Cardiac Auscultation in the Older Adult

Mark E. Williams, MD

January 18, 2012

Auscultation Over the Tricuspid Area (the Left Lower Sternal Border)

When you have completed your examination of the apex, move to the left lower sternal border. Tricuspid murmurs and some asymmetric septal hypertrophy murmurs are heard best here.

Listen to S1

Hearing a split S1 over the tricuspid suggests a bundle branch block or a right ventricular S4-S1.

Listen to S2

Hearing a split S2 over the tricuspid but not at the apex suggests that either P2 is too loud or there is a right ventricular S3 gallop. You may hear the S3 increase in inspiration by pushing on the liver or by passively elevating the legs to increase venous return. Loss of the second heart sound after swallowing suggests obstruction of the lower esophagus (Meltzer sign). Appendicitis can increase the intensity of the second heart sound (Mannaberg sign).

Listen to Systole

A murmur heard best here suggests tricuspid regurgitation, mitral regurgitation, mitral valve prolapse, or aortic stenosis. Hearing an extra sound here suggests an ejection click, a click of mitral valve prolapse, or a pericardial friction rub, which is a leathery sound, like the heart is beating inside a paper sack.

Listen to Early Diastole

Hearing an extra sound suggests an S3 gallop (usually right ventricular), an opening snap, the beginning of mitral stenosis murmur, or an aortic regurgitation murmur.

Listen to Late Diastole

An extra sound in late diastole suggests an S4 gallop (usually right ventricular).

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Cite this: Mark E. Williams. Cardiac Auscultation in the Older Adult - Medscape - Jan 18, 2012.

General Comments
Auscultation at the Apex (Mitral Area)
Auscultation Over the Tricuspid Area (the Left Lower Sternal Border)
Auscultation of the Pulmonic Area (Left Upper Sternal Border)
Auscultation of the Aortic Area (Right Upper Sternal Border)
Characteristics of Cardiac Murmurs
Specific Murmurs and Their Characteristics
Other Cardiac Sounds
Clinical Maneuvers That Affect Murmurs
Special Circumstances
Further Reading

Table 1. Differentiating the Causes of a Split First Heard Sound
Reason For Split	Differentiating Clues
Split S1 from right bundle branch block	Wide split S2
S4 and S1	S4 gallop is not as crisp as an ejection click; may be palpable; disappears when the bell of your stethoscope is pushed; disappears during extrasystole; usually not audible at the base
S1 and ejection click	Ejection clicks are usually crisp and high pitched; moves closer to S1 when the patient stands; may hear other clicks or mitral valve prolapse murmur

Table 2. Grading Criteria for Cardiac Murmurs
Grade	Criterion
1	Faint murmur softer than S1 and S2
2	Faint murmur about the same intensity as S1 and S2
3	Murmur louder than S1 and S2 without a thrill
4	Loud murmur with a palpable thrill
5	Loud murmur with a palpable thrill, heard with the lightest touch of the stethoscope to the skin
6	Murmur that can be heard without the stethoscope

Table 3. Typical Characteristics of Common Murmurs
Murmur	Timing	Characteristic Sound	Radiation
Tricuspid stenosis	Diastolic	Soft rumbling increases with inspiration	None
Tricuspid insufficiency	Systolic	Holosystolic fine to coarse increases with inspiration	No pattern
Pulmonic stenosis	Systolic	Diamond-shaped coarse increases with inspiration	Left upper sternal border, under left clavicle
Pulmonic insufficiency	Early diastolic	Soft, high-pitched, short decrescendo increases with inspiration	Left sternal border
Mitral stenosis	Diastolic	Rumbling, low-pitched decrescendo crescendo	None
Mitral insufficiency	Systolic	Blowing or coarse holosystolic	Left axilla
Aortic stenosis	Systolic	Mid-to-high-pitched, coarse, diamond shaped	Under right clavicle and carotids
Aortic insufficiency	Early diastolic	Soft, high-pitched, early diastolic decrescendo	Left lower sternal border, right upper sternal border