Peform auscultation: Focus Attention Systematic Approach Determine Significance

Stethoscope AUS areas Heart Sounds Extra Sounds Murmurs Maneuvers

STETHOSCOPE

Stethoscope
Earpieces must fit well. Double-tubing stethoscopes are superior than the 'Y' shaped. Tubing length should be less than 12 to 15 inches. Diaphragm piece should be 1.5 inches in diameter, the Bell piece 1.0 inch.

Diaphragm
For High-pitched sounds. Apply firm pressure.
e.g.: 1S (1st sound), Mitral and tricuspid. 2S (2nd sound), Aortic and Pulmonary, snaps, clicks.

Bell
For Low-pitched sounds. Apply light pressure (form an air bubble).
e.g.: 3S (3rd sound), 4S (4th sound), diastolic murmurs.

AUSCULTATION AREAS

VALVE AREA	Auscultation Area	Diaphragm	Bell	comments
AORTIC	2nd Right ICS LSB	AS, A2, P2, mitral os
PULMONARY	2nd Left ICS LSB	PS, A2, P2, click, PDA
AORTIC Accessory	3rd Left ICS LSB	same as Aortic
	4th and 5th Left ICSs LSB	S1, S2, mitral os, AR, VSD: valsalva	MR, TR, PR	best area for emphysema
TRICUSPID	epigastrium, xiphoid process	S1, S2, TR, tricuspid os	S3
MITRAL	5th Left ICSs MCL (apex)	S1, S2, MS, mitral os, AR	S3, S4, MS post-exercise
KEY: A2 = aortic sound. AS = aortic stenosis. ICS = intercostal space. LSB = left sternal border. MCL = mid-clavicular line. MR = mitral regurgitation. MS = mitral stenosis. os = opening snap. P2 = pulmonary sound. PDA = patent ductus arteriosus. PR = pulmonary regurgitation. PS = pulmonary stenosis. TR = tricuspid regurgitation. VSD = ventricular septal defect.

Additional Auscultation Areas

Neck	both sides (radiations, clicks)
Left Axilla
2nd Left ICS MCL	continuous murmur of PDA
Left Interscapular-vertebral	systolic murmur of aortic coarctation
Right Interscapular-vertebral	systolic murmur (rupture of the chordae tendinae)

HEART SOUNDS

Heart Sounds

First Sound (S1)

Second Sound (S2)

Third Sound (S3)

Forth Sound (S4)

EXTRA SOUNDS

Extra Sounds

MURMURS

Murmurs

MANEUVERS & INTERVENTIONS

Maneuvers