Cardiac & Respiratory Auscultation

Stethoscope Components

Diaphragm (flat side) — High-frequency sounds

S1 — mitral/tricuspid closure ("lub")
S2 — aortic/pulmonic closure ("dub")
Murmurs — aortic stenosis, mitral regurgitation
Pericardial friction rub
Most breath sounds, pleural rub

Bell (dome side) — Low-frequency sounds

S3 gallop — ventricular filling sound
S4 gallop — atrial kick
Mitral stenosis low-pitched mid-diastolic rumble
Apply with light pressure only — heavy pressure stretches skin, converting bell into a diaphragm and filtering out low frequencies

Patient Positions for Auscultation

Sitting forward / leaning forward

Aortic regurgitation (early diastolic murmur, left sternal border)
Pericardial friction rub — louder with breath held on expiration
Graham-Steell murmur (pulmonic regurgitation)

Left lateral decubitus (left side down)

Mitral stenosis — low-pitched mid-diastolic rumble
S3 gallop — brings apex closer to chest wall
S4 gallop
Mitral regurgitation pansystolic murmur enhanced

Supine

Standard for all areas; routine assessment

Standing / Valsalva manoeuvre

HOCM murmur increases (decreased preload)

Auscultation Areas — Location & Significance

Area	Location	Valve / Sound Best Heard	Key Murmur / Finding
Aortic	2nd right ICS, sternal border	Aortic valve	Aortic stenosis (radiates to carotids), ejection click of bicuspid AV
Pulmonic	2nd left ICS, sternal border	Pulmonic valve; S2 split best here	Pulmonic stenosis, A2-P2 splitting assessment
Erb's Point	3rd left ICS, sternal border	S3, S4, aortic regurgitation	Early diastolic murmur of AR; S3/S4 with bell; both aortic & pulmonic murmurs may radiate here
Tricuspid	4th–5th left ICS, lower sternal border	Tricuspid valve	Tricuspid regurgitation (increases with inspiration — Carvallo's sign), VSD
Mitral / Apex	5th ICS, mid-clavicular line	Mitral valve; S1 loudest here	Mitral regurgitation (radiates to axilla), mitral stenosis (left lateral + bell), S3/S4, MVP click

S1 Heart Sound

lub

Start of systole

Closure of mitral + tricuspid (atrioventricular) valves
Marks beginning of systole
Loudest at the apex (mitral area)
Coincides with carotid pulse upstroke
Loud S1: mitral stenosis (pliable valve), tachycardia, high output states, thin chest wall
Soft S1: mitral regurgitation (MR), first-degree AV block (long PR — valve drifts open)
Variable S1: complete heart block, AF

S2 Heart Sound

dub

End of systole

Closure of aortic (A2) + pulmonic (P2) valves
Marks end of systole / beginning of diastole
Loudest at the base (aortic / pulmonic areas)
Loud A2: systemic hypertension, tachycardia
Soft A2: severe aortic stenosis (rigid valve)
Loud P2: pulmonary hypertension (right heart strain)

S2 Splitting

Physiological: A2 then P2 — wider on inspiration (RV fills more → P2 delayed). Closes on expiration. Normal.
Fixed split: ASD — split unchanged with respiration. Increased RV volume both phases.
Paradoxical split: LBBB or severe AS — split widens on expiration (A2 delayed, P2 moves before A2).

Radiation Patterns

        Aortic Stenosis

        Radiates to bilateral carotids ("carotid bruit"). Heard over entire precordium.

        Mitral Regurgitation

        Radiates to left axilla (and sometimes left infrascapular area / back).

        Tricuspid Regurgitation

        Radiates to right sternal border; increases on inspiration (Carvallo's sign).

GCC Context: Rheumatic heart disease (RHD) remains prevalent among expatriate South Asian and African populations in the GCC due to prior Group A streptococcal pharyngitis causing autoimmune valve damage. Mitral stenosis is the most common RHD valvular lesion. Always consider this diagnosis in immigrants presenting with dyspnoea, AF, or a mid-diastolic rumble.

S3 Gallop

Ken-tu-cky

S1 — S2 — S3 | Early diastole

Timing & Mechanism

Occurs in early diastole — rapid ventricular filling phase
Vibration of the ventricular wall during rapid passive filling
Low-pitched — use bell with light pressure
Best heard at apex, patient in left lateral decubitus

Clinical Significance

PATHOLOGICAL in adults >40 years: Indicates ventricular dysfunction (systolic heart failure), volume overload — dilated cardiomyopathy, MR, AR, VSD.

        PHYSIOLOGICAL: Children, young adults (<40), pregnancy, athletes — increased flow, compliant ventricle. No clinical significance.
      

S4 Gallop

Ten-nes-see

S4 — S1 — S2 | Late diastole

Timing & Mechanism

Occurs in late diastole — atrial contraction ("atrial kick") against a stiff ventricle
Vibration from forceful atrial systole filling a non-compliant ventricle
Low-pitched — use bell with light pressure
Best heard at apex

Causes — Reduced Ventricular Compliance

Systemic hypertension (most common) — LV hypertrophy
Hypertrophic cardiomyopathy (HOCM)
Aortic stenosis — chronic pressure overload
Acute myocardial infarction / ischaemia
Restrictive cardiomyopathy

S4 is never heard in atrial fibrillation (no atrial contraction). Its absence does not exclude the above conditions.

Pericardial Friction Rub

Characteristics

Triphasic scratchy / creaking / leathery sound
Components: ventricular systole, rapid filling (early diastole), atrial contraction (late diastole)
Both systolic and diastolic components present
Heard best at left sternal border, sitting forward, breath held on expiration
Varies with position — distinguishes from pleural rub (which varies only with breathing)
May be transient — listen repeatedly

Causes

Acute pericarditis — viral (most common), bacterial, TB, autoimmune (SLE, RA)
Post-MI (Dressler's syndrome)
Uraemia
Post-cardiac surgery

Pericardial rub may disappear as effusion accumulates — development of a large effusion may actually reduce the rub while increasing the risk of tamponade.

Opening Snap (OS) — Mitral Stenosis

High-pitched, sharp snapping sound
Timing: early diastole, shortly after S2
Heard at apex to lower left sternal border
Due to sudden tensing of stiffened mitral leaflets as valve opens (pliable but stenotic)
Use diaphragm (high-pitched)

        A2-OS Interval & Severity:

        Shorter interval = higher left atrial pressure = more severe MS. Severe MS: interval <60–70ms. Mild MS: interval >100ms.

OS disappears when valve becomes heavily calcified (rigid leaflets cannot snap)

Ejection Clicks & Mid-Systolic Clicks

Ejection Click

High-pitched, early systole (immediately after S1)
Aortic ejection click: bicuspid aortic valve — most common cause of ejection click in young adults. Heard at apex and base. Does NOT vary with respiration.
Pulmonic ejection click: heard at pulmonic area, decreases with inspiration (unique among right-sided sounds)

Mid-Systolic Click

Mitral Valve Prolapse (MVP) — commonest valvular abnormality overall
Click in mid-systole followed by late systolic murmur (MR)
Click moves earlier with standing/Valsalva (reduced preload); moves later with squatting (increased preload)
May progress to significant MR, arrhythmias, sudden cardiac death (rare)

Summary Table — Extra Heart Sounds

Sound	Timing	Pitch	Tool	Position	Significance
S3	Early diastole (after S2)	Low	Bell	Apex, left lateral	HF/volume overload (adults); physiological (young/pregnancy)
S4	Late diastole (before S1)	Low	Bell	Apex	Reduced compliance (HTN, HOCM, AS, MI)
Pericardial rub	Systolic + diastolic	High (scratchy)	Diaphragm	LSB, sitting forward, breath held expiration	Pericarditis
Opening snap	Early diastole (after S2)	High	Diaphragm	Apex → LLSB	Mitral stenosis (RHD)
Ejection click	Early systole (after S1)	High	Diaphragm	Apex/base	Bicuspid AV / pulmonic stenosis
Mid-systolic click	Mid-systole	High	Diaphragm	Apex	Mitral valve prolapse (MVP)

Murmur Grading — Levine Scale (1–6)

Grade	Description	Thrill?
1	Barely audible, requires intense concentration, not heard in all positions	No
2	Quiet but heard immediately upon placing stethoscope	No
3	Moderately loud, clearly heard	No
4	Loud with a palpable thrill	Yes
5	Very loud; heard with stethoscope partly off chest; thrill present	Yes
6	Audible without a stethoscope (stethoscope off chest)	Yes

Grades 1–2: typically innocent or functional. Grades 3+: warrant investigation. Grades 4–6: significant pathology until proven otherwise. Grading written as e.g. "3/6 ejection systolic murmur."

Systolic Murmurs

Ejection Systolic (Crescendo-Decrescendo / Diamond-shaped)

Diagnosis	Grade	Best Heard	Radiation	Key Features
Aortic Stenosis (AS)	2–4/6	Aortic area	Bilateral carotids	Slow-rising (parvus et tardus) pulse, heaving apex, soft A2, ejection click (if bicuspid), syncope/angina/dyspnoea triad
HOCM	3–4/6	Left sternal border	No carotid radiation	Increases with Valsalva/standing (reduced preload), decreases with squatting/lying; bifid pulse (bisferiens)
Pulmonic Stenosis	2–4/6	Pulmonic area (2nd LICS)	Left clavicle/back	Wide splitting of S2, RV heave, pulmonic ejection click (decreases on inspiration)
Innocent / Flow Murmur	1–2/6	Pulmonary / LSB	None	Soft, short, no radiation, no other signs, normal ECG/CXR. Common in children, pregnancy, anaemia, fever, hyperthyroidism

Pansystolic (Holosystolic / Plateau)

Diagnosis	Best Heard	Radiation	Key Features
Mitral Regurgitation (MR)	Apex	Left axilla ± back	Soft S1, possible S3. Left lateral decubitus enhances. Associated with MVP, RHD, ischaemic MR, dilated CMP
Tricuspid Regurgitation (TR)	Left sternal border / xiphoid	Right sternal border	Carvallo's sign — louder on inspiration. Pulsatile liver, elevated JVP with large v-waves, AF
VSD	Lower left sternal border	Right sternal border	Harsh, may have thrill. Small VSD = loud murmur ("Maladie de Roger"). Large VSD — Eisenmenger risk

Late Systolic

      Mitral Valve Prolapse (MVP): Mid-systolic click followed by late systolic murmur of MR. Click + murmur moves earlier with standing/Valsalva.
    

Diastolic Murmurs — ALWAYS Pathological

Any diastolic murmur in an adult is pathological until proven otherwise. Requires urgent echocardiographic evaluation.

Early Diastolic (High-Pitched, Decrescendo — starts immediately after S2)

Diagnosis	Best Heard	Position	Key Features
Aortic Regurgitation (AR)	Left sternal border (Erb's point)	Sitting forward, breath held expiration	Wide pulse pressure (>80 mmHg), collapsing/water-hammer pulse, Corrigan's pulse, De Musset's sign (head bobbing), Quincke's sign (nail pulsation), Austin Flint murmur (relative MS — functional mid-diastolic rumble at apex)
Pulmonic Regurgitation (PR)	Left sternal border, pulmonic area	Sitting forward	Graham-Steell murmur — high-pitched early diastolic, due to pulmonary hypertension. Loud P2, signs of RV enlargement

Mid-Diastolic (Low-Pitched, Rumbling)

Diagnosis	Best Heard	Position	Key Features
Mitral Stenosis (MS)	Apex	Left lateral decubitus, bell	Loud S1, opening snap, pre-systolic accentuation (if sinus rhythm — atrial kick). AF common. Short A2-OS = severe. RHD most common cause in GCC expatriate population.
Tricuspid Stenosis (TS)	Lower left sternal edge	Supine or left lateral	Louder on inspiration; elevated JVP with prominent a-wave; rare, usually co-exists with MS in RHD

Continuous Murmur

Patent Ductus Arteriosus (PDA): "Machinery" murmur, continuous throughout systole and diastole, loudest at 2nd left ICS infraclavicular. Peaks at S2. Wide pulse pressure, bounding pulse.
Cervical venous hum: Benign continuous murmur in children, disappears on lying flat or compressing ipsilateral jugular vein.

Auscultation Technique

Ask patient to breathe deeply through mouth
Posterior chest: Start at apex (above scapula), move down comparing left vs right side-to-side at each level
Anterior chest: Apices (above clavicles), infraclavicular, axillae
Listen for: air entry (symmetry), quality of breath sounds, added sounds
Document: presence/absence of breath sounds, type of added sound, location, relationship to inspiration/expiration

Normal Breath Sounds

Type	Location	Quality	Inspiration vs Expiration
Vesicular	Most of lung parenchyma	Soft, rustling, gentle	Inspiration >> Expiration (expiration barely audible)
Bronchovesicular	1st–2nd ICS anteriorly; between scapulae posteriorly	Medium pitch and intensity	Inspiration = Expiration
Bronchial (Tubular)	Over trachea only (normal)	Harsh, hollow, high-pitched, gap between phases	Expiration ≥ Inspiration

Bronchial breathing heard over lung tissue = PATHOLOGICAL — indicates consolidation (pneumonia), as patent bronchi surrounded by fluid-filled alveoli transmit sound. Also: compressed lung tissue above pleural effusion.

Crackles (Discontinuous Explosive Sounds)

Fine Crackles

Timing: late inspiratory
Quality: high-pitched, short, "velcro" tearing quality, like rubbing hair near ear
Location: gravity-dependent (posterior/basal), bilateral
Do NOT clear with coughing
Causes: pulmonary fibrosis (ILD — basal), pulmonary oedema (basal early → bilateral with severity), early pneumonia

Coarse Crackles

Timing: early inspiratory and/or expiratory
Quality: low-pitched, bubbly/gurgling, loud
May clear or change with coughing — secretions moving
Causes: bronchiectasis, COPD (secretions), pneumonia, pulmonary oedema (severe — "wet" sounds)

Wheeze (Continuous Musical Sounds)

Polyphonic Expiratory Wheeze

Multiple pitches simultaneously, diffuse
Prolonged expiratory phase
Asthma — reversible bronchoconstriction
COPD — chronic partially reversible obstruction

Monophonic Wheeze

Single pitch, fixed location
Large airway obstruction — tumour, foreign body, mucus plug
Warrants urgent investigation

Inspiratory Stridor

EMERGENCY — Upper Airway Obstruction
High-pitched, predominantly inspiratory, heard without stethoscope. Causes: epiglottitis, croup, foreign body, anaphylaxis, bilateral vocal cord palsy, laryngeal tumour. Requires immediate airway assessment.

Pleural Friction Rub

Quality: creaking / leathery / grating sound
Heard during both inspiration and expiration
Localised to site of inflammation
Disappears when patient holds breath (differentiates from pericardial rub)
May be accompanied by pleuritic chest pain

Causes

Pleuritis (viral, bacterial, TB)
Pulmonary embolism (infarction)
Pneumonia with pleuritic extension
Autoimmune (SLE, RA)
Mesothelioma

Vocal Resonance Techniques

Technique	Method	Normal	Increased (Consolidation)	Decreased (Effusion/Collapse)
Bronchophony	Patient says "99" while auscultating	Muffled, unclear	Clear "99" transmitted (consolidation)	Absent/very muffled
Whispering Pectoriloquy	Patient whispers "1-2-3"	Barely audible, indistinct	Clearly heard whispered words (consolidation — very sensitive)	Absent
Egophony	Patient says "eee" — listen for "aaa" quality	"eee" heard (same)	"eee" sounds like "aaa" — E-to-A change (consolidation, compressed lung above effusion)	Absent over fluid

Respiratory Signs Summary — Pattern Recognition

Condition	Breath Sounds	Added Sounds	Percussion	Vocal Resonance
Consolidation	Bronchial	Coarse crackles	Dull	Increased (bronchophony, whispering pectoriloquy, egophony)
Pleural Effusion	Reduced/absent	Pleural rub (early), egophony above	Stony dull	Reduced/absent; egophony above fluid level
Pneumothorax	Absent	None	Hyper-resonant	Reduced/absent
Asthma (acute)	Reduced (severe); ↑ expiratory time	Expiratory wheeze (polyphonic); silent chest = SEVERE	Hyper-resonant	Normal
COPD	Reduced, prolonged expiration	Wheeze, coarse crackles	Hyper-resonant	Reduced
Pulmonary Fibrosis	Vesicular, reduced	Fine late inspiratory crackles (basal, bilateral)	Normal or dull	Normal or reduced
Pulmonary Oedema	Reduced (basal)	Fine-coarse crackles (basal → bilateral in severe)	Dull (basal)	Variable

Peripheral Signs — Cardiovascular Examination

Pulse Character

Normal: smooth upstroke, regular, 60–100 bpm
Slow-rising (parvus et tardus): Aortic stenosis — reduced stroke volume, delayed peak
Collapsing/water-hammer: Aortic regurgitation — wide pulse pressure, rapid rise and fall. Feel with wrist elevated.
Pulsus paradoxus: systolic BP drop >10 mmHg on inspiration — cardiac tamponade, severe asthma, COPD exacerbation, constrictive pericarditis
Pulsus alternans: alternating strong/weak beats — severe LV systolic dysfunction (poor prognostic sign)
Bisferiens pulse: double-peaked systolic — HOCM with obstruction; severe AR with AS; high-output states
Corrigan's pulse: visible carotid pulsation — AR

Blood Pressure Analysis

          Wide Pulse Pressure (>80 mmHg):

          Aortic regurgitation, severe aortic atherosclerosis, AV fistula, PDA, thyrotoxicosis, anaemia, fever

          Narrow Pulse Pressure (<40 mmHg):

          Aortic stenosis (severe), cardiac tamponade, pericardial effusion, cardiogenic shock, severe heart failure

Four-Limb BP

Right arm > left arm by >15 mmHg: subclavian stenosis, aortic dissection
Arm > leg: coarctation of the aorta

Jugular Venous Pressure (JVP)

Assessment

Patient at 45° reclined; assess internal jugular vein (medial to SCM)
Normal JVP: <4 cm above sternal angle (<9 cm above right atrium)
JVP is non-pulsatile and non-palpable (vs carotid)
JVP falls on inspiration (physiological — reduced RA pressure as thoracic pressure falls)

Waveforms

a wave: atrial contraction (absent in AF; large in TS/PS/TR)
v wave: venous filling during systole (large in TR)
x descent: atrial relaxation
y descent: tricuspid valve opening (steep in constrictive pericarditis)

Key Signs

          Kussmaul's Sign:

          JVP rises with inspiration (paradoxical). Causes: constrictive pericarditis, cardiac tamponade, severe RV failure, restrictive cardiomyopathy

          Hepatojugular Reflux:

          Sustained JVP rise (>3 cm, >10 seconds) with firm right upper quadrant pressure — indicates elevated central venous pressure (RV failure, biventricular failure)

Elevated bilateral JVP + oedema: right heart failure, cardiac tamponade
Unilateral neck vein distension: SVC obstruction (Pemberton's sign if bilateral)

Apex Beat Assessment

Normal position: 5th ICS, mid-clavicular line
Displaced laterally/inferiorly: LV enlargement (MR, AR, DCM)

Character

Heaving (sustained, forceful): Volume overload — LV enlargement (MR, AR). Apex lifts examining finger slowly and holds up.
Thrusting (hyperdynamic): High-output states, AR
Tapping: Mitral stenosis — palpable loud S1. Feels like a tap rather than a sustained push.
Dyskinetic (double impulse): LV aneurysm post-MI; HOCM (triple impulse)
Non-palpable: Emphysema, obesity, pericardial effusion

Other Palpation Findings

Parasternal Heave

Palpate left sternal border with heel of hand
Heave (lifting of hand with each beat) = RV enlargement / hypertrophy
Causes: pulmonary hypertension, MS (RV pressure overload), ASD, PS, severe TR

Thrills

Palpable vibration = murmur grade ≥4/6
Systolic thrill at apex = MR or VSD
Systolic thrill at base = AS or PS
Diastolic thrill at apex = severe MS

Peripheral Oedema

Bilateral pitting: cardiac (RV failure), hypoalbuminaemia, venous insufficiency
Unilateral: DVT, lymphoedema, cellulitis, venous obstruction

Systematic Cardiovascular Nursing Assessment

Step	Assessment	Key Findings to Report
1	General inspection	Dyspnoea at rest, malar flush (MS), pallor, cyanosis (central/peripheral), clubbing, xanthomata
2	Hands	Clubbing (IE, cyanotic CHD, fibrosis), splinter haemorrhages (IE), Janeway lesions/Osler nodes (IE), peripheral cyanosis
3	Pulse	Rate, rhythm, character (slow-rising/collapsing/bisferiens/alternans), volume
4	Blood pressure both arms	Pulse pressure (wide/narrow), arm asymmetry (>15 mmHg)
5	JVP	Height, waveform (large a/v waves), Kussmaul's sign, HJR
6	Face / Eyes	Conjunctival pallor (anaemia), xanthelasma, corneal arcus, De Musset's sign, Roth spots (fundoscopy)
7	Precordial inspection	Visible pulsations, scars (sternotomy, lateral thoracotomy, CABG)
8	Precordial palpation	Apex beat (position + character), parasternal heave, thrills
9	Auscultation (all 5 areas)	S1/S2 (intensity, splitting), extra sounds (S3/S4/OS/clicks), murmurs (timing, grade, location, radiation)
10	Lung bases	Crackles (pulmonary oedema), dullness
11	Abdomen	Hepatomegaly (pulsatile = TR), splenomegaly (IE), aortic aneurysm
12	Lower limbs	Peripheral oedema, peripheral pulses, capillary refill, DVT signs