Cardiac Auscultation

Of all the skills of the diagnostician the auscultation of the heart is particular difficult to learn. I hope that this page make it more easy to carry out.

Jos-paul Scholten.

The stethoscope

The bell, Is better for Low-pitched sounds, while the high-pitched sounds are best heard with the diaphragm.

The technique

On auscultation one should first try to discriminate :

At first listen to the S1 at every location. Then listen to the S2. After they are recognised, listen to the sounds witch are around the S1 and S2.

The 1st heart sound (S1)

It represents the closure of mitral and tricuspid valves. It is best heard in mitral and tricuspid areas.

Normal, Splitted S1, Wide splitted S1.

The 2nd heart sound (S2)

Represents the closure of the aortic and pulmonary valves. It is best heard in the aorta and pulmonary areas.

Splitted S2, Wide splitted 2S, Reversed splitting.

The 3rd heart sound (S3)

Occurs shortly after S2. It is early diastolic and occurs during passive diastolic filling. It Is low pitched, has a long duration and is best heard with the bell in the mitral and tricuspid areas.


The 4th sound (S4)

Occurs just before S1. It is produced by the augmented diastolic ventricular filling near the end of the diastole and is caused by atrium contraction. It is loud due to a stiff ventricle. It is a low-pitched sound and best heard with the bell of the stethoscope. The ventricle can made stiff by : aortic stenosis, acute ischemia, hypertensive heart disease and myocard infarct.


Summation gallop

Occurs when both S3 and S4 are present in a patient with tachycardia. Diastole may be shortened and the two sounds may be merged.

Summation gallop.

Ejection,systolic click

Heard in early systole and it represent, aorta stenosis or systemic hypertension.

Ejection systolic click.

Mid systolic click

Occur in mitral prolapse.

Mid systolic click.

Diastolic sounds

Opening snap.

Precedes the mid diastolic murmur of mitral stenosis when not calcified. Rare is tricuspid stenosis. Often heard at the apex or at the left sternal border. It is best heard with the diaphragm of the stethoscope.

opening snap.


Murmurs may be systolic, diastolic, or continuous. High-pitched are best heard with the diaphragm, low-pitched with the bell of the stethoscope.


Murmurs are graded according to their intensity.

Regurgitant murmurs:

Occur when a valve is meant to be closed, and it is not.

Stenotic murmur:

Occur when a valve meant to be fully open, and it is not.

Systolic murmurs

ejection murmur

this originate from the turbulent flow through narrowed or irregular valves or outflow tracts. It has a crescendo- decrescendo, diamond-shaped character.

Aotra stenosis, Mitral insufficiency.

holosystolic murmur

A holosystolic murmur is do to regurgitation or shunts into chambers that throughout systole are at lower resistance.


Diastolic murmurs

Early diastolic murmurs :

Listen in the early diastole, for the absence of silence.

Aorta regurgitation.

Mid diastolic murmurs

Mitral stenosis.

Continuous murmurs

Continuous murmurs indicate a constant shunt flow throughout systole and diastole and may be due to patent ductus arteriosus. It is loudest at the 2nd intercostal space just below the medial end of the left clavicle.

Dutus arteriosis.

Pericardial Friction Rub

The sound has the character of pieces of leather squeaking as they are rubbed together. Is a superficial, high-pitched, or scratchy sound that may be systolic, diastolic or triphasic. The rubs are best heard with the patient leaning forward or upon hands and knees with breath held in expiration.

Pericardial rub.

Author: Jos-Paul Scholten

Last Revision: 01 Sept 1998
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