Cardiac Exam

The first thing to do is to read the Art of Auscultation article. It's well-written and enormously helpful in defining the sounds you hear, and in explaining basic auscultation technique. It should be required reading for all med students.

After that, take a look at the following suggestions and tips that we've picked up along the way, and please contact us with anything you come across that might be helpful to other students.

Heart Sounds and Review of Fundamentals

The Saia Method

The best advice I've ever gotten on the cardiac exam was from Dr. John Saia during a review for our checkout exams during second year. It boiled down to just being complete and methodical. This was it:

  1. Feel the PMI (Point of Maximal Impact).
  2. Listen to the aortic window (immediately right of the sternum, 3rd intercostal space).
  3. Listen to the pulmonary artery window (immediately left of the sternum, 3rd intercostal space).
  4. Listen to the tricuspid valve window (immediately left of the sternum, 5th intercostal space).
  5. Listen to the mitral valve window (left mid-clavicular line, 6th intercostal space).
  6. Listen to the right, then to the left carotid artery.
  7. At each area, stop and identify - then characterize - each of these sounds:

The Fedorowski Method

This method forces you to really think about the heart, its function, and its anatomy. The fundamental principle is to "follow the blood" through the heart, listening to all the possible places where problems may occur. This approach is the standard approach to cardiac auscultation in parts of Europe. The windows are the same (obviously, since the valves are in the same place), but the sequence is different.

The Right heart exam is similar: Basically, the primary pattern is an "X" - Apex, RUSB, LLSB, LUSB - with additional auscultation beyond that X (axilla, carotids, etc) as indicated.
Thanks to Jaroslaw Fedorowski MD and Peter Gajecki MD for their assistance.

Common auscultatory findings in patients with cardiovascular disease
First heart sound (S1)
  1. Louder than normal
  2. Variable in intensity
  3. Diminished in intensity
  1. Mitral stenosis, short PR interval
  2. Atrial fibrillation, complete heart block
  3. Mitral regurgitation, severe aortic regurgitation, long PR interval, calcified mitral valve
Second heart sound (S2)
  1. Fixed splitting
  2. Wide, physiologic splitting
  3. Paradoxical splitting
  4. Increased intensity of A2
  5. Increased intensity of P2
  6. Decreased intensity of A2
  7. Decreased intensity of P2
  1. Atrial septal defect
  2. Right bundle branch block, pulmonic stenosis
  3. Left bundle branch block, aortic stenosis
  4. Severe hypertension
  5. Pulmonary hypertension
  6. Calcific aortic stenosis
  7. Pulmonic stenosis
Extra heart sounds
  1. Third heart sound (S3)
  2. Fourth heart sound (S4)
  3. Opening snap
  4. Ejection sound
  1. Markedly diminished left ventricular diastolic function
  2. Modestly diminished left ventricular diastolic function
  3. Mitral stenosis
  4. Bicuspid aortic valve, pulmonary valve stenosis
Systolic murmurs
  1. Early systolic
  2. Midsystolic
  3. Holosystolic
  4. Late systolic
  1. Acute, severe mitral regurgitation, low-pressure tricuspid regurgitation
  2. Aortic sclerosis, aortic dilatation, aortic stenosis, pulmonic stenosis, hypertrophic cardiomyopathy, increased aortic valve flow (can also be caused by anemia, fever, or thyrotoxicosis)
  3. Mitral regurgitation, high-pressure tricuspid regurgitation, ventricular septal defect
  4. Mitral valve prolapse
Diastolic murmurs
  1. Early diastolic
  2. Mid-diastolic
  3. Late diastolic
  1. Aortic regurgitation, high-pressure pulmonary regurgitation
  2. Mitral stenosis, tricuspid stenosis, severe mitral regurgitation
  3. Mitral stenosis, severe aortic regurgitation (Austin Flint murmur), left atrial myxoma
Continuous murmurs
  1. Peaks before and after S2
  2. Rough, noisy, or high-pitched, louder during diastole
  3. Louder during systole
  1. Patent ductus arteriosus
  2. Normal venous hum
  3. Mammary souffle


Places to Hear Heart Sounds

The following resources are available for physicians interested in fine tuning and practicing their auscultatory skills. These pages have audio files.

The Auscultation Assistant

Cardiac Auscultation

Virtual Stethoscope