1. Introduction to Auscultation
Dr Zoltán Pozsonyi
3rd Dep. of Int. Med.
Semmelweis University

2. History

3. History
• before: ear on the chest
• Laennec- 1816:
– rolled up piece of paper in case of an obese
female patient with suspicion of heart disease
• the first single ear stethoscope
• later: made of wood and plastic

4. Auscultation
• very important, simple, effective clinical
technique to evaluate circulatory and
respiratory system
• very useful in examination of arteries and
abdomen
• understanding of underlying
pathomechanisms and practice!!

5. Significance
• Nowadays (echo, X-ray, CT, MRI) the
importance of auscultation is smaller
• limited access to imiging modalities
• auscultation is available anywhere

6. Technique of auscultation
• quiet environment
– ER, other patients, computers; close the
doors
• proper position
– may need help; ICU
• stethoscope on the bare skin
– rubbing
• proper size of diaphragm of the
stethoscope
– children; slim, skinny patients

7. Auscultation of the abdomen
• Bowel motility and abdominal complaints
• Searching for renal stenosis (hypertension)
• How to ...
– supine position
– place the stethoscope on the abdomen
– bowel sounds:
• normal sounds: clicks and gurgles 5-30/min
• wildly transmitted: one place is enough usually

8. Abnormal bowel sounds
• Increased intensity and frequency:
– diarrhea
– intestinal obstruction=obstructive ileus
• Decreased intensity and frequency, or on
sounds at all:
– paralytic ileus (dumb abdomen)
– peritonitis
• Splash in ileus (lot of air and liquid)

10. Bruits over the abdomen
• Normally there is no bruit
• for stenosis of the renal artery:
– listening for bruits (vascular sound; like heart
murmurs)
– in each upper quadrant of the epigastrium
– costovertebral angels

11. Bruits
• Atherosclerosis--stenosis
• Carotid artery (part of routine exam.)
–
–
–
–
stenosis=bruits (not always)
ischaemic stroke, TIA, embolization
ask the patient to turn his/her neck back
ask the patient to stop breathing momently
• Femoral bruits (above the aorta, iliac arteries)
– suspicion of insufficient arterial circulation of lower
extremities (pain, induced by walking; smoking; HT;
DM)

13. Before auscultation of lungs
• Patients arms crossed in front of the chest
• Diaphragm of the stethoscope
• Ask the patient not to speak and to breathe
deeply through the mouth
• Hyperventilation should be avoided (collapse)
• Always compare the two sides at the identical
locations
• At least one full breath at each location
• In case of suspitous sounds, auscultate nearby

14. Location of auscultation

15. Topographic considerations
Posterior view
Anterior view

16. Lung sounds
inspiration
pause
expiration
pause
• Expiration is longer than expiration
• Normally expiration is less loud, so at
auscultation it seems, these are at the
same length

17. Lung sounds-normal sounds
Two forms
• Tracheal or bronchial breath sounds
• Origin: turbulent airflow in central airways
• Turbulence is less in expiration, so expiration is
more quiet
• Not transmitted through air filled lung, but cab be
transmitted in atelectasy
• Normally can not be heard
• Can be heard in pneumonia, when lung tissue loses
air, or in case of large pleural effusions
• Loud, high pitched, (like over the trachea, scapula)

18. Normal sounds
• Vesicular breath sounds
• Origin: distal to the trachea, proximal to
the alveoli
• Normally vesicular sounds are over the
lung
• Soft and low pitched

19. Abnormal sounds
Absent or decreased breath sounds
• Severe asthma bronchiale: decreased
sounds
• Emphysema: decreased sounds
• Pneumothorax: absent or decreased
sounds
• Bronchial: pneumonia, effusion

20. Adventitious breath sounds
• Crackles (rales), discontinuous, non-musical, brief
•
•
•
•
•
sounds
more commonly on inspiration.
fine (high pitched, soft, very brief)
or coarse (low pitched, louder,less brief).
Mechanical basis: small airways open during inspiration
and collapse during expiration causing the crackling
sounds. (fine crackles)
Another explanation for crackles is that air bubbles
through secretions or incompletely closed airways during
expiration (coarse crackles)

21. Crackles- conditions
•
•
•
•
•
•
pneumonia
ARDS
bronchiectasis
early CHF
interstitial lung disease
pulmonary edema

22. Wheeze
• continuous, high pitched, hissing sounds
• heard normally on expiration but also
sometimes on inspiration
• produced when air flows through airways
narrowed by secretions, foreign bodies, or
obstructive lesions.

23. Wheeze-Conditions:
•
•
•
•
•
asthma bronchiale
CHF
chronic bronchitis
COPD
pulmonary edema

24. Stridor
• inspiratory musical wheeze heard loudest
over the trachea during inspiration
• stridor suggests an obstructed trachea or
larynx
• constitutes a medical emergency that
requires immediate attention
• foreign body

25. Pleural Rub
• creaking or brushing sounds produced
when the pleural surfaces are inflamed
and rub against each other
• may be discontinuous or continuous
sounds
• usually localized at a particular place on
the chest wall and are heard during both
the inspiratory and expiratory phases

26. Pleural Rub-condition
• Pleuritis
• Pneumonia with pleuritis
• Postthoracothomy syndrome

27. Auscultation of the heart
• bare skin; displace gently large left breast
• supine position first
• location
– anatomic references: sternum, midclavicular
line, axillary lines, costal interspace
Apex:
• timing
S1
S1
S2
systole
diastole
S2
time
– hard in case of tachycardia; intensity of heart
sounds may help

28. Heart
• Diaphragm: high pitched sounds:
– S1, S2, systolic murmurs (common)
• Bell: low pitched sounds:
– S3, S4, diastolic murmurs (rare)
• Throughout the entire praecordium
• (stop breathing)
• Usually supine position, but:
– mitral stenosis
– aortic regurgitation

29. What to listen for
• First heart sound (S1: closure of mitr. & tricusp.
valves)
– intensity, splitting (PHT, BB)
• Second heart sound (S2: closure ao. & pulm valves)
– intensity, splitting (respiratory cycle)
• Comparing intensity of S2
• Systolic extra sound
– click, ejection sounds,
• Diastolic extra sound
– S3, S4, opening snap
• Diastolic and systolic murmurs (longer than sounds)

30. Examples
• Expiratory slitting of S2 is abnormal
• Loud P2= pulmonary hypertension
• Systolic click: in mitral valve prolpase

31. Heart murmur, what should be
described
• timing, shape, loc. of max. intensity,
radiation, intensity, pitch, quality

32. Timing of a murmur
S1
S2
S1
midsystolic murmur (aortic
stenosis)
pansystolic murmur (mitral
regurg)
late systolic murmur
(mitral prolaps)

33. Timing of a murmur
S1
S2
S1
early diastolic (aortic regurg)
mid-diastolic (mitral stenosis)
late diastolic= praesystolic
(mitral stenosis)

34. Timing of a murmur
• Continuous murmur
• Throughout in diastole and systole
– pericardial friction rubs, patent ductus Botalli

35. Shape of a murmur
crescendo
decrescendo
crescendodecrescendo
(diamond shaped)
platau murmur

36. Location of maximal intensity
• The site where it can be heard best
– anatomic pos.
"Traditional areas"

37. Intensity of a murmur
Grade
Murmur Grades
Volume
Thrill
1/6
very faint, only heard in ideal
circumstances
No
2/6
3/6
4/6
loud enough to be generally heard
louder then grade 2
louder then grade 3
No
No
Yes
5/6
heard with stethoscope partially off
chest
Yes
6/6
heard with stethoscope entirely off
chest
Yes

38. Radiation of a murmur
• radiation from the point of maximal intensity
– for ex.: AS to the carotid arteries (blood flow)
Pitch
– high, medium, low
Quality
– blowing, harsh, rumbling, musical

39. Aortic stenosis
S1
S2
S1
Timing: midsystolic
Location: right 2nd intercostal space
Radiation: to the neck, carotid arteries
Intensity: often loud
Pitch: medium
Quality: often harsh

40. Mitral regurgitation
S1
S2
S1
Timing: systolic, holosystolic
Location: apex
Radiation: left axilla
Intensity: soft to loud
Pitch: medium to loud
Quality: blowing

41. What else is the stethoscope
good for?
• look like a doctor
• blood pressure measurement
• to transmit infection from patient to patient
– wash it sometimes, not just your hands

42. How to choose a stethoscope?
when I was a 3rd y student
•
•
•
•
•
•
good for decades
if you want to be a cardiologist,..
price
size of the diaphragm
digital is not better
color