2, the split is wide in
expiration, but narrows during inspiration
28. A single second sound
Either A2 or P2 or a combination of both
The decision whether it is aortic or pulmonary
or a combination is based on clinical profile
Tetrology of fallot A2
VSD with pulmonary hypertension
Combination
* Interpretation of single second sound is not
dependant on auscultation alone
29. Third heart sound (S3)
Protodiastolic sound or ventricular gallop,
produced by intial passive filling of ventricles
Heard best with bell at the apex
Normally present in children and athletes
Pathological causes :
• High output states
• Congenital heart diseases
• Regurgitant lesions
• HOCM
• Systemic hypertension
30. Fourth heart sound (S4)
Presystolic gallop/atrial gallop, produced by
rapid emptying of atrium into a non-compliant
ventricle
Confused with ejection click
Always pathological :
• HOCM
• Systemic hypertension
• Ventricular failure
• Pulmonary hypertension
32. Murmurs
Turbulence caused by increased flow through
normal/stenosed valve or a normal flow
through a stenosed valve/orifice
Ausculation should be done over precordium,
back and over the carotids
Note :
Changing murmurs
• Various charecteristics of the murmer
• Position of the patient in which the murmur is best
heard
33. Site
Note the site of maximum intensity of murmur
VSD – Murmur best heard in left 3rd and 4th
ICS
Pulmonary ejection systolic murmur – left 2nd
ICS
34. Timing
Timing of the murmur in relation to ventricular
activity noted
Appreciated by palpating the carotid artery
while auscultating the precordium
1.Systolic
2.Diastolic
3.Continuous
35. Systolic murmurs
Heard during systole
1. Regurtitant systolic murmurs
• Start immediately after 1st heart sound and may
continue to 2nd sound
• Usually pansystolic or holosystolic
• Intensity is uniform throughout
• Causes : VSD
Tricuspid regurgitation
Mitral regurtitation
1. Regurtitant systolic murmur
2. Ejection systolic murmur
36. 2. Ejection systolic murmur
• Due to the blood flow in pulmonary or aortic
outflow tracts
• There is gap b/n first heart sound and murmur
• Intensity of murmur follows a diamond shaped
configuration with midsystolic peak
• Causes : Pulmonary stenosis
Aortic stenosis
Pulmonary hypertension
Tetrology of fallot
37. Diastolic murmurs
Heard in diastolic phase of cardiac cycle
Three mechanisms
According to timing
a) Semilunar valve regurgitation
b) Atrioventricular valve stenosis
c) Increased blood flow through AV valve
1. Early diastolic
2. Mid diastolic
3. Presystolic
38. Early diastolic mumur
Decresendo murmur starts immediately after
second heart sound
Causes :
• Aortic regurgitation
• Pulmonary regurgitation
39. Mid diastolic murmur
Starts after the second heart sound
Clear gap present between second sound and murmur
Occcurs due to functional or anatomic stenosis of AV
valves
Causes :
Due to MITRAL valve Due to TRICUSPID
valve
• Mitral stenosis
• Mitral regurgitation
• VSD
• PDA
• Tricuspid stenosis
• Tricuspid regurgitation
• ASD
* Presystolic murmur occurs in mitral and tricuspid stenosis
40. Continuous murmurs
Starts in systole and continue into diastole
Causes :
• PDA
• Venous hum
• Rupture of sinus of valsalva
• Arteriovenous shunts
• Pulmonary A-V fistula
• Coronary A-V fistula
• VSD with AR
• MR with AR
• AS with AR
• Due to combination of
systolic and diastolic murmur
• Known as to and fro murmur
41. Intensity
Grading
Grading Character
Grade 1 Very soft (heard in quiet room)
Grade 2 Soft, but easily audible
Grade 3 Moderate – no thrill
Grade 4 Loud with thrill present
Grade 5 Very loud with thrill and murmur heard with
stethoscope barely placed on chest wall
Grade 6 Loud and audible with a stethoscope just
off the chest wall
42. A cresendo murmur increases in intensity
(MS, PDA)
A decresendo murmur decreases in intensity
(AR)
Venous hum has no change
43. Pitch
High pitched or Low pitched
See if the murmur is best heard with the bell or
diaphragm of the stethoscope
Low pitched
High pitched
44. Character or Quality
Soft/harsh/blowing/rough/vibratory or humming
Rough when obstruction to blood flow (AS,
PS)
Blowing in case of incompetent valves (MR)
45. Conduction or Transmission
Conducted murmur Transmitted murmur
Same intensity Decreased intensity
Same duration Decreased duration
Generally, murmurs from aortic and mitral valve may be
conducted to other parts of precordium
Functional or flow murmurs are heard over wide area of
the precordium
* ESM of AS is loudest in the aortic area and will be radiated to the
axilla and the apex
* Pansystolic murmur of MR is best heard in the mitral area and may
be conducted to axilla or back
46. Variation of murmur with various
Manoeuvres
Respiration : There is accentuation of right
side murmurs during inspiration and left sided
murmurs during expiration
Posture : Venous hum murmur varies with
posture
Certain manoeuvres :
47. Description of murmurs
Condition Murmur Description
Mitral regurgitation Pansystolic High pitched, soft blowing pansystolic
murmur of grade __ best heard with the
diaphragm of the stethoscope,
conducted/transmitted to axilla and back
with the patient lying in left lateral position
with breath held in expiration
Ventricular septal
defect
Pansystolic High pitched, soft blowing pansystolic
murmur of grade 4 best heard with the
diaphragm of the stethoscope in the left
3rd and 4th ICS in parasternal region
Patent ductus
arteriosus
Continuous Grade 4 continuous murmur best heard
with the diaphragm of the stethoscope in
the left 2nd ICS
48. Innocent murmurs
Functional or benign murmurs
Occur in the absence of abnormality
Accentuated during periods of febrile illness or other
high – output states
Features :
• Asymptomatic
• Normal cardiac silhouette on chest X-ray
• Normal ECG
• Usually systolic, may be continuous
• < grade 3/6 with no radiation or transmission
• No cyanosis
• Normal pulses and heart sounds
* They are usually present in children
49.
50. Common innocent murmurs
Still’s murmur
Venous hum
• Low pitched vibratory or musical murmur heard in mid systole
• Soft quality, short in duration
• Best heard in left lower sternal border and apex, no radiation
• Grade 2 – 3/6, common after 3 years of age and rare in infancy
• No cardiac abnormalities present
• Continuous murmur
• Best heard with bell in right supraclavicular region
with head turned to oppoite side in sitting posture
• Disappears on lying down
51. Dynamic auscultation
Manoeuvres include :
• Inspiration
• Expiration
• Valsalva manoeuvre
• Muller manoeuvre
• Squatting to standing
• Standing to squatting
• Passive leg exercise
• Isometric hand grip
• Transient arterial occlusion
• Administration of amyl nitrate
• Leaning forwards
• Chin turned upwards
52. Valsalva manoeuvre
This is an attempted forced expiration in
closed glottis when mouth and the nose are
closed
Significance :
• Increases heart rate, BP and then decreases
the heart rate in that order. This sequence will be
absent in CCF
• Ejection systolic murmur in PS will be increased
and that of AS will be decreased
• Murmur of mitral valve prolapse becomes
longer and louder
• HOCM – systolic murmur becomes louder