Test: Heart Auscultation

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Background/Purpose

Held by many as the key to physical examination, the importance of auscultation remains, but is diminished in an age of increasingly portable echocardiography.

Heart sound variations
When listening to heart sounds, note their volume (normal, diminished, loud) and whether physiological splitting is present.

Physiological splitting of the second heart sound is when the sound of aortic valve closure (A2) occurs earlier than that of pulmonary valve closure (P2). It occurs in inspiration and is more common in the young. It is caused by increased venous return and negative intrathoracic pressure. This delays right ventricular emptying and pulmonary valve closure, at the same time that pooling of blood in the pulmonary capillary bed hastens left ventricular emptying and aortic valve closure. Reverse splitting of the second heart sound can occur in conditions where aortic valve closure is delayed, such as left bundle branch block or paced right ventricle, or where pulmonary valve closure occurs early, such as in the B form of Wolff–Parkinson–White syndrome. Wide fixed splitting of the second heart sound occurs in atrial septal defect.

A third heart sound may be heard soon after the second heart sound. It is thought to be due to rapid, high-volume filling of the left ventricle. As such, it is found in pathological (left ventricular failure) as well as physiological (athletic heart, pregnancy) states.

A fourth heart sound may be heard just before the first sound. This is caused by atrial contraction filling a stiff left ventricle, eg, hypertensive heart or diastolic heart failure.

Murmurs
When you have considered these heart sound variations, move on to consider the gaps between the heart sounds. If you hear a murmur, first establish whether it occurs in systole or diastole (time against the carotid pulse if necessary). Then determine its length and, if short, its exact position (early, mid, or late; systole or diastole)

Added sounds
An opening snap occurring after the second heart sound represents a diseased mitral valve opening to a stenotic position. An ejection click soon after the first heart sound occurs in aortic stenosis and pulmonary stenosis. A mid systolic click is heard in mitral valve prolapse.

After listening to the heart
Listen to the base of the lungs for the fine inspiratory crackles of pulmonary edema. If you suspect right-sided cardiac pathology, palpate the liver, which will be enlarged, congested, and possibly pulsatile in cases of right ventricular failure or tricuspid valve disease. Also, check the patient's ankles for swelling.

Procedure

Listen over the aortic (second right intercostal space) and pulmonary (second left intercostal space) areas and at the left lower sternal edge with the diaphragm of your stethoscope (better for higher pitches), then use the bell for the apex (better for lower pitches). If in doubt, use both. Press lightly with the bell. If you hear an abnormality over the aortic or pulmonary areas, you should listen over the carotids. If you hear an abnormality at the apex, listen in the axilla. Listen systematically. Start with the heart sounds – ignore everything else.

Performed: Bilaterally

Dialog

Auscultation using a stethoscope to multiple areas of the heart.

Criteria

• Normal rate and rhythm
• Normal heart sounds

Measurement

LOINC Code

Scale/Grading

selection range; grade - LOINC ID
Option - Value option selection range; grade - LOINC IDPass ; Pass - Fail ; Fail -