How to perform heart auscultation: do minimum, hear everything
So, here you are with stethoscope in your hands facing your first patient. Or maybe not the first?
Auscultation has to be performed quickly but without any omissions. One more time: quickly and comprehensively.
The rest is in the slideshow.
More information about heart auscultation and cardiological diagnosis: http://cardiacauscultation.com
How can you take the greatest possible advantage of your
capacities with the least possible strain? By cultivating the
system. I say cultivating advisedly, since some of you will
ﬁnd the acquisition of systematic habits very hard.
Sir William Osler
Of course you are free to auscultate in
a way that is convenient for you,
but the systemguarantees (almost certainly;-)
that you will hear everything that can be heard
by spending the least amount of time and efforts.
It may seem that the actions, suggested
by the system, will take too much time.
But the entire process described here takes
3 to 5 minutes per patient for most cases.
The entire process of heart auscultation
has two sides:
External: what we do
with a stethoscope
and a patient. It is
visible to everyone.
Internal: what is
happening in our heads at
the same time. This side is
not visible to anyone.
External side is comprised of:
✤ Patient’s position during auscultation
✤ Position of the stethoscope and the way we use it (bell
✤ The optimal sequence of actions, leading to the best
A patient should be examined in the
✤ lying on the back
✤ lying on the left side
It is desirable to examine your patient in a squatted
position first, and then standing position immediately
This is a valuable diagnostic technique for mitral valve prolapse and
hypertrophic obstructive cardiomyopathy.
After listening in the
stethoscope is placed
into aortic area.
Then we move it in small steps (3 to 4 cm)
through the following route: aortic area -
pulmonic area – back to Erb’s point – ﬁfth
left intercostal space – and ﬁnally apex.
Then, stethoscope is placed
at the area symmetrical to
the Erb’s point on the right
side of the sternum.
This matters in diagnosing aneurysm of
Then, we move on
to the suprasternal
Hence, we won’t miss aortic stenosis.
After that – on to carotids
(no specific location, listen at
the point with the best
contact between stethoscope
and patient’s skin).
Hence we won’t miss stenosis of carotid
arteries or aortic stenosis.
Then – under the
That way we won’t miss patent ductus
Now, on to
This is signiﬁcant for diagnosing stenosis
of branches of abdominal aorta.
Then, patient turns
into the left lateral decubitus position
Do not fail to find a place, where apical imPulse is palpable,
and then conduct auscultation there.
Auscultate in the Erb’s point and at the left fifth intercostal space
Only at the left lateral decubitus position we must use both - the bell and
the membrane in each point
While auscultating in
other positions and
only is sufficient
Ask your patient to
exhale, hold the
breath and lean
Look for an early diastolic murmur of
aortic regurgitation at the Erb’s point and
in symmetrical area on the right of the
sternum. Press stethoscope’s membrane
ﬁrmly against the thorax. So ﬁrm, that
diaphragm’s imprint remains visible on
the skin (not forever!)
Listen through membrane over the Erb’s
point and at the apex of the heart. Look
for a systolic murmur.
goes back into
Examine with a membrane in Erb’s point
and at the apex. Look for a systolic
That is it.
Whoever is observing us
won’t notice anything else.
This is what happens in your head while
doing everything you’ve just read about
All this time you worked to obtain a disordered sonic flow encrypted to
contain surprisingly a lot of information about your patient’s heart.
Now, you need to analyze this sound flow by splitting it in components
and then interpret the data.
As a result, we obtain information about the structure
and the functions of the heart we’ve been examining
all this time.
But we will understand nothing by
perceiving heart sound in general.
Each component of the sonic flow should be picked out and analyzed
While analyzing specific sound, we must concentrate
on it and exclude everything else from our attention.
No matter what area we put stethoscope on, we should sequentially
concentrate our attention on the first heart sound initially
Then, we search for extra sounds and murmurs during systole
Then, we search for extra sounds and murmurs during diastole
That’s how we scanned complete cardiac cycle without missing anything
By the way, this is a picture of mitral stenosis with
mitral opening snap in early diastole and low-
frequency diastolic murmur with the presystolic
Loud ﬁrst heart sound
And aortic systolic ejection
murmur (aortic stenosis?)