Bedside Physical Examination

(iii) Various positions in Auscultation

As previously mentioned in positions of auscultation mitral stenosis, the examiner must compare the loudness of S1 and S2, and make sure to hear a small sound of the S4, like "u", just before S1.

Among the middle-aged, S4 is audible in only about 50% of people, because of the lowering of compliance of myocardium. In diseased conditions such as hypertension, ischemic heart disease and hypertroplic cardiomyopathy, S4 is audible.

Mitral stenosis shows a characteristic loud S1, followed by OS and a mid-diastolic rumbling murmur.

In the hypertensive heart disease, mitral regurgitation, aortic regurgitation and dilating cardiomyopathy, the cardiac impulse is displaced to the left downward. In these cases, the examiner is able to hear S4, S1, S2, & S3, bedside heart murmur. Occasionaly a pericardial friction rub can be heard.

The cardiac auscultation of patients is to listen to heart sounds and murmurs using various positions. One must remember to listen to S1, S2, S3, & S4 and to make sure the presence of systolic and diastolic murmur to confirm the nature of the murmur.