BDX2  Technique of Auscultation and Valve Closure Sounds

Michael S. Feldman, M.D., F.A.C.C.
Disclosures		The author has no relationships with commercial interests related to the content of the presentation.

Bernard Segal, M.D., F.A.C.C.
Disclosures		The author has no relationships with commercial interests related to the content of the presentation.

Michael S. Feldman, MD, is Clinical Professor of Medicine at the University of Pennsylvania School of Medicine, and chairman of Graduate Education Foundation. Bernard Segal, MD, is professor of medicine at Thomas Jefferson University Hospital, and director of the Jefferson Heart Institute. Here, they discuss auscultation technique and valve closure sounds and offer a step-by-step guide for listening to the heart properly. Auscultatory examples of the normal valve closure sounds and the most common abnormal variants are provided.

The patient, the authors say, should be gowned so as to leave the precordium completely exposed, and should be placed in a semi-recumbent position. The examiner should perform the examination from the patient's right side – and should listen for only one thing at a time. An examination room free of extraneous noise from computers, televisions, phones, and conversation is essential for conducting effective auscultation.

Drs. Feldman and Segal provide a step-by-step guide to auscultation technique, starting with identifying and evaluating first and second heart sounds, and examining systolic and diastolic timing for such abnormal sounds as ejection clicks, mid systolic clicks, atrial and ventricular gallops, and pericardial knocks. They go on to discuss the frequency, intensity, quality, and duration of heart sounds – and how these sounds are transmitted and received. They discuss the cardiac cycle as a series of electrical and mechanical events that propel blood into the pulmonary and systemic circulation, and list the six categories of heart sounds – valve closure; valve opening; ventricular filling; ejection, mid- and late systolic clicks; extracardiac sounds.

Valve closure sounds, the authors note, comprise the first and second heart sounds, the first occurring with closure of the mitral and tricuspid valves, and the second with closure of the aortic and pulmonary valves. Abnormalities in the intensity of the first heart sound as seen in disease processes such as mitral stenosis and in the second heart sound as may be seen in aortic stenosis or arterial hypertension are identified and reviewed. They go on to state that valve closure sounds may vary in intensity and the degree of splitting, and the lecture concludes with an explanation of when and how splitting occurs in the first sound and the second sound.