Learning Objectives

Identify the anatomical locations for optimal auscultation of specific heart valves. Distinguish between systolic and diastolic murmurs based on clinical presentation. Predict how dynamic bedside maneuvers (e.g., Valsalva, Squatting) alter murmur intensity. Correlate heart sounds with underlying valvular pathologies such as Stenosis and Regurgitation.

Auscultation Areas: Where to Listen (APT M)

Efficient auscultation requires placing the stethoscope in areas where sound from specific valves radiates most clearly.

• Aortic Area (A): 2nd Right Intercostal Space. Best for Aortic Stenosis and flow murmurs.
• Pulmonic Area (P): 2nd Left Intercostal Space. Best for Pulmonic Stenosis and Atrial Septal Defect flow murmurs.
• Left Sternal Border: Best for Aortic/Pulmonic Regurgitation (diastolic) and Hypertrophic Cardiomyopathy (systolic).
• Tricuspid Area (T): 4th/5th Left Intercostal Space. Best for Tricuspid Regurgitation, VSD (holosystolic), and Tricuspid Stenosis (diastolic).
• Mitral Area (M/Apex): 5th Left Intercostal Space (mid-clavicular). Best for Mitral Regurgitation (holosystolic), Mitral Prolapse, and Mitral Stenosis (diastolic).

Dynamic Maneuvers and Murmur Intensity

Bedside maneuvers change preload, afterload, or chamber volume to help differentiate similar-sounding murmurs.

High-Yield Murmur Patterns

• Systolic Ejection Murmurs: Crescendo-decrescendo pattern. Seen in Aortic Stenosis and Pulmonic Stenosis.
• Holosystolic Murmurs: Constant intensity from S1 to S2. Seen in Mitral/Tricuspid Regurgitation and VSD.
• Diastolic Murmurs: Usually decrescendo (AR/PR) or mid-diastolic rumbles with an opening snap (MS/TS).

Activity