Elliot Kim
To listen to a person's heart sounds, a medical professional will use a stethoscope, placing it flat on the body at different locations corresponding to the heart. The stethoscope has two sides: the diaphragm, which is the larger, flat side, typically used to hear normal high-pitched sounds, and the bell, which is cone-shaped and used to hear low-pitched sounds. There are five points of heart auscultation, which are the aortic, pulmonic, tricuspid, and mitral valves, as well as an area called Erb's point. To listen to the mitral area of the heart, for example, a medical professional would place the stethoscope at the apex of the heart, on the left side of the sternum at the fifth intercostal space.
| Characteristics | Values |
|---|---|
| Technique | Auscultation |
| Purpose | Listening to the internal sounds of the body, such as heart, lung, and bowel sounds |
| Medical Instrument | Stethoscope |
| Stethoscope Parts | Diaphragm (larger flat side), Bell (cone-shaped side) |
| Stethoscope Use Case | Diaphragm: Hear normal high-pitched sounds; Bell: Hear low-pitched sounds |
| Heart Auscultation Points | Aortic, Pulmonic, Tricuspid, Mitral valve, Erb's point |
| Tricuspid Area Listening | Stethoscope placed on the lower left sternal border at the 4th intercostal space |
| Mitral Area Listening | Stethoscope placed at the apex of the heart or left side of the sternum at the 5th intercostal space |
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The aortic valve
The sound produced by the closure of the aortic valve is called A2, and it is normally much louder than the sound produced by the closure of the pulmonary valve (P2) due to higher pressures in the left side of the heart. The A2 sound radiates to all cardiac listening posts and is the loudest at the right upper sternal border. The combination of the A2 and P2 sounds makes up the S2 heart sound, which is described regarding splitting and intensity.
Aortic stenosis can affect the audibility of the A2 component. In severe cases, the A2 component may not be audible at all. A physiologic split S2 occurs when the A2 sound precedes P2, allowing both sounds to be heard separately. This typically happens during inspiration when increased venous return to the right side of the heart delays the closure of the pulmonic valve. During expiration, the distance narrows, and the split S2 is no longer audible. A paradoxical split S2 heart sound is heard during expiration and disappears during inspiration, which is the opposite of the physiologic split S2.
Aortic valve problems can also cause extra heart sounds, such as ejection sounds heard in early systole and systolic ejection clicks. Systolic ejection clicks are frequently indicative of a bicuspid aortic valve, where the leaflets dome suddenly before opening, creating the click. These clicks may be challenging to hear in the presence of significant aortic stenosis.
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The pulmonic valve
The APE to Man mnemonic can be used to remember where to place the stethoscope to listen for the pulmonic valve closing. The 'P' in APE stands for the aortic and pulmonary valves, and the sound of the closure of the pulmonic valve is best heard when the stethoscope is placed on the left side of the sternum at the 2nd intercostal space.
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The tricuspid valve
The sound of the tricuspid valve opening and closing is one of the sounds you hear in a heartbeat. The first heart sound, or S1, occurs when the mitral and tricuspid valves close after blood enters the ventricles. This represents the start of systole.
To listen to the tricuspid valve, a clinician will place a stethoscope on the lower left sternal border at the 4th intercostal space, or between the fourth and fifth ribs. The tricuspid valve is loudest in this location.
A clinician can listen to the tricuspid valve to assess its function. If the tricuspid valve is not functioning properly, blood may not flow efficiently in the correct direction or it may leak in the wrong direction. There are three main types of tricuspid valve problems: tricuspid atresia, tricuspid regurgitation, and tricuspid stenosis.
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The mitral valve
To listen to the mitral valve, a clinician will place a stethoscope at the apex of the heart, which is located on the left side of the sternum at the 5th intercostal space, between the fifth and sixth ribs, on the midclavicular line. In individuals with breasts, this space might be covered with breast tissue, so the clinician should request that the individual lifts the breast tissue to allow for proper auscultation.
Mitral valve abnormalities can result in various types of heart murmurs. For example, mitral regurgitation produces a pansystolic murmur of roughly even intensity throughout systole, while mitral stenosis produces a diastolic murmur described as presystolic. Mitral valve prolapse can cause a mid-systolic click, and mitral valve leaflet prolapse can result in a diamond-shaped systolic murmur associated with aortic stenosis.
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Erb's point
At Erb's point, both the S1 and S2 sounds can be heard. The S1 sound is produced by the closure of the mitral and tricuspid valves, while the S2 sound is produced by the closure of the aortic and pulmonic valves. The S1 and S2 sounds are also referred to as "Lub" and "Dub" respectively, with the combination of the two sounds creating the typical "Lub-Dub" sound associated with the heartbeat.
The APE to Man mnemonic is often used to remember the points of auscultation of the heart and the order in which the valves are heard. In this mnemonic, the "APE" stands for the aortic and pulmonary valves, as well as Erb's point, where the S2 sound is best heard. The "To" stands for the tricuspid valve, and the "Man" for the mitral valve.
Auscultation at Erb's point can provide valuable insights into heart health and potential abnormalities. Healthcare professionals can use this technique to gain a better understanding of cardiac health and potentially detect heart conditions earlier, leading to improved management of cardiac issues. However, it is important to note that factors such as body habitus, lung sounds, and ambient noise can affect the clarity of heart sounds at Erb's point. Therefore, auscultation at this location should be considered alongside other diagnostic methods for a comprehensive cardiac evaluation.
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Frequently asked questions
Auscultation is a technique used by healthcare professionals to listen to the internal sounds of the body, such as heart, lung, and bowel sounds.
A stethoscope is used to listen to heart sounds. It has two earpieces connected by tubing to a chest piece with a diaphragm and bell.
The aortic valve is located at the second right intercostal space near the sternum.
The pulmonic valve is located at the second left intercostal space near the sternum.
To listen to the tricuspid valve, place the stethoscope on the lower left sternal border at the fourth intercostal space.
