Heart sounds - Physical Exam

Heart sounds

·        Stethoscope head:

o  Bell: good for low pitched sounds, eg diastolic murmur (mitral stenosis) or 3^rd heart sound. Don‟t press too hard otherwise skin becomes a diaphragm

o  Diaphragm: good for high pitched sounds, eg systolic murmur or 4^th heart sound

·        Using stethoscope, ausciltate:

o  Mitral area (4^th intercostal space, left mid-clavicular line) with bell and diaphragm

o  Tricuspid area (5^th intercostal space, left sternal edge) with diaphragm

o  Pulmonary area (second intercostal space, left sternal edge) with diaphragm

o  Aortic area (second intercostal space, right sternal edge) with diaphragm

·        Heart Sounds:

o  First heart sound: closure of mitral and tricuspid valves at beginning of systole. Mitral closes slightly before tricuspid but you won‟t hear the difference

o  Second heart sounds: closure of aortic and pulmonary valves. Lower pitch. End of systole. Aortic closes first (higher back pressure on valve) ® splitting of heart sounds. But pulmonary closure is not heard over all the praecordium, so splitting best heard over pulmonary area. Inspiration ® ­venous return ® later closure of pulmonary valve ® enhanced splitting

o  Use carotid pulsation to orientate to timing.  This occurs during systole, between S1 and S2

Abnormal Heart Sounds

Extra Heart Sounds

Miscellaneous Sounds

·        Opening Snap: High-pitched sound after S2 in mitral stenosis, due to sudden opening of the mitral valve. Don‟t confuse with widely split S2 (snap is higher pitched)

·        Systolic ejection click: early systolic high-pitched sound over aortic or pulmonary areas. Is caused by pulmonary or aortic congential stenosis and is followed by a systolic ejection murmur

·        Non-ejection systolic click: high pitched systolic sound over the mitral area. Common. May be followed by systolic murmur. Due to mitral prolapse and atrial septal defects

·        Diastolic pericardial knock: may occur if there is a sudden cessation of ventricular filling in constrictive pericardial disease