S A* <* S A* <*
reversed s#lit S*
hypertrophic obstructive cardiomyopathy, left bundle branch block,
severe systemic 4., large <"A,
severe AR
?!piration %nspiration
S <* A* S S
Added sou$ds
i!
S-• ombination of tachycardia and loud S9 gives a characteristic cadence to the heart sounds described as gallop rhythm $ triple rhythm
• %n any clinical setting presence of S9 indicates abnormal 8 filling with high end diastolic pressure
ii! S. (refer table above) iii! O#e$i$) s$a#
• 3igh pitched sound
• 4eard all over precordium
• est heard with diaphragm Bust Medial to the
(pe-• ?asily mistaken for split S*
• Accentuated by e!ercise & 'idens on standing
• <ersists despite atrial fibrillation & even after mitral valvulotomy
• 0ccurs in MS when the stenosed valve moves forward towards the left ventricle at the beginning of systole
• Absent in =S in the following conditions
o mild =S
o alcified $ markedly 5ibrosed valve
o Associated significant =R
Mechanism:
.he sound is due to sudden $ sharp tensing of the cusps of the mitral valve as it tries to open during early diastole, when the left Atrial pressure left ventricle pressure
iv! EBectio$ clic,s
• 4igh pitched sounds closely following +6
• "ue to opening of semilunar valves
• =imic the split S
• .ypes
*7 aortic ejection click (?) 97 pulmonary ?
+7 mid systolic click
Cause Character Clinical conditions
Aortic "C Abnormality of
aortic valve cusps 'ell heard thru out precordium,
best heard at ape! ongenital AS # bicuspid aortic valve
Pulmonar y "C
Abnormality of
pulmonary valve 4eard at pulmonary area
2nly right sided event that
ommonly invalvular +
Also in dilatation of
6
cusps becomes softer on inspiration but loud * sharp on e-piration
pulmonary artery due to idiopathic nature $
pulmonary 4.
&id systolic click
arise from halting of mitral leaflet as it prolapses into the left atrium during systole
• 8oud clicks occurring in mid systole in association with
=<
• =imics S9 but differentiated by its high fre:uency (S9 is
of low fre:uency)
• 8ate systolic murmur (sometimes absent)
=itral valve prolapse (=<)
Also in .ricuspid vale prolapse, aneurysm of
interatrial $ interventricular septum, Severe AR
v7 Pericardial ru2
• haracter / Scratching $ grating $ creaking
• .riphasic (mid systolic, mid diastolic & presystollic)
• ?vanescent, vary with time & posture
• est heard # along left sternal edge in 9rd & +th spaces
• 4eard in
7 pericarditis # viral $ pyogenic $ tuberculous
*7 acute =%
97 acute rheumatic fever & rheumatoid arthritis
• =echanismN <roduced due to sliding of the * inflamed layers of pericardium
vi! Pericardial ,$oc,
• 8oud, 4igh fre:uency diastolic sound
• 4eard in constrictive pericarditis
• <roduced due to abrupt halt of early diastolic filling Murmurs
• Def N relatively prolonged series of auditory vibrations of variable intensity, Uuality,
5re:uency due to turbulence arising when blood velocity increases due to increased flow via a constricted $ irregular orifice
• =ote the following features
o Area over precordium where best heard, conduction
o Systolic $ diastolic
o .iming & character,
o %ntensity (grading)
• 1rading of S3S.08% murmurs (8ance & 5reeman-s grading)
! ery soft (heard in a :uiet room)
!! Soft
!!! =oderate
!$ 8oud with thrill
$ ery loud
$! ery loud (heard even when
stethoscope is away from chest wall)
• 1rading of "%AS.08% murmurs (8ance & 5reeman-s grading)
! ery soft
!! Soft
!!! 8oud
!$ 8oud with .hrill
o <itch
o etter heard with bell $ diaphragm
o ariation with respiration, posture, dynamic auscultation
Classification of murmurs
Dia!nosis of the &D& (mid diastolic murmur)
• Mitral stenosis (low pitched, rough, rumbling, 8ong drawn ="= with presystolic Accentuation ending in loud S with $ without 0pening snap,
heard in left lateral position, @ell of the stethoscope reath held in
-piration/
Ty#e Causes
+ystolic . from S to S*)
7 ?arly systolic Q7
*7 =id systolic Q777 97 8ate systolicQQ +7 <an systolicQQ7
S", acute severe .R, acute severe =R
AS, <S, hypertrophic cardiomyopathy(40=)
=itral alve <rolapse (=<), .<
=R, .R, S"
Diastolic
7 ?arly QQQQ7
*7 =id QQQQ777 97 8ate QQQQ77 (presystolic)
AR, <R
=S, .S (other rare causes given below)
=S, .S, Atrial my!omas, complete heart block
Continuous Refer below
6*
Differential dia!nosis of &D&
7 Austin flint murmur
*7 5low murmur in AS",S", <"A,
97 arey # oombs murmur ( soft, low# pitched MDM in (cute rheumatic mitral valvulitis usually Transient )
+7 8eft Atrial =y!omas 67 all valve thrombus
;7 .ricuspid stenosis (best heard in left sternal edge !ncreases in !nspiration e-aggerated &a' wave in ?$ )
Comparison of &itral 'tenosis * Austin lint &urmur
2pening snap <resent Absent
+ 8oud 2ormal
+ Absent <resent
Left $entricular lift Absent ommon
Right ventricular heave <resent Absent
Rhthym Atrial 5ibrillation Sinus rhythm
alpitation ommon Kncommon
3emoptysis ommon Kncommon
Thrill ommon Kncommon
eripheral signs of (R Absent <resent
Dia!nosis of pan systolic murmur
• =itral regurgitation
%t is a high pitched, Soft, an systolic murmur , well heard in the mitral area, in left lateral position with diaphragm, breath held in e!piration conducted to a!illa
& back7
o .he conduction of the murmur depends on the leaflet involved
(nterior leaflet A!illa & back
osterior leaflet ase
Differential dia!nosis of pan systolic murmur
=est "eard over Associated
co$ditio$s
61 Tricuspid regurgitation
8eft lower strnal edge
%ncreases with inspiration Severe pulmonary 4., pulsatile liver
41 $+D .Loud*
harsh/
8eft 9rd & +th %S .hrill
Dia!nosis of eection systolic murmur
• Aortic stenosis
Rough crescendo # decrescendo well heard in sitting position with breath held in e!piration conduction to carotids
Differential dia!nosis of eection systolic murmur
i7 4ypertrophic cardiomyopathy
ii7 Stenosis/ Sub/valvular aortic, Supra/valvular aortic, <ulmonary iii7 AS"
iv7 <ulmonary arterial hypertension v7 .hyroto!icosis
vi7 hysiological
7 %nnocent systolic murmur,
*7 Anemia, 97 <regnancy,
+7 chest wall deformity (pectus e!cavatum)
Dia!nosis of "D&
• A0R.% regurgitation/
high pitched, blowing, decrescendo, early diastolic murmur, well heard in aortic area & ?rb-s area, patient sitting & leaning forward, breath held in
e!piration
Etiolo)y o& AR EDM %2est "eard' Rheumatic etiology 8eft *nd %S Aortic root dilatation Right *nd %S
Differential dia!nosis of early diastolic murmur
<ulmonary regurgitation (1raham # Steell murmur)
!n case of a murmur better heard along rt side of sternum search for non#
rheumatic etiology
6+
onditions resulting in AR murmur best heard on right side of sternum i7 Aortic aneurysm # cystic medial necrosis, Syphilis, %diopathic,
=arfan-s
ii7 Sinus of alsalva aneurysm, iii7 Aortic dissection
Com#ariso$ o& AORTIC 9 P;LMONARY i$com#ete$ce
eripheral signs
<resent Absent
Chamber enlargement
8eft ventricle Right ventricle
(pical impulse
4yperdynamic 2ormal
Murmur Right *nd %S &
?rbs area 8eft *nd %S
Relation of respiration
0n e!piration 0n inspiration
CONTIN;O;S murmur
• egins in systole, overlaps the S* & spills over to diastole for a variable period generated by flow of blood from Jone of high resistance to a Jone of low
resistance without interruption during both systole & diastole
• Differentiated from +ystolico E diastolic murmurs and To * fro murmurs by prominent +41
Systolico( diastolic murmur To 9 Fro murmur
Definition 0ccupies both systole & diastole but the murmur occurs thru different channels and doesn-t peak around S*
0ccupies both systole and diastole but both
components originate across a single channel
+een in S" with AR/ systolic murmur originates across S" & diastolic murmur across aortic valve
AS with ARI <S with <RI
=S with =R
Differential dia!nosis of continuous murmur /
<"A, Aorto/ pulmonary window, Rupture of sinus of alsalva, Artereio venous (A) fistula, oronary A fistula,
Anomalous origin of 8eft oronary Artery from <ulmonary Artery (A8A<A),
enous hum,
=ammary soufflV +ENO;S 0;M
• ontinuous ruit heard over neck veins due to increased velocity of flow 0R diminished viscosity
• <atient # sitting position
• ell of steth used lightly etween the * heads of Sternomastoid
• "isappears with compression of root of neck
• 0ccurs in Anemia, .hyroto!icosis, %ntracranial A fistula E<ami$atio$ o& ot"er systems
*'+ look for bilateral basal crackles
<leural effusion, 5, ronchiectasis, commonly on left side in =S
Abdomen/ look for hepatosplenomegsaly, free fluid,in abdomen, 5, infective endocarditis,
CN'+ look for any focal neurological deficit due to emboli in the form of stroke
Clinical dia!nosis of common cardiovascular diseases
! MITRAL STENOSIS
• ulse 8ow volume with regular $ irregular rhythm, tapping in character
• @ is normal
• <alpable <* with variable <arasternal heave
• "iastolic thrill
• loud Swith $ without opening snap
• mid diastolic murmur
o low pitched, rough, rumbling, 8ong drawn
o presystolic accentuation
o 4eard in left lateral position
o ell of the stethoscope
o reath held in ?!piration
• (ssessment of severity:
7 "uration of murmur N shorter the duration, less severe the stenosis
6;
*7 A* # 0S interval N
Severe =S 76 # 7> sec
=ild =S 7 # 7* sec 97 %ntensity doesn-t correlate with Severity +7 alve Area
2ormal 6 s:7 cm
Asymptomatic *76 s:7 cm
=ild 76 # *76 s:7 cm
=oderate # 76
Severe C s:7 cm
*! MITRAL REG;RGITATION
• ulse / 2ormal $ large volume pulse with $ without A5
• 4yperdynamic (! # thrill rarely made out
• 8eft arasternal lift ,
• Soft S
• Audible S9,
• ?vidence of pulmonary 4.
• <an systolic murmur
o 4igh pitched soft
o well heard in mitral area
o in left lateral position
o with diaphragm
o breath held in e!piration
o conducted to a!illa & back
• Assessment of dominant lesion in combined =S & =R
ositive signs &itral 'tenosis &itral re!ur!itation
+6 8oud Soft
Thrill "iastolic Systolic
(pical !mpulse .apping 4yperdynamic
+ Absent <resent
-! AORTIC STENOSIS Slow Rising pulse
arotid thrill
Apical impulse # heaving
S9 # heard all over aortic area S+ may be heard
Rough, crescendo/ decrescendo eBection systolic murmur
est heard in sitting position
reath held in e!piration
onducted to the carotids
(ssessment of severity
7 according to alve area
*7 according to S*
A* followed by <* Mild
Single S* Moderate
Reversed Split S* +evere 97 long drawn murmur with 8ate <eaking Msevere
+7 presence of S+ & absence of A* M severe .! AORTIC REG;RGITATION
• eripheral signs of (ortic Regurgitation
7 lighthouse sign # alternate flushing & blanching of forehead
*7 landolfi-s sign # change in papillary siJe inaccordance to cardiac cycle and not related to light
97 de musset sign # head nodding with each heart beat +7 mullers sign # pulsatin uvula
67 :uinke sign # capillary pulsation
;7 orrigan sign # dancing carotids
>7 water hammer pulse # collapsing pulse
@7 pulsus bisferians # double peaking pulse, both peaks in systole F7 traube sign # pistol shot sound over femoral artery
+ s:7 cm =ormal C 7>6 s:7 cm +evere C 76 s:7 cm Critical
6@
7duroJeiJ sign / systolic murmur heard over femeral artery with pro!imal compression and diastolic murmer with distell compression
7 hill signs # popliteal cuff systolic < e!ceeds brachial cuff pressure by *
mm4g
C * mm4g =ormal
* to + mm4g Mild (R + to ; mm4g Moderate (R
; mm4g +evere (R
*7osenbach sign # pulsatile liver
971rehadt sign/ pulsatile spleen
+7ecker sign # retinal arteriolar pulsation
• Cardiovascular findings
• 8arge volume pulse
• 4igh Systolic < with very 8ow "iastolic <
• 4yperdynamic Apical %mpulse
• 4eart sounds # Soft S L presence of S9
• ?"=
o high pitched, blowing, decrescendo, early diastolic murmur
o well heard in aortic area & ?rb-s area
o patient sitting & leaning forward
o breath held in e!piration
• (ssessment of severity
7 =arked peripheral signs
*7 isferians pulse
97 4ill-s sign ; mmhg
+7 "uration of =urmur # occupying *$9 rd of the "iastole 67 Austin flint murmur
Assessment of dominant lesion in presence of combined AS & AR
Positive si)$s For AR 9 For AS
eripheral signs 8 slow rising pulse
<eripheral signs Slow rising pulse
ulse pressure 'ide 2arrow
+ystolic thrill in (ortic area
Absent <resent
@ 4igh systolic < & low
diastolic < Systolic "ecapitation
/! +e$tricular Se#tal De&ect %+SD)
• <alpitation, "yspnoea on e!ertion, 5re:uent respiratory infections
• 2ormal $ wide pulse pressure
• 4yperdynamic precordium with systolic thrill in left 9rd & +th %S
• S & S* masked by murmur at the left sternal border
• 'ide split S* with variable attenuation of <*
• S may be heard at the ape!
• <S= over left <ara sternal area, not conducted to a!illa
• 5low ="= may be heard over ape!
Com#ariso$ o& murmurs o& MR TR 9 +SD
Features MR TR +SD
@est heard Ape! .ricuspid area 8eft para/asternal area
Thrill Rare Absent ommon
Conduction A!ial and back 2ot conducted Absent
Character Soft blowing Soft blowing Rough harsh
Relation to respiration
?!piration in lying
position %nspiration in sitting Knrelated
(ssociated features
8 hypertrophy Soft S
8ow volume S9
R hypertrophy
Signs of <ulmonary 4.
?levated G< # EvO
iventricular hypertrophy Apical ="=
Sym#toms 9 si)$s o&
ASD PDA Tetrolo)y o& Fallot
61 +ymptoms 1enerally
asymptomatic Symptomatic since childhood
<alpitation, ?ffort
intolerance, 5re:uent chest
Symptomatic since
childhood, Ano!ic spells,
"yspnoea on e!ertion,
?!ercise intolerance,
;