Auscultation Rules of Thumb "All Physicians Take Money" (rule of thumb/mnemonic) aortic valve upper right sternal border aortic stenosis flow murmur aortic valve sclerosis left ventricular outflow tract obstruction lateral displacement of maximal impulse S4 gallop upper left sternal border (ULSB) harsh, crescendo-decrescendo systolic murmur hypertrophic obstructive cardiomyopathy pulmonic valve ULSB pulmonic stenosis flow murmur (e.g., ASD) tricuspid valve lower left sternal border (LLSB) pansystolic murmur (tricuspid regurgitation and VSD) diastolic murmur (tricuspid stenosis and ASD) mitral valve apex systolic murmur (mitral regurgitation) diastolic murmur (mitral stenosis) 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) -- --