Let us analyze the acoustic events at the upper right sternal edge using the diaphragm of the stethoscope. We want to analyze both heart sounds and murmurs. Let’s start with the murmurs because they are the most impressive acoustic events in this case. We shall listen carefully, using the carotid arterial pulse as our timing device, and we are assisted a bit by the cotton swab, and as the tip of that swab moves, we recognize systole. Let’s listen very carefully to these heart murmurs.
Those murmurs were impressive, and they were heard in both systole and diastole. But to understand them, we have to take them one at a time. Overall, we heard “shwi-koo,” “shwi-koo,” but let’s take the systolic – the “shwi,” that occurred with the carotid impulse. That murmur was mid frequency, crescendo-decrescendo, and early in systole. Then there was the diastolic murmur – the “koo.” And that was high frequency. It started with the second sound and tailed off in late diastole. Again, “koo” – so that we heard “shwi-koo,” “shwi-koo.” These murmurs are consistent with disease of the aortic valve, well heard at the upper right sternal edge. The question is – is that systolic murmur reflection of obstruction of that valve? Is the diastolic murmur a reflection of leaking of that valve? Or is it a combination thereof? We’ll have to analyze further, both acoustically and integrate our findings at the bedside to answer these questions.
Heart sounds
The murmurs at the upper right sternal edge were impressive - “shwi-koo,” “shwi-koo,” “shwi-koo.” However, we must now tune in on the heart sounds. We may get some additional information to put the murmurs in perspective. Again, we tune in. Let’s listen carefully at the upper right sternal edge. As usual, we should get a timing device using the carotid arterial impulse, and let us all listen carefully and tune in on the acoustic events, the sounds, at the upper right sternal edge.
Review acoustic events
Let us review the acoustic events at the upper right sternal edge. Following S1 there is an ejection sound. An ejection sound may arise from either a pliable, congenitally deformed semilunar valve or in association with a dilated great vessel. The fact that this ejection sound is heard at the upper right sternal edge makes it most likely aortic in origin. In contrast to pulmonary ejection sounds, aortic ejection sounds do not show respiratory variation.
The ejection sound is followed by a short, early-to-mid systolic, crescendo-decrescendo systolic murmur. This murmur is likely due to increased flow across a non-stenotic aortic valve, as it occurs during maximal ejection and may be related to turbulence alone. The diastolic murmur is decrescendo, begins with the S2 and is consistent with aortic regurgitation.
Ejection sound video
You know, when you first listened to the acoustic events at the upper right sternal edge, we were nearly overwhelmed by the murmurs – “shwi-koo,” “shwi-koo,” “shwi-koo.” They impressed us. But then we went back and we tuned in, and then we heard something very important amongst the heart sounds, not just “lub-dub,” S1 and S2, but we heard an ejection sound, and that ejection sound occurred just after the first heart sound, didn’t vary with respiration, high in frequency, almost clicking in nature, and that ejection sound tells us something. It confirms what we suspected. There is disease at the level of the aortic valve. Now, this constellation of acoustic events at the upper right sternal edge is quite difficult at times to take apart. So what we’re going to do is get come help from an oscilloscopic image. Let’s listen again, upper right sternal edge. Let’s analyze, let’s dissect, let’s tune in to the acoustic events at the upper right sternal edge. Everybody listen and let’s watch the oscilloscope.
Oscilloscope
By freezing the oscilloscopic image and simultaneously listening we can further appreciate these auscultatory events.