Cardiac Auscultation in the Older Adult

Mark E. Williams, MD


January 18, 2012

In This Article

Auscultation of the Pulmonic Area (Left Upper Sternal Border)

Once your examination of the left lower sternal border is completed, move up to the left upper sternal border. Pulmonic valve murmurs and patent ductus arteriosus are loudest here, and it is the best place to hear the split in S2. Having the patient sit upright (or examining a wheelchair-bound patient) will increase the respiratory changes and bring out the S2 in this location.

Listen to S1

S1 normally will sound softer than S2 at this location.

Listen Carefully to S2

S2 is normally louder than S1 at this location. Louder P2 than A2 suggests pulmonary hypertension or aortic stenosis.

Focus on the Split in S2

Focus on the nature of the split in S2 (ie, hearing a muffling or 2 distinct sounds).

Hearing a split in inspiration and no split in expiration is normal.

Appreciating a narrow, fixed split suggests pulmonary hypertension. The split is narrow because of reduced compliance in the pulmonary vascular bed.

A wide split where the 2 sounds never come back together suggests right bundle branch block (check for a split first heart sound), left ventricular PVC, mitral regurgitation, massive pulmonary embolus, severe right heart failure, pulmonic stenosis, ventricular septal defect with left-to-right shunt, or atrial septal defect (including postoperative).

Other causes of an apparent split S2 are an S2 and S3 (the split will be louder over the ventricle rather than the base), S2 and an opening snap, S2 and a pericardial knock, and S2 and an atrial myxoma tumor plop.

Hearing a paradoxical split where you hear no split in inspiration but a split in expiration (A2 after P2) suggests left bundle branch block, aortic stenosis, tricuspid regurgitation, or patent ductus arteriosus with left-to-right shunt.

Listen to Systole

A murmur heard best in systole suggests pulmonic stenosis. A pulmonary systolic murmur radiating to the left clavicle is Petteruti sign.

Listen to Early Diastole

Murmur heard best in diastole suggests pulmonic regurgitation.

Listen to Late Diastole

An extra sound heard just before systole is likely a right-sided S4.