The next step in evaluating our patient is auscultation. Of course, we listen in the four classic acoustic areas and, in our patient, we’ll begin at the apex. I’ll use the diaphragm of the stethoscope and, again, we’ll use the cotton swab to time systole by placing it on the carotid, and everybody also watch respiration. Everybody listen together.

And what did we hear at the apex in our patient? Well, we suspect our patient may have pericarditis, and what we heard is clearly consistent with a pericardial friction rub. It was very scratchy, as if you were rubbing two pieces of sandpaper together. It occurred in systole and with respiration, it varied somewhat. That is, when the patient breathed out, it got a bit louder.

Now, beware. Even though this is likely a pericardial friction rub, you can’t be sure this isn’t just a “scratchy systolic murmur.” What you must do is find a diastolic component to add to this systolic component, and then you can define this as a friction rub.

So let’s all listen together to other areas seeking a diastolic component for what we suspect is a pericardial friction rub.