Auscultation Rules of Thumb "All Physicians Take Money" (rule of thumb/mnemonic) aortic valve upper right sternal border login to view 3 more bullets left ventricular outflow tract obstruction lateral displacement of maximal impulse S4 gallop upper left sternal border (ULSB) harsh, crescendo-decrescendo systolic murmur login to view 1 more bullet pulmonic valve ULSB login to view 2 more bullets tricuspid valve lower left sternal border (LLSB) login to view 2 more bullets mitral valve apex login to view 2 more bullets Murmur Cheat Sheet Crescendo/Decrescendo Holosystolic Systolic AS (to neck) MVP (click) HOCM MR (to axilla) TR (inspiration increases) VSD (harsh) Diastolic Aortic regurgitation MS (opening snap) NOTE: See chart below for abbreviations Murmur Identification Systolic Lesion Shape Location Heard Altered by Characteristics Aortic stenosis (AS) Crescendo-decrescendo Radiates to neck (carotids) and apex -- "Parvus et tardus" (pulses weak compared to heart sounds) Follows ejection click (due to halting of valve leaflets) Hypertrophic cardiomyopathy (HOCM) Crescendo-decrescendo -- ↓ venous return (e.g.,Valsalva) - increases murmur -- Mitral valve prolapse (MVP) Late crescendo -- ↑ TPR (e.g.,squatting, hand grip) - decreases murmur ↓ venous return (e.g., Valsalva) - increases murmur Mid-systolicclick (tensing of chordae tendinae)Loudest at S2Later with ↑ afterload (e.g., hand grip). Mitral regurgitation (MR) Holosystolic Radiates to axilla ↑ TPR (e.g., squatting, hand grip) ↑ LA return (e.g.,expiration) High-pitched, blowing Tricuspid regurgitation (TR) Holosystolic Radiates to right sternal border ↑ RA return (e.g.,inspiration) High-pitched, blowing Ventricular septal defect (VSD) Holosystolic -- -- Harsh-sounding Diastolic Lesion Shape Location Heard Altered by Characteristics Aortic regurgitation (AR) Early decrescendo Left sternal border with patient leaning forward -- High-pitched blowing heard at end of expiration Mitral stenosis (MS) Late rumble Heard in lateral left decubitus position ↑ LA return (e.g., expiration) Opening snap (tensing of chordae tendinae) in early diastole after A2 Other Lesion Shape Location Heard Altered by Characteristics Patent ductus arteriosus (PDA) Continuous ULSB -- Machine-like continuous/constant murmur heard through systole and diastole Atrial septal defect (ASD) Systolic and diastolic Systolic: ULSB (pulmonic valve) Diastolic: LLSB (tricuspid valve) -- --