What are the findings of a complete cardiac auscultation during a Physical Examination (PE)?

From the Guidelines

A complete cardiac auscultation during physical examination should be performed systematically using both the diaphragm and bell of the stethoscope at five key locations: the aortic area, pulmonic area, Erb's point, tricuspid area, and mitral area, as this approach ensures thorough evaluation of all heart valves and chambers, allowing detection of abnormalities that might indicate valvular disease, heart failure, or other cardiac conditions 1. The key locations for auscultation include:

• Aortic area (2nd right intercostal space)
• Pulmonic area (2nd left intercostal space)
• Erb's point (3rd left intercostal space)
• Tricuspid area (4th-5th left intercostal space at the lower sternal border)
• Mitral area (5th intercostal space at the midclavicular line) At each location, listen for S1 and S2 heart sounds, any additional sounds (S3, S4), and murmurs, noting their timing (systolic or diastolic), intensity (grade I-VI), quality, pitch, and radiation, as the production of murmurs is due to three main factors: high blood flow rate through normal or abnormal orifices, forward flow through a narrowed or irregular orifice into a dilated vessel or chamber, and backward or regurgitant flow through an incompetent valve 1. The patient should assume different positions to enhance certain sounds, such as:
• Leaning forward for aortic regurgitation murmurs
• Lying on the left side for mitral stenosis murmurs
• Standing or performing a Valsalva maneuver to accentuate hypertrophic cardiomyopathy murmurs The diaphragm is best for high-pitched sounds like S1, S2, and most murmurs, while the bell better detects low-pitched sounds like S3, S4, and diastolic murmurs, and echocardiography is particularly useful in evaluating cardiac murmurs, as discussed in the “ACC/AHA/ASE 2003 Guidelines for the Clinical Application of Echocardiography” 1. The evaluation of heart murmurs using echocardiography aims to define the primary lesion, hemodynamics, coexisting abnormalities, detect secondary lesions, evaluate cardiac chamber size and function, and establish a reference point for future comparisons, and diastolic murmurs virtually always represent pathological conditions and require further cardiac evaluation, as do most continuous murmurs 1.

From the Research

Cardiac Auscultation Findings

The findings of a complete cardiac auscultation during a Physical Examination (PE) include:

• Distinguishing between innocent heart murmurs and pathologic murmurs, with characteristics of pathologic murmurs including a holosystolic or diastolic murmur, maximal murmur intensity at the upper left sternal border, and increased intensity when the patient stands 2
• Describing murmurs by their timing in the cardiac cycle, intensity, shape, pitch, location, radiation, and response to dynamic maneuvers 2
• Identifying normal and pathologic heart sounds, including the use of a high-fidelity simulator to teach cardiac auscultation skills 3
• Using cardiac auscultation to make a rapid and accurate cardiac diagnosis, with the stethoscope remaining a valuable and cost-effective clinical tool 4

Comparison to Echocardiography

Studies have compared the accuracy of cardiac auscultation to echocardiography, finding:

• Almost perfect agreement between cardiac auscultation and echocardiography for the detection of mitral stenosis and ventricular septal defect 5
• Substantial agreement for aortic stenosis, pulmonary stenosis, and atrial septal defect 5
• Moderate agreement for mitral regurgitation, aortic regurgitation, and tricuspid regurgitation 5
• Careful clinical auscultation using a stethoscope remains a valuable tool for cardiac diagnosis, and decision on initial diagnosis and management of valvular and congenital heart diseases should be based on clinical examination and integrating such information with echocardiography as required 5

Practical Application

The practical application of cardiac auscultation includes:

• Using a stethoscope to hear, recognize, and interpret heart sounds and murmurs 6
• Practicing cardiac examination skills, including the use of a heart sounds auscultation simulation manikin 3
• Emphasizing the proper use of the stethoscope and the diagnostic and prognostic significance of heart sounds and murmurs 4