Cardiac Auscultation

Auscultation is perhaps the most important, basic, and effective clinical technique you will ever learn for evaluating a patient's cardiovascular function. It is an essential skill to acquire in order to evaluate common chief complaints that may be potentially quite serious. Before you begin, there are certain things that you should keep in mind: a) Try to create a quiet environment as much as possible. This may be difficult in a busy emergency room or in a room with other patients and their visitors. Eliminate noise by closing the door and turning off any radios or televisions in the room. b) The patient should be in the proper position for auscultation, i.e. sitting up in bed leaning forward, lying on his/her left side, or supine or at 30 degree elevation on the examining table. c) Your stethoscope should be touching the patient's bare skin whenever possible or you may hear rubbing of the patient's clothes against the stethoscope and misinterpret them as abnormal sounds. You may wish to wet the patient's chest hair with a little warm water to decrease the sounds caused by friction of hair against the stethoscope. d) Always ensure patient comfort. Be considerate and warm the diaphragm of your stethoscope with your hand before auscultation. A thorough cardiac history and exam are particularly important when your patient presents with chest pain, shortness of breath,orthopnea, palpitations, syncope, edema in dependent areas (ie legs and sacrum), and paroxysmal nocturnal dyspnea (PND). It is also important to evaluate patients with risk factors for atherosclerosis (eg male, smoker, hypertension, diabetes, hypercholesterolemia, family history of heart disease < 55 yo, postmenopausal female, obesity, etc). A complete investigation of cardiovascular function must include vital signs, respiratory exam, peripheral vascular assessment, measurement of jugular venous pressure (JVP), evaluation of peripheral and sacral edema, and, of course,cardiac exam which will be discussed in the following sections. For other parts of the cardiovascular exam, please refer to a textbook of physical examination.

B. Cardiac Examination
Inspection & Palpation

During inspection of the anterior chest, you should be looking for scars, obvious abnormalities, and the apical impulse. Tangential lighting will help you in visualizing impulses, but do not worry too much if you still cannot see them especially if the patient is particularly obese or muscular. Palpation enables you to feel any thrills (large areas of sustained outward motion) and heaves (vibration). These are best felt through the ball of your hand pressed firmly against the patient's chest. Thrills usually are associated with loud, harsh, or rumbling murmurs such as aortic stenosis or mitral stenosis. Heaves often indicate right ventricular hypertrophy. Palpate the 4 auscultatory areas with the patient in supine position: 1) LV area: apex of the heart at 4th or 5th intercostal space (ICS) along MCL 2) RV area: 3rd to 5th ICS along the left sternal border (LSB) 3) pulmonic area: 2nd ICS along the LSB 4) aortic area: 2nd ICS along the right sternal border (RSB) 1) LV AREA Using your fingertips, palpate for the apical impulse which is normally located in the 4th or 5th ICS along the midclavicular line (MCL). In women, you may find it helpful to ask the patient to displace her breast superiorly and laterally. If the apical impulse is not readily palpable in the supine position, you may wish to ask your patient to lie on his/her left side. Note the characteristics of the apical impulse: location, diameter, duration, amplitude. It may be easier to assess these characteristics by having the patient exhale and hold his/her breath for a few seconds if possible. Location of the apical impulse lateral and inferior to the 4th or 5th ICS along the MCL suggests an enlarged or displaced heart. If the diameter of the impulse exceeds 3cm, you should evaluate the patient for an enlarged LV. An apical impulse is said to be sustained if it lasts longer than half of systole. Finally, notice if the amplitude of the apical impulse is increased, suggesting a hyperkinetic state eg hyperthyroidism, LV hypertrophy, after exercise. Careful inspection and palpation may also sometimes reveal S3 (occuring during middiastole) and S4 (occuring just before systole) beats. 2) RV AREA Using the fingertips, palpate the areas of the 3rd to 5th ICS along the LSB feeling for the systolic impulses of the RV. Having the patient exhale and hold his/her breath

may help if the RV impulse is hard to find. An increase in amplitude but not in duration of the RV impulse (RV rock) occurs with chronic volume overload leading to RV hypertrophy. 3) PULMONIC AREA The pulmonic area is found in the 2nd ICS along the LSB which is over the pulmonary artery. Ask the patient to hold his/her breath and feel the impulses of the pulmonary artery. Prominent pulsations are felt if the pulmonary artery is dilated or carrying increased blood flow. Pulmonary hypertension leads to a palpable S2. 4) AORTIC AREA The aortic area is found in the 2nd ICS along the RSB which overlies the aorta. Pulsations felt here may indicate an aortic aneurysm or dilated aorta while palpable S2 indicates systemic hypertension. Auscultation Listen to the heart sounds with the diaphragm of your stethoscope beginning at the apex, in each ICS along the LSB, and in the 2nd right ICS. You may follow this pattern or you might prefer to begin auscultation at the 2nd right ICS. Do not feel that you must adhere strictly to these areas only. If you notice any abnormal sounds or murmurs, you should auscultate adjacent areas to determine where these sounds are the loudest and their areas of radiation. When auscultating, first concentrate on the S1 and S2 sounds, next listen for S3 and S4 sounds before looking for murmurs and other abnormal heart sounds. The diaphragm is most useful for picking up high-pitched sounds eg S1, S2, aortic or mitral regurgitation, pericardial friction rubs. The bell is most useful for picking up low-pitched sounds eg S3, S4, mitral stenosis. When using the bell, press it gently against the skin. Applying more pressure stretches the skin taut and results in the bell functioning like the diaphragm. Listen to all the auscultatory areas with the patient in a supine position. You may also wish to use other patient positions in order to elicit or accentuate other heart sounds.
Patient Positions and Special Techniques for Auscultation

Position

supine sitting up and leaning forward aortic stenosis, aortic regurgitation, pericardial rubs and holding exhalation left lateral decubitus S3, S4, mitral stenosis (using bell of stethoscope) increases intensity of mitral valve prolapse and Vasalva manoeuver hypertrophic cardiomyopathy, decreases intensity of aortic stenosis increases intensity of aortic stenosis, decreases intensity squatting and standing of outflow obstruction in hypertrophic cardiomyopathy

Use general auscultation and most heart sounds

C. Evaluating Murmurs
When you encounter a murmur while auscultating, it is important to evaluate the following characteristics: 1. systolic vs. diastolic 2. duration 3. pitch: high, medium, low 4. quality: harsh, rumbling, blowing 5. intensity: eg crescendo, decrescendo, crescendo-decrescendo, plateau 6. best heard location 7. areas of radiation: eg axilla, carotids 8. grade of murmur (see table below) 9. variation with respiration and/or change of position 10.other associated sounds: S3, S4, ejection click, opening snap
Grading of Murmurs Description very faint; not always heard in all positions quiet but not difficult to hear moderately loud loud +/- thrills very loud +/- thrills; may be heard with stethoscope partly off chest may be heard with stethoscope completely off chest; +/- thrills

Grade 1/6 2/6 3/6 4/6 5/6 6/6