Physical examination maneuver
Physical Exam
Cardiac Auscultation
🎬
Video coming September 2026
How to Perform
With the patient supine or seated in a quiet room, listen directly on the skin in the second intercostal space at the right sternal border, the second intercostal space at the left sternal border, the lower left sternal border at the fourth or fifth intercostal space, and the fifth intercostal space at the left midclavicular line. At each site, listen with light pressure using a tunable diaphragm (or a lightly applied bell) for lower-pitched sounds, then press the tunable diaphragm more firmly for higher-pitched sounds. Identify S1 and S2 and listen through systole and diastole for murmurs or added sounds. If a murmur is loud, place the finger pads directly on the skin over the site where the murmur is loudest and palpate for a thrill. Use the presence or absence of a thrill as part of grading the murmur.
How to Interpret
Showing 35 of 91 findings
Acute Aortic Dissection
Diastolic murmur of aortic regurgitation
Rule in
Minimally helpful
Rule out
Not helpful
Evidence:Strong
Aortic Regurgitation
Decrescendo diastolic murmur at left sternal border
Rule in
Helpful
Rule out
Somewhat helpful
Evidence:Limited
Aortic Stenosis
Systolic murmur
Rule in
Somewhat helpful
Rule out
Very helpfulDerived CI
Evidence:Limited
Broad apical murmur pattern
Rule in
—
Rule out
Helpful
Evidence:Limited
S1 inaudible
Rule in
Helpful
Rule out
—
Evidence:Limited
Coarse quality murmur
Rule in
Somewhat helpful
Rule out
—
Evidence:Limited
Murmur same intensity in beat after pause
Rule in
—
Rule out
Somewhat helpful
Evidence:Limited
Left lower sternal border murmur pattern
Rule in
—
Rule out
InconclusiveWide CI
Evidence:Limited
S2 loud
Rule in
InconclusiveWide CI
Rule out
—
Evidence:Limited
Diminished or absent A2 (soft second heart sound) on auscultation
Rule in
Very helpful
Rule out
Somewhat helpful
Evidence:Strong
Mid-to-late peaking systolic murmur (peak past mid-systole)
Rule in
Very helpfulDerived CI
Rule out
Somewhat helpfulDerived CI
Evidence:Limited
Systolic murmur radiating to the carotids
Rule in
Somewhat helpful
Rule out
Helpful
Evidence:Strong
S4 gallop
Rule in
Somewhat helpful
Rule out
Somewhat helpful
Evidence:Limited
Blowing murmur quality
Rule in
—
Rule out
Very helpfulNo CI
Evidence:Limited
Early-systolic murmur timing
Rule in
—
Rule out
Very helpfulNo CI
Evidence:Limited
Prolonged murmur duration
Rule in
Somewhat helpfulDerived CI
Rule out
HelpfulDerived CI
Evidence:Limited
Gallavardin phenomenon (musical, high-pitched component of the aortic stenosis murmur at the apex, mimicking mitral regurgitation)
Rule in
Somewhat helpfulDerived CI
Rule out
Minimally helpfulDerived CI
Evidence:Limited
Murmur grade 3 or louder
Rule in
Not helpfulDerived CI
Rule out
InconclusiveWide CI
Evidence:Limited
Functional Systolic Murmur
Systolic murmur judged functional/innocent on bedside auscultation
Rule in
HelpfulDerived CI
Rule out
Somewhat helpfulDerived CI
Evidence:Limited
Heart Failure
S3 gallop
Rule in
Very helpful
Rule out
Not helpful
Evidence:Strong
Hypertrophic Cardiomyopathy
Systolic murmur louder on standing up from a squat
Rule in
HelpfulNo CI
Rule out
Very helpfulNo CI
Evidence:LimitedResearch in progress
Systolic murmur softer on squatting from standing
Rule in
HelpfulNo CI
Rule out
Very helpfulNo CI
Evidence:LimitedResearch in progress
Systolic murmur that increases with the Valsalva maneuver
Rule in
Very helpfulNo CI
Rule out
Somewhat helpfulNo CI
Evidence:LimitedResearch in progress
Systolic murmur softens with passive leg elevation
Rule in
HelpfulNo CI
Rule out
HelpfulNo CI
Evidence:LimitedResearch in progress
Systolic murmur that decreases with isometric handgrip
Rule in
Somewhat helpfulNo CI
Rule out
HelpfulNo CI
Evidence:LimitedResearch in progress
Mitral Regurgitation
Systolic murmur louder with isometric handgrip
Rule in
HelpfulNo CI
Rule out
Somewhat helpfulNo CI
Evidence:LimitedResearch in progress
Systolic murmur unchanged in intensity in the beat after a pause (irregular pulse)
Rule in
Somewhat helpful
Rule out
—
Evidence:Limited
Broad apical-base murmur pattern
Rule in
Not helpful
Rule out
Not helpful
Evidence:Limited
Systolic murmur
Rule in
Not helpful
Rule out
Not helpfulDerived CI
Evidence:Limited
Mitral Valve Prolapse
Mid-systolic click
Rule in
Minimally helpfulDerived CI
Rule out
Somewhat helpfulDerived CI
Evidence:Limited
Myocardial Infarction
Third heart sound
Rule in
Somewhat helpfulDerived CI
Rule out
—
Evidence:Limited
Pulmonary Embolism
Loud P2
Rule in
Somewhat helpfulDerived CI
Rule out
Not helpfulDerived CI
Evidence:Limited
Pulmonary Hypertension
Loud P2
Rule in
InconclusiveWide CI
Rule out
Minimally helpful
Evidence:Limited
Right-sided Valvular Lesion
Carvallo sign (systolic murmur intensity increases with inspiration)
Rule in
HelpfulDerived CI
Rule out
Very helpfulDerived CI
Evidence:Limited
Tricuspid Regurgitation
Broad apical-base murmur pattern
Rule in
Not helpfulWide CI
Rule out
Not helpfulWide CI
Evidence:Limited