Complex Conditions - Auscultation Course

This course covers complex cardiac conditions where there are murmurs in both systole and diastole. Before taking this auscultation course you should be familiar with the previous material on systolic murmurs, diastolic murmurs, extra heart sounds, etc.

Using this course

Each lesson in this course includes text describing the heart or lung abnormality and a simulated torso indicating the stethoscope chestpiece location. An audio recording of the sound is provided. Phonocardiograms or waveforms are included with each lesson. These waveforms can be a highly useful aid in learning to recognize heart murmurs. In addition, short videos clips illustrate the heart's motion for each abnormality. These animations indicate the origin of each murmur. Blood flow is also animated. For lung sounds, the source (location) of the sound can be revealed.

After completing a lesson, use the lesson table of contents to navigate to another lesson.

When all lessons have been completed, we recommend using the auscultation practice exercises or quiz. In order to gain a certificate of achievement, please complete the course lessons and practice drill during one session. Most users complete the course's lessons and quiz in 30-45 minutes.

Click To Begin Training Module

Lessons

Lesson #1: Mitral Regurgitation - Severe

This is an example of severe mitral regurgitation which is caused by degeneration of the mitral valve leaflets. The first heart sound is normal. The second heart sound is widely split. Following the second heart sound there is a third heart sound gallop. There is a loud, rectangular, pansystolic murmur. There is a brief, rumbling, diamond-shaped diastolic murmur immediately following the third heart sound. In the anatomy video you can see the enlarged left atrium and left ventricle. You can see the turbulent blood flow from the left ventricle into the left atrium. This is the systolic murmur. You can see the brief turbulent blood flow from the left atrium to the left ventricle in diastole. This is caused by too much blood in the left atrium which forces blood back into the ventricle during diastole producing the flow rumble.

Lesson #2: Tricuspid Regurgitation - Severe

This is an example of severe tricuspid regurgitation which is caused by degeneration of the tricuspid valve leaflets. The first heart sound is normal. The second heart sound is unsplit. There is a loud, rectangular, pansystolic murmur. There is a brief, rumbling, diamond-shaped diastolic murmur. In the anatomy video you can see the enlarged right atrium and right ventricle. You can see the turbulent blood flow from the right ventricle into the right atrium. This is the systolic murmur. You can see the brief turbulent blood flow from the right atrium to the right ventricle in diastole. This is caused by too much blood in the right atrium which forces blood back into the ventricle during diastole producing the flow rumble. To differentiate tricuspid regurgitation from mitral regurgitation, the maximum intensity of the tricuspid murmur is heard at the left lower sternal border. In addition, the murmur intensity increases with inspiration.

Lesson #3: Mitral Stenosis Severe and Regurgitation Mild - Rheumatic Origin

This is an example of severe mitral stenosis combined with mild mitral regurgitation in a patient with rheumatic heart disease. The first heart sound is slightly louder than normal. The second heart sound is unsplit. There is an opening snap fifty milliseconds after the second heart sound. There is a low-frequency murmur filling all of diastole. The first two-thirds of the murmur is diamond shaped and the last third is a crescendo. There is a rectangular medium frequency murmur which fills the first half of systole. In the anatomy video you can see an enlarged left atrium and thickened mitral valve leaflets which barely moved. The turbulent blood flow represents the systolic and diastolic murmurs.

Lesson #4: Aortic Stenosis Moderate and Regurgitation Mild - Rheumatic Origin

This is an example of moderate aortic stenosis combined with mild aortic regurgitation in a patient with rheumatic heart disease. The first heart sound is normal. The second heart sound is unsplit. There is an aortic ejection click in systole followed by a diamond-shaped systolic murmur. There is a high-pitched decrescendo murmur which fills the first two thirds of diastole. In the anatomy video you can see a thickened left ventricle and thickened but mobile aortic valve leaflets. There is moderate turbulent flow across the aortic valve in systole and mild regurgitant turbulent flow into the left ventricle in diastole. The turbulent blood flow causes the systolic and diastolic murmurs.

Lesson #5: Mitral Regurgitation and Aortic Regurgitation

This is an auscultation example of moderate regurgitation of both the aortic and mitral valves. The first heart sound is minimally decreased due to minimal closure of the mitral valve leaflets in early systole. The second heart sound is normal. There is a rectangular murmur which takes up most of systole and a decrescendo murmur which takes up most of diastole. Both murmurs are of moderate intensity. The combination of the two murmurs creates a to-and-fro sound character. In the anatomy video you see an enlarged left atrium and left ventricle. You see regurgitant turbulent flow into the left atrium from the left ventricle (the systolic murmur) and regurgitant turbulent flow from the aorta into the left ventricular outflow tract (the diastolic murmur).

Lesson #6: Acute Pericarditis

This is an example of acute pericarditis as auscultated at Erb's Point. Murmurs are caused by turbulent blood flow across incompetent or stenotic valves. In contrast, a pericardial friction rub is caused by the rubbing together of two surfaces of the pericardial sack. The pericardial friction rub has three parts; a systolic component, an early diastolic component and a late diastolic component. The first and second heart sounds are obscured by the rubbing sounds. In the anatomy video you can see the yellow fluid accumulation around the heart caused by an inflamed pericardial sack.

Authors and Reviewers

Heart sounds by Dr. Jonathan Keroes, MD and David Lieberman, Developer, Virtual Cardiac Patient.
Lung sounds provided by Diane Wrigley, PA
Heart sounds mentorship by W. Proctor Harvey, MD>
Reviewed by Dr. Barbara Erickson, PhD, RN, CCRN.
Last Update: 12/14/2022

Sources

Heart Sounds and Murmurs Across the Lifespan (with CD) by Dr Barbara Ann Erickson
Publisher: Mosby
ISBN-10: 0323020453; ISBN-13: 978-0323020459
Heart Sounds and Murmurs: A Practical Guide with Audio CD-ROM 3rd Edition
Elsevier-Health Sciences Division
Barbara A. Erickson, PhD, RN, CCRN
Heart Sounds Made Easy with CD-ROM: (with CD-ROM) 2nd Edition
Anthony P. Salmon
ISBN-13: 978-0443069079
NCBI Review of Heart Sounds and Murmurs: A Practical Guide
The Virtual Cardiac Patient: A Multimedia Guide to Heart Sounds And Murmurs Jonathan Keroes, David Lieberman
Publisher: Lippincott Williams & Wilkin)
ISBN-10: 0781784425; ISBN-13: 978-0781784429
Ventricular Function Curves in the Exercising Dog
JONATHAN KEROES , ROGER R. ECKER , and ELLIOT RAPAPORT
Circulation Research, Vol. 25, No. 5
Electrocardiographic changes associated with ritodrine-induced maternal tachycardia and hypokalemia American Journal of Obstetrics Gynecology, VOLUME 154, ISSUE 4, P921-923, APRIL 01, 1986
Susan K Hendricks, MD, Jonathan Keroes, MD, Michael Katz, MD
A Multimedia Guide to Heart Sounds and Murmurs
January 2007 JAMA The Journal of the American Medical Association 297(2):217-218
DOI:10.1001/jama.297.2.217. M. Saleem Seyal, MD, Reviewer
Clinical Heart Disease W Proctor Harvey, MD