Cardiac Auscultation in the Older Adult

Mark E. Williams, MD


January 18, 2012

In This Article

Other Cardiac Sounds

Means-Lerman Scratch

A Means-Lerman scratch is a mid-systolic sound over the upper sternum. It occurs in end expiration and is associated with hyperthyroidism. It is caused by a pulmonary ejection murmur in the setting of a hyperdynamic heart.


Systolic ejection clicks suggest mitral valve prolapse. In this case, the click moves earlier in systole with standing. Hypertension and tortuous aortic root can produce an early systolic click with no change in position. This is usually in the setting of a hyperdynamic state, such as anemia, hyperthyroidism, or medication effect. Rarely, in mitral valve prolapse there will be an early diastolic click. Additional causes of clicks are tricuspid valve prolapse, a bicuspid aortic valve, or a prosthetic valve.

Mechanical heart valves produce characteristic mechanical clicks. One trick to determine whether the click is from a mechanical valve is to listen over the shoulder near the acromioclavicular joint. The high-pitched click will be transmitted to bone, while the native clicks will not.

Mediastinal Crunch

Mediastinal crunch (Hamman sign) is a characteristic crunching sound coexistent with the heartbeat. It implies mediastinal emphysema or pneumopericardium. There is loss of cardiac dullness to percussion. The crunch usually extends into the neck.

Splash of Air Embolism

A loud churning sound (mill wheel murmur) suggests air embolism. In this case, immediately roll the patient onto the left side with the head down (Trendelenburg position) to decrease risk of cerebral air embolism.