Heart auscultation

The Goals of Auscultation
The intensity of S1 in all areas
The intensity of S2 in all areas
The characterization of any systolic sounds
The characterization of any diastolic sounds

Normal heart sounds
In younger patients physiologic splitting of S2. is possible
S2 is made up of 2 components, aortic (A2) and pulmonic (P2) valve closure.
On inspiration, venous return to the heart is augmented and pulmonic valve closure is delayed, allowing you to hear first A2 and then P2.
On expiration, the two sounds occur closer together and are detected as a single S2.
The two components of S1 (mitral and tricuspid valve closure) occur so close together that splitting is not appreciated.

Extra heart sounds
While present in normal subjects up to the ages of 20-30, they represent pathology in older patients.
An S3 is most commonly associated with left ventricular failure and is caused by blood from the left atrium slamming into an already overfilled ventricle during early diastolic filling.
The S4 is a sound created by blood trying to enter a stiff, non-compliant left ventricle during atrial contraction. It's most frequently associated with left ventricular hypertrophy that is the result of long standing hypertension.
Positioning the patient on their left side while you listen may improve the yield of this exam.
The presence of both an S3 and S4 simultaneously is referred to as a summation gallop.

Factors that may influence the intensity of the heart sounds: first sound
Loud first sound
Hyperdinamic circulation
Mitral stenosis
Atril myxoma (rare)
Soft first sound
Low cardiac output (rest, heart failure)
Tachycardia
Severe mitral reflux (caused by destruction of valve)
Variable intensity of first sound
Atrial fillibration
Complete hart block

Factors that may influence the intensity of the heart sounds: second sound
Loud aortic component of second sound
Systemic hypertension
Dilated aortic root
Soft aortic component of second sound
Calcific aortic stenosis
Loud pulmonary component of second sound
Pulmonary hypertension

Points for auscultation

Any Murmurs Describtion
Timing in the cardiac circle
Location
Radiation
Duration
Intensity
Pitch
Quality
Relationship to respiration
Relationship to body position

Systolic murmurs

Differentials of systolic murmurs
Ejection systolic
Innocent systolic murmur
Aortic stenosis
Pulmonary stenosis
Hypertrophic cardiomyopathy
Flow murmurs
atrial septal defect
fever
athlete’s heart
Pansystolic
Tricuspid
Mitral reflux
Ventricular septal defect

Diastolic murmurs

Grading the intensity of murmurs
Grade 1 just audible with a good stethoscope in a quiet room
Grade 2 quiet but readily audible with a stethoscope
Grade 3 easily heard with a stethoscope
Grade 4 a loud, obvious murmur
Grade 5 very loud, heard not only over the precordium but elsewhere in the body