Heart Landmarks When Performing Auscultation Assessment

Front 1

Auscultation Sounds: Expected
*S1
*S2
*S3
*S4
*Murmurs
*Gallops

Back 1

Unexpected:
*S3 (except in children)
*S4
*Murmurs
*Gallops

Front 2

Aortic: 2nd right intercostal space.

Back 2

S2 heard best at Aortic

Front 3

Pulmonary: 2nd left intercostal space.

Back 3

S1 sound heard best at Pulmonic

Front 4

Tricuspid: 4th intercostal space, at lower left sternal border.

Back 4

S3 heart sound

Sound: in early-mid diastole, low-pitched, "gallop sounding".
Where: apex, louder on expiration.
Why: ventricular distension, may be normal.
DDx:
• Normal in children
• Constrictive pericarditis.
• Mitral regurgitation
• Tricuspid regurgitation
• LVF, RVF

Front 5

Mitral: 5th left intercostal space, 1 cm medial to midclavicular line.

Back 5

S4 heart sound

Sound: higher pitch, late diastole, "gallop sounding"
Where:
Why: ventricular filling resistance, always pathologic.
DDx:
• HTN
• MI
• AS
• Heart block

Front 6

Murmurs:
Can be either systolic or diastolic. Students will only hear systolic.
Mnemonic for whether murmur is systolic diastolic:
• PASS and PAID:
• Pulmonary, Aortic Stenosis = Systolic.
• Pulmonary, Aortic Insufficiency = Diastolic.
• Then mitral and tricuspid must be opposite to these.

Back 6

Murmurs: grading

Graded on scale of 1 to 6.

Only cardiologist can hear.
Trained doctor can hear.
Student can hear. No thrill.
Thrill barely palpable.
Thrill easily palpable.
Can hear murmur by being in the room without a stethoscope