EXAMINATION OF THE CHEST (HEART AND LUNGS)

SILVERMAN TRANSCRIBED NOTES

GENERAL EXAM OF CHEST
Sequence of examination varies depending on the
cooperation of the child
Auscultation of heart and breath sounds is possible even
with a crying child:
o During inspiration can hear all adventitious
sounds except expiratory wheeze
o During expiratory important heart sounds
Thorough examination of heart requires a quiet
child/environment.
Examination of the chest: Inspection, palpation,
percussion, auscultation.
Inspection
Size
Shape
Visible abnormalities
Movement with respiration
SIZE
Measured at midinspiration
Uses plastic or cloth tape
Horizontally round the chest at level of xiphisternum
Position
o First 5 years lying down
o After 5 years standing
Normal chest circumference:
o Birth
33 cm (30-36)
o 1 y/o
48 cm (45-51)
o 3 y/o
52 cm (50-56)
Chest circumference < head circumference (first 9-12
mos of life)
Chest circumference > head circumference (after 1 y/o)
o Persistent infantile proportion = hydrocephalus
Large head: macrocephaly
Small head: microcephaly
Rapid growth: hydrocephalus
Lack of growth: craniostenosis
o Small thoracic cage = Ellis van Crevald syndrome
SHAPE
Transverse diameter vs AP diameter
o In infancy: transverse = Anteroposterior
round shape
o After 2 y/o: transverse > AP oval shape
Round chest in older child = Chronic Obstructive Lung
Disease (asthma)
MOVEMENT WITH RESPIRATION
Newborns and young infants
o Mostly abdominal respiration.
o A flat abdomen with diminished abdominal
excursions in a newborn = diaphragmatic
abnormalities
o Shift to intercostal space = inflamed peritoneum
After 4-5 y/o
o Mostly intercostals muscles
Normal breathing
o Chest moves evenly with each inspiration &
expiration
o Short grunt during expiration = painful condition
o Splinting with reduced total excursion during
inspiration or cough = pleural irritation
o Avoidance of deep inspiration/cough: CNS
irritation, ICP
o Unequal movement of chest = unilateral lung
prob., foreign body**
Imp to get history of chewing on a FB,
choking, coughing during recent meal

VISIBLE ABNORMALITIES
Abnormality
Absence of clavicle
Presternal edema
Unilaterally prominent
anterior chest
Hypoplastic nipples
Supernumerary nipples
Shield-shaped chest
Pectus excavatum
-depressed sternum
Pigeon breast
-protrusion of sternum

Costochondral swelling
Deep groove along
sides of chest parallel
to lower ribs
Absence of pectoralis
muscle unilaterally
flattened upper chest
High scapula with lower
angle toward spine

Ins

Exp

Dse

Associated Disorder
Cleiodocranial dysostosis
Mumps
Rib anomalies
Scoliosis
Cardiac problems
Down syndrome
Turner syndrome
Renal anomaly
Turner syndrome
Isolated Congenital anomaly
Chronic nasal obstruction
(adenoidal hypertrophy)
Normal,
Pectus carinatum
Osteomalacia
Rickets
Ricket , rosary beads/rachitic
Normal (especially in premature),
If deep: Harrisons sulcus in rickets,
COPD
Absence of nipple & breast devt.,
Pleural herniation
Sprengels deformity

Non-paroxysmal
breathing
Chest and abdomen
move
Abdominal movements
are more visible
Abdomen bulges
Downward movement
of diaphragm.
Thorax moves upward
and outward (chest
expansion)
Abdomen flattens
Thorax returns to
resting position
Normal

Accessory muscles of respiration

INspiration
Muscles Scalenii
Sternomastoids
Trapezii
Dse
Upper airway obs.
(croup, diphtheria)
Lower airway obs.
(asthma)
Assoc
Supraclavicular
retract
Suprasternal
retraction
Moderate lower
airway obs: lower IC
retraction and
epigastric retraction

Paroxysmal breathing
Requires
fluoroscopy(paradoxical
respiration)
Abdomen flattens

Abdomen bulges

Diaphragmatic
paralysis/paradoxical
respiration (congen,
poliomyelitis,
pneumothorax

EXpiration
Abdominal muscles
Latissimus dorsi
Airway obstruction
(bronchial asthma)

Fixed shoulder joint

-act on ribs and augment
expiratory efforts

Most standardized method of measuring chest expansion

is one used by rheumatologists
o Conventional tape measure is used
o Measured in centimeters
th
o Taken at 4 ICS (page 78: at level of substernsal
notch)
o Should be held loosely around chest
o Chest expansion: Difference between
circumference at height of
Maximum inspiration
Maximal expiration
*Restriction of chest expansion: major feature of Ankylosing
Spondylitis.
Palpation
Obvious swelling & tenderness
Trachea
Cardiac impulse
Movements
Vibrations (fremitus)
SWELLING & TENDERNESS
Texture, temperature, tension, tenderness
Note tenderness: Along ribs, IC muscles, costochondral
junctions, manubrium
Prominent xiphoid process may cause normal
protrusion(distal end of sternum)
Sternal tenderness = leukemia
TRACHEA
Palpation
o With index finder and ring finger on sternal
attachment of sternomastoid
o Feel with middle finger on suprasternal notch
the position of trachea
Notch
o Shallow suprasternal notch with easily palpated
traches = anterior displacement of trachea
mediastinitis
o Deep suprasternal notch, trachea not easily
palpable = anterior mediastinal tumor
Deviation
o Slight deviation to the R = normal
o Marked deviation = may be due to:
Ipsilateral pull collapse, fibrosis
Contralateral push pneumothorax,
effusion
o Exclude scoliosis before interpreting tracheal
deviation
Movement
o Pendular(movt on 1 side upon inspiration and
to opposite upon expiration) = obstruction of
large bronchus, large pneumothorax
o Palpate: Rhonchus, thud = tracheal/laryngeal
obstruction
CARDIAC IMPULSE
th
PMI: Usually of 5 ICS, midclavicular line
Change in position suggest deviation of mediastinum:
o Lung disease
o Congenital defects in infants
Dextrocardia
Large diaphragmatic hernia
CHEST EXCURSION
Palms are laid on posterior surface of chest symetrically
Thumbs touching each other in midline
Fingers are spread over the sides of the chest
Arms of examiner are steadied against examinees chest
wall
Excursions are noted with each inspiration
Normally palms move equally
o Symetrically, way from midline: inspiration
o Comes back together:expiration
o Asymmetry = effusion, collapse, consolidation

VOCAL FREMITUS
conduction capacity of the lung
Child is asked to repeat one or ninety-nine while the
examiner palpates all areas of the chest
Hand should detect distinct vibrations of equal intensity

Pathology
Collapse of lung
Effusion
Consolidation
Large cavity

Disease
FBO of bronchus
Pneumonia

To-and-Fro Rub = inflamed pleura(palpable pleural rub)

Palpable thud = Foreign body in trachea

Percussion
Purpose: make a comparison of the percussion note between
the corresponding areas of the two sides of the chest.
Division of the chest/ anatomical surface landmark:
Anterior
o Presternal area
o R & L anterior portions
Supraclavicular above the clavicle
nd
Infraclavicular up to 2 rib
th
Mammary up to 5 rib
Inframmary
Lateral
th
o Axillary region up to 4 rib
o Infraaxillary region
Posterior
o Suprascapular
o Interscapular
o Infrascapular

Needs cooperative patient. Preferable if child is sitting or

lying flat on the back observe then compare
Findings cannot be truly compared in patients with
scoliosis
Presence of altered resonance: collapsed lungs,
cavitation, consolidation, pleural fluid.

Direct
One finger
- For smaller
infants
-requires
experience.

Indirect
Two fingers- commonly used
Pleximeter middle finger (middle
phalanx), rests firmly on chest wall
Plexor tip of middle/index of
other hand; should strike
perpendicularly (not an angle)and
spring back quickly
Other fingers should not touch the
chest wall(pleximeter)
Movement of plexor originate at
the wrist not elbow, which is
likely to produce heavy percussion
notes.

Method:
o Start at top(supraclavicular area),then proceed
downward systematically.
o Cover front, sides, back of the chest
o Percuss left side then right side, systematically
o Place pleximeter parallel(ex. to ribs) to expected
line of dullness

Physiologic
Pathologic
th
Liver(10 ICS,
Effusion (stony
th
midclavicular; 8
dullness,
rib on midaxillary ABSOLUTE***),
th
line; 10 rib
Not absolute:
posteriorly), firm Consolidation(portion
(not solid-hard)
of lungs),Fibrosis,
Heart(normal
Collapsed lungs(no air),
dullness at
Pleural thickening
precordium)
Resonant
Lung
Hyperresonant Lung of infants,
Emphysema
Thin chest wall,
(asthmatic)
Stomach
Pneumothorax
Tympanic
Stomach
Transposition of viscera dullness on left, resonant on
right
Dextrocardia dullness over right mammary region
Widened mediastinum dullness on either side of
sternum

Due to movement of air in and out of chest during the

respiratory cycle

Physio/
Patho

Dullness

Auscultation
o Bronchospasm: produces wheeze NOT RONCHI;
interpretation of physical findings.
o Upper and lower lobes of lungs overlap
General points to remember:
Listen directly over chest wall, without clothes.
Positioning:
o In young infants one has to catch what is
available in whatever position they are in lying
or sitting.
o In cooperative sitting
o Toddler best heard when held by parent
o Prone or supine position is acceptable, but not
when the child is lying on one side
Use bell of the stethoscope= in younger infants.
Make sure the chest piece is not cold.
Make sure the child is not shivering (Shivering: (+)
adventitious sounds)
Childs face= should be in a neutral position because a
faced turned to one side may= cause variation in
intensity of sounds.
Examine the child in a methodical fashion=include all
parts.
LUNGS
Main goals of examination with the stethoscope
1. Listen to the characteristics of breath sounds in various
areas
2. Compare one side with the other
Characteristics of breath sounds:
o Normal breath sounds
o Vocal resonance/sounds
o Adventitious breath sounds
Normal breath
Vocal
Adventitious
sounds
resonance/sounds breath sounds
Vesicular, brochial,
bronchovesicular

Bronchophony,
Crackles(rales),
Whispered
wheezes(rhonchi),
pectoriloquy
rub
Normal Breath Sounds
Normal breath sounds: Vesicular and brochial.
All should be described in relation to LIPT
o Location
o Intensity
o Pitch
o Timing (inspiration, expiration)

Vesicular
Physiologic:
Produced by
transmission of
sounds thru alveoli
Alveoli act like
mufflers in a car.

Location

Entire chest
Axilla,
infrascapular

Inspiratory

High-intensity
rushing sound
Low-pitch

Expiratory

Heard
immediately after
inspiration
Only during early
exp
End expiration is
silent
W/o
I > E by 2x

Pause
Duration

Intensity of breath sounds

Bronchopneumonia
Collapse of lung due to FBO
- Conditions with air entry

Bronchial
Pathologic:
Occur when
patent bronchi
communicate
sounds to the
chest wall through
a uniform soundconducting
medium:
Consolidation,
large cavity, small
effusion
Trachea
Above the midline
in upper anterior
chest
Small infants:
heard normally at
nd
2 Thoracic spine
over the posterior
chest
Anywhere else =
pathologic!
o Produced by
conditions
that remove
muffler effect
of alveoli
Higher in pitch
Aspirate quality
Heard throughout
inspiratory phase
Harsher than
inspiration
Heard throughout
expiration
Prolonged*

With
I=E
I<E

or absent
Fibrosis
Thickened pleura
Pleural effusion
Pneumothorax

VOCAL RESONANCE
Ask the child to repeat one or ninety-nine
Listen with stethoscope
Main point in listening is comparison of the
corresponding areas of two halves of the chest.
Normally:
o Sound is transmitted through the lung
o Heart over the chest with a resonant quality
o Words are indistinct
Increase resonance:
o When sound are heard as if they are close to the
ear or when words are heard distinctly
o Bronchophony when sound is heard as if
originating in the ears rather than chest wall
o Whispered pectoriloquy even a whisper by
the patient is heard distinctly

Pathology
Air cannot pass through air
passages
Air cannot be conducted to
chest wall

Example
FBO
Massive Pleural
effusion,
Pneumothorax

HEART
Examination of the heart should include:
Arterial pulse
Venous pulse
Blood pressure
Arterial pulse (rate, rhythm, volume, tension)

Emphysema, Pleural thickening

Consolidation
(+ Bronchophony and +
Whispered pectoriloquy)

Massive lobar
pneumonia,
Large cavity (TB),
above the level of
fluid in pleural
effusion

ADVENTITIOUS SOUNDS
Rales breathe with noise, death rattle
Rhonchus- latin translation of French word rales;
confusing when translated to English.
Preferred terms for adventitious sounds:
o Crackles discontinuous, interrupted
Rales
Crepitations
o Wheezes continuous, uninterrupted
Rhonchus
Wheeze

Description

Qualifiers

Crackles
Discontinuous,
interrupted.
Explosive, non-musical
Occur in bursts
Resemble bubbles
popping
Coarse, medium, fine
Coarse crackles:
louder; last longer
than fine crackles
Rales and crepitations

Early Inspiratory
Very few bubbly
sounds
Lower portions of the
chest
Independent of
patients position
Heard in airway
obstruction
End Inspiratory
Profuse nature
Better heard when
sitting
Heard in restrictive
disease

Wheeze
Continuous,
uninterrupted
Musical
High-pitch, whistling
quality(like in asthma)
Low-pitched, snoring
quality(like in
emphysema)

Rhonchus and wheeze

Pitch
High or low
Complexity
Monophonic asthma
Polyphonic chronic
obstructive bronchitis
Duration
Long incomplete
obstruction of bronchus
Short fibrosing
alveolitis
Timing
Inspiratory croup
Expiratory asthma

Pleural Friction Rub

Rubbing leathery sound
Both inspiration and expiration
Both discontinuous and continuous
Tugging sound heard in trachea = Foreign Body
Crunching sound over left chest close to pericardium =
pneumothorax

1. Normal pulse rate

Age
Newborn
Up to 1 year
2 years
4 years
6 years
8-10 years
Adolescent years
18 years and over

Pulse rate/ minute

70-170
80-160
80-130
80-120
75-115
70-110
65-110
55-95

2. Rhythm: regular or irregular, listen to the heart.

-one can have an arrhythmia in which every other beat is not
carried to the periphery as pulse.(pulse rate is 50% of heart
rate)
- a regular rhythm may be perceived peripherally even
though a serious arrhythmia exist.
- Sinus arrhythmia is characterized by a rapid pulse during
inspiration and a slower pulse during expiration.
- Auricular fibrillation- irregularly irregular pulse.
3. Volume: -the lift of fingers as the pulse waves pass
through.
= force with which the finger is lifted and the duration in
which the force is maintained.
LARGE VOLUME PULSE:
Fever
Thyrotoxicosis
Anemia
Patent ductus
Aortic regurgitation
SMALL VOLUME PULSE
Shock
Aortic stenosis
4. Tension: the intensity of pressure required to obliterate
the pulse. (unnecessary to do)
CERTAIN TYPES OF PULSE DIAGNOSTICALLY IMPORTANT:
SINUS ARRYTHMIA- rapid pulse during inspiration
and a slower pulse during expiration.
COLAPSING PULSE- best felt with arms raised above
the head and pulse is felt by the examiner,seen in
PATENT DUCTUS ARTERIOSUS and AORTIC
REGURGITATION.
PULSUS PARADOXUS- pulse volume gets lower and
even disappears at the end of inspiration. Best
confirmed by listening to the korotkoff sound, while
measuring the BP during inspiration and expiration.
A difference of 10 mm hg bet systolic pressure
obtained during inspiration and systolic pressure
during expiration. Seen in PERICARDIAL EFFUSION,
SEVERE AIRWAY OBSTRUCTION-BRONCHIAL
ASTHMA. (feel for radial artery, temporal arteries,
femoral arteries and dorsalis pedis)
How to feel for the femoral artery?
Femoral pulse- midway bet symphisis pubis and ASIS along
the inguinal ligament.
COARTATION OF AORTA
Feel for the radial artery and femoral artery, compare the
two. Delay in pulse.
Patient in supine position, flex the legs, if the legs
becomes pale- suspect COA.

Blood pressure
Cuffs available: 3cm, 5 cm, 8 cm, 12 cm, 18cm. 18 cm for
lower limbs and obese adolescents.
American heart assoc- cuff must be 20% wider the than
the diameter of the limbs on which it is used.
Narrower cuff- high bp
Broader cuff- low bp
Mercury manometer is superior to aneroid
If aneroid, checked for accuracy against a properly
functioning mercury manometer.
Mercury- check for leaks and must be on the 0 line.
Patient must be relaxed, and lying down, not tense,
crying or agitated.
Mercury column must be vertical and eye level
Cuff wrapped should have space
Palpate bp before auscultate
Lower limb systolic bp higher by 10-40mmhg
compared to upper limb, diastolic- same
Dyspnea and arrhythmia- the reading at which the
sound disappear should be recorded for both the
strong sound and the weaker sound.
How to get the bp
*place the stethoscope at the brachial artery inflate +1020 to palpatory bp Release (2-4mm hg per heartbeat)
st
listen to korotkoff sound 1 sound systolic, last = diastolic.
CHEST LANDMARKS
Horizontal Axis
Angle of Ludwig
o Junction of manubrium & sternal body
o Location of R2 costochondral junction
o Below is ICS2
Xiphisternum
o Starts at the level of R6 connection to lower end of
sternum
Vertical Axis
Anterior aspect Midsternal line, laternal sternal line,
midclavicular line
Lateral aspect Ant, mid-, post-axillary lines
Posterior aspect Midscapular line
INSPECTION
Undress the patient fully
Observe for pulsation over various parts of the chest and
epigastrium
o Right side = dextrocardia
o Posterior = aortic coarctation with collateral arterial
circ intercostal Artery pulsations
*apparent when patients untreated with COA gets
older
o Epigastric = normal in thin or excited children;
pulsatile liver as seen in TR; enlarged RV
PALPATION
Apex beat
Lowest and outmost point of cardiac impulse
th
Visible at/inside midclavicular line on 5 ICS5
o Obscured = pericardial effusion, emphysema, obesity
o Hyperdynamic = fever, impending HF, hypertension,
hyperthyroidism
o Displaced = lung disease, scoliosis
o Otherwise, consider dextrocardia or cardiac
enlargement
Cardiac impulse
RV Enlargement
LV Enlargement
Palpable impulse
More forceful
close to sternum
Max farther on left
Impulse hits &
Stays only temporarily with
stays with palm
palm
Systolic overload (aortic stenosis)
o Forceful sustained heave
Diastolic (mitral regurgitation)
o Impulse is less forceful

Pulmonary artery
If enlarged can be palpated over the LICS2 at lateral
sternal line
Intense second pulmonary sound can also be palpated
Thrill
Purring sensation under the palm over the precordium
in the presence of certain organic heart disease
Locate its point of maximum intensity (PMI) and its
relationship to the cardiac cycle
Time the thrill in relation to the maximum cardiac
impulse
Area
Systolic
Diastolic
Pulmonary area
PS
PR
Mitral area
Regurgitation
MS
Aortic area
AS
To-and-fro over L
PDA
infraclavicular
L parasternal
ASD, PS, VSD
AR
Blood vessels
Aneurysm, AV fistula
*ASD = auricular septal defect

Functional murmurs are almost never associated with a

thrill except in children with a very thin chest wall
a palpable thrill over blood vessels may indicate
presence of aneurism or AV fistula.

PERCUSSION
A very poor method for determining heart size
Useful in pericardial effusion; dullness is absolute
Two methods for making a rough estimate
In Children, the only important condition for which
percussion will be useful in pericardial effusion.
Direct Percussion
*Percuss with plexor finger
parallel to heart border (i.e.
parallel to sternum on the R
& L side; parallel to ribs at
ICS1 & ICS2).
*Start away from heart and
move toward heart at inch
intervals.

Indirect Scratch
*Keep stethoscope over
the heart.
*Scratch over the chest
wall with a finger vertically
along the right ant axillary
line.
*Repeat scratching the
chest vertically at inch
intervals, starting medial to
AAL and proceeding
toward the right sternal
border.

AUSCULTATION
Should be examined both sitting & supine since murmurs
may vary with position
Bells and diaphragm should be used (both):

Diaphragm
High frequency
nd
2 sounds

Bell
Low frequency
st
nd
th
1 , 3 , 4 sounds

Diastolic of AR or PR

Atrial defect

Should be performed in a systematic fashion starting

over mitral area, moving clockwise or counterclockwise
over the four major areas corresponding to the four
major valves and:
o LICS2 where PDA is best heard
o Back & neck organic murmurs, stenosis (softer
murmurs such as ASD do not transfer well)

Functional murmurs
o Do not spread far from their PMI

Finding for each major area of precordium are to be

expressed under the following headings:
o Heart sounds
st
nd
rd
th
1 , 2 , 3 , 4 sounds
Splitting & spacing
Opening snap, ejection click
Triple rhythm
Gallop rhythm
o Adventitious sounds
Murmur
Rub
Pleuropericardial

HEART SOUNDS
First (S1) and Second Heart Sounds (S2)
Intensity of sound alone may not be valuable
Faint & weak in shock & myocarditis
Faint & distant in obese, emphysema & pericardial
effusion
st
Accentuated aortic 1 sound in fever, thyrotoxicosis,
systemic hypertension, MS
nd
Accentuated pulmonary 2 sound in PHTN

Desc
Sound
Cause
Split

S1
Short, sharp
Lup
Closure of mitral &
tricuspid
Rare; hard to detect,
not indic heart
disease; can be
confused with sys
ejection click

S2
Dup
Closure of aortic &
pulmonic
Normal due to
delayed pulmonic
closure; best heard
over pulmonic area

st

Split of 1 heart sound difficult to detect

nd
Split of 2 heart sound best heard in pulmonic
Split sounds should be distinguished from systolic
ejection click:
rd

Location

Split
Pulmonary area (normal)

Apex

Intensity
Interval
Variation

Equal
Very short
(+) with resp (a2&p2)

Different
Longer
(-) with resp (a2&s3)

3 Sound

Listen in quiet room & listen for split during peak of

inspiration and end of expiration
o Split is more marked and recognized during peak of
inspiration
Questions to be asked:
o Is splitting present?
If (-), consider AS/severe PS
If (+), is it normally split?
o If it is split widely with prolongation of the interval
between the aortic and pulmonic component, is it
fixed (without difference during insp/exp)?
If (+), consider large ASD
o Is the split paradoxical (aortic component after
pulmo)?
If (+), the split narrows during insp (instead
of widening); consider AS, LBBB, PDA

Third Heart Sound (S3)

Caused by rapid flow of blood to ventricle
May be heard normally during diastole over the apex
(mitral area)
Best heard in L lateral position during expiration
Increased intensity is often associated with
hyperdynamic heart (anemia, large LV shunt)
Should be diff from splitting S1/S2, opening snap, gallop
rhythm

Opening Snap
Clicking sound heard in diastole almost immediately after
the second heart sound
Indicative of MS with mobile anterior leaflet
Occasionally mistaken for a widely split S1:
Split S1
Over precordium (ICS4
over L lower sternum)
Best heard in EXP
(-) variation with resp

Opening Snap
Over pulmonary area
Best heard in INSP
(+) variation with resp

Should be differentiated from S3:

S3
Low-pitch, muffled
Over apex

Opening Snap
Sharp quality
Occurs earlier than S3,
later than S2

Ejection Sounds & Clicks

Heard during systole
High-pitched sound
Produced by abnormal semilunar valve or conditions
leading to sudden dilatation of pulmonary artery or aorta
May be associated with a murmur

Relation of
sounds
Relation to
respiration

Separated from S1
by milliseconds
No relationship

Pulmonary
Upper L
sternal border
Close to or on
top of S1
Better heard
during EXP;
diminishes
during INSP

Intensity

Not sharp

Sharp

Location

Aortic
Entire precordium

Systolic Click
Sounds heard during mid or late systole
Have a clicking quality
May or may not be associated with murmur
o Apical midsystolic click (always abnormal) =
prolapsed MV
o Assoc with resp = small pneumothorax
Triple Rhythm
Heard over mitral area
May be caused by:
o Normal S3
o Gallop rhythm palpable third comp, appears with
serious heart disease
Gallop Rhythm
Heart sounds that resemble the sound of galloping
horses rather than tick-tack, lup-dub, to-and-fro
characteristics of normal
There is a third or fourth component
o Third sound (protodiastolic) gallop over apex, sign
of heart failure
o Fourth sound (presystolic) gallop
o Summation gallop produced in the presence of
tachycardia when the two components fuse
It is hard to differentiate between subtypes
Fourth Heart Sounds (S4)
Characteristically similar to S3 sounds
Best heard over apex in L lateral position with bell of the
stethoscope
Accentuated during expiration, before S1
Caused by atrial contraction
Mostly considered abnormal

ADVENTITIOUS SOUNDS
Not heard in normal individuals except the functional
murmur
Heard in addition to the heart sounds
Classified as:
o Murmurs
o Rubbing sounds
o Cardiorespiratory sounds
Precordial murmurs should be described as to:
o Location
o Relationship to cardiac cycle
o Direction of spread
o Intensity
o Intensity in relation to respiration
o Intensity in relation to posture
Location & Relation to Cardiac Cycle
Location
Systolic
Mitral area
MR
Functional
Pulmonary area
PS, ASD
Functional
Aortic area
AS
CoA
Tricuspid area
TR
LLSB
VSD, AS
Functional
LICS2
PDA
Neck
AS, PS
Venous hum
Back
Valvular Stenosis

Diastolic
MS
PHTN
AR
TS
AR, PR
PDA

Systolic occur with/following S1, before S2

Diastolic occur after S2, before S1
o Always organic
o Early diastolic = PR, AR
o Mid-diastolic = early MS
Continuous occur through systole & diastole
o Seen in PDA & AV fistula

Technique
Concentrate on first sound and keep saying, one, one
as S1 is heard, for 5-6 cycles
Try to locate the relationship of murmur to S1
Repeat the same steps with attention on S2, to recognize
charac of diastolic murmur
Systolic Murmurs
Try to determine whether early, mid or throughout
systole
Systolic murmurs may be:
Holosystolic

Begin with S1
End with S2
(through-out)

*MR
*VSD

Early Systolic

Midsystolic

Ejection
murmur
Begin with S1

Flow murmur

End midsys
Short, soft
Mild intensity
(-) Spread
(-) Thrill
*Functional
murmur
*AS

After S1
Peak midsys
End before S2
Few milliseconds
into systole(not at
very beginning)
*Functional
*Mild AS/PS
*ASD

Intensity
Not necessarily related to seriousness of dse
o A small VSD very rough, harsh
o Diastolic murmur of AR soft, hardly audible
o Incompetent valves (leak of blood) soft, blowing
o Narrowed valves (obstruction) rough

Graded from I to VI:

I
II
III
IV
V
VI

Soft
Some positions
Soft
All positions
Loud
Loud
Louder
Loudest (even without stet

(-) thrill
(-) thrill
(-) thrill
(+) thrill
(+) thrill
(+) thrill

Intensity in Relation to Respiration

Originating on the R side (ASD, PS)
o Increase in intensity during inspiration caused by
increase in SV of R side during inspiration
o Return to control intensities quickly
Originating on the L side (VSD)
o Accentuated during expiration
o Return to control intensities slowly
Stills type of functional murmur
o Vary in intensity with respiration
Technique
Ask the patient to hold his or her breath and listen to the
intensity of the murmur
With the patient breathing normally, listen to murmur
intensity for 10-12 cardiac cycles
Direction of Spread
Said to radiate if it is heard with equal intensity some
distance away from PMI
Presence of a thrill and radiation away from point of
origin indicate that the murmur is an organic murmur
Innocent murmurs
o Not associated with thrill
o Do not radiate to the back
o Pulmonary ejection type may radiate along the
parasternal line to ICS4
Lesion
MR
MS
PS

Murmur
Mitral systolic
Mitral diastolic
Pulmo systolic

PR
AS

Pulmo diastolic
Aortic systolic

AR
PDA
ASD
VSD

Aortic diastolic
To-and-fro over L
infraclav
ICS2-3
Parasternal
ICS3-5
Parasternal

Radiation
Lat & post chest
Lat & post chest
L infraclavicular area
L neck, back
L parasternal line
Neck along carotids
May transmit to apex
Along LLSB
ICS2-3
Parasternal
Poor transmission
Entire precordium
R sternum

Relationship to Posture
Determine the effect of posture on murmur
Cervical venous hum
o Heard over root of neck (R side) when sitting;
disappears when supine
Ejection type of functional murmur
o Heard over pulmonary area
o Best heard in supine position
Aortic regurgitation
o Best heard when patient is sitting, leaning forward,
holding breath in exp
Mitral regurgitation, aortic stenosis
o Dec in intensity when patient goes from a
recumbent to sitting position
Soft systolic murmur of ARF
o May not be heard when supine
o Ask patient to sit from a supine position for 10-15
times
o Best heard if patient turns to L side
Systolic murmur of mitral valve prolapse
o Accentuated by repeatedly going from standing to
squatting position

Innocent (Functional, Physiologic) Murmurs

These can be heard in seven areas:
1. Systolic murmurs
- Over the head of young children especially
before closure of fontanel
- Heard symmetrically above both ears and
parietal bones
2. Near the tip of mastoid close to where vessels
enter base of skull
- Symmetrical
3. Central venous hum (cont murmur)
- Over R side of neck
4. Root of neck, but only in systole
5. Originating above the clavicle but radiates below
the clavicle
6. Basal systolic functional murmur
7. Stills murmur
Most common functional murmurs:
Twanging-string murmur of Still Basal ejection murmur
Venous hum (#7, #6, #3)
Twanging-string
Still Murmur
Musical,
Crescendodescrendo,

Basal Ejection
Murmur
Harsh
(-) Thrill
(-) Trans to post
chest
May be
mistaken for PS
murmur.

Over midprecordium to
the LLSB; supine
Heard in first 1/3
of systole
Intensity may
increase with
exercise

Over LICS2

Cervical Venus Hum

Low-pitch, continuous
(systole and diastole)
(+) Thrill
(+) Trans to RICS2

Physio, but seen in

high output state
(anemia)
At neck base; R side
for CVH,

Characteristic of the Variables

Normal heart sound originate from closure and opening
of AV and semilunar valves
Normal breath sounds are due to passage of air to and
from the alveoli through bronchi
Chest contents attenuate sound waves
o Sounds originating in the major valves are best heard
over that area of the chest wall, which is reached
via a path of minimum attenuation
Frequency cycles of heart & lung sounds range from 120
to 1000 cycles/sec. Most are below 600 cps range.
o An occasional click or rub can be heard by the
patient/observer without aid
o Breath sounds have a higher pitch than heard
sounds
Frequency Cycle of Various Heart & Lung Sounds
Sound
Freq (cps)
Heart
Low-pitch murmur
400

Heard in first 1/3

of systole

High-pitch murmur
Sys & dias murmurs

by sitting;
(-) when supine;
Obliterated with SVC
Obstruction, Valsalva,
Constrictive
Pericarditis
*Organic murmurs have (+) thrill and (+) transmission to
posterior chest wall.

The ear is the recording mechanism

The brain interprets the sounds
Final interpretation of sounds is subject to the following
variables:
o Related to the source of sound
Origin (heart or lung)
Frequency of vibrations
Sound pressure (energy)
Conducting medium of chest
o Related to the stethoscope
Type of chest piece
Tubing
Earpiece
o Related to the interpreter
Age & experience
Characteristics of the human ear and bran

Valsalva Maneuver
o Performed by straining in which the patients
attempts forced expiration with mouth and nose
closed

Rubs
To-and-fro leathery, scratching sound heard with systole
and diastole
Heard only for a short duration, disappears, then
reappears again
Disappears with effusion
Best heard with the patient sitting up and the
stethoscope held over LICS2-3 immediately left of the
sternum
Cardiorespiratory Murmurs
Heard at the apex or over areas where heart and lung are
close together
Heard as if they originate close to the stethoscope, vary
with respiration, mid or late systolic, high pitch
Often heard in pericarditis and emphysema

PHYSICAL PRINCIPLES OF AUSCULTATION

During auscultation, vibrations from inside the chest wall
are picked up by the chest piece of the stethoscope,
transmitted through the column of air in the tubing, and
reach the ear

Lung

Presystolic murmur
Pericardial rub
Rales
Amphonic breathing
Bronchial

660
120-600
(up to 1000)
140
140-660
120-1000
240-660
240-1000

The human ear is a good detector of change in frequency

cycles, if the change is gradual
o Not adequate for detecting changes in intensity at
very low energy levels characteristic of heart &
lung sounds
o As intensity increases, low-pitched tones become
more prominent, since high-pitched tones are
masked
Masking of sounds
o Obesity effects quality of heart sounds
o When an S1 or S2 is very loud and is followed by a
low-intensity murmur, the ear is fatigued after the
loud sound and misses the murmur; a diaphragmtype of chest piece is capable of attenuating the
loud sound making the low-intensity murmur more
audible (ie. Use diaphragm while listening for aortic
diastolic murmurs)
The bell is capable of picking up all the sounds generated
in the chest
o When the bell is applied, the skin under the bell acts
as a diaphragm
o When applied firmly on the chest, lower freq sounds
are attenuated
S1/S2 intensity
high-pitch diastolic murmur
o When applied lightly on the chest, low-pitched
murmurs, S3, and gallop rhythm are heard more
audibly

Since the pressure variations at the ear are inversely

proportional to volume of air in the bell, it is better to
use bells with small volume
o Very shallow bells may get obliterated by flesh in
obese patients
o Diaphragm-type is particularly useful to detect highpitched sound (aortic diastolic murmur, bronchial
sounds)
Length and rigidity of the tubing can affect the acoustics
of the a stethoscope
o At frequencies between 100-1000 cps, efficiency
decreases with increasing length of tubing
o A well-fitting earpiece, which does not hurt is
important
The human ear is not a major consequence
o Younger ears can hear high freq better
o Hearing loss of old age is for sounds of frequency
cycles >3000 cps, which is above the level of the
frequency spectrum of heart and lung sounds.
Experience of old age helps

Additional from page 319:

3 systolic innocent murmus are:
STILL
Midsystolic and
vibratory
Heard in apex and
left lower sternal
border

BASAL EJECTION
Midsystolic, hight
pitched
Upper right or left
sternal border

CAROTID BRUIT
Early systolic, high
pitched
Above the
clavicles

2 continuous murmur
1. venous hum- low pitch, unrelated to timing to the
cardiac cycle, heard under the clavicle and in the
neck.
2. Mammary souffl heard over the breast of
pregnant and lactating mothers.