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