Advanced Physical Diagnosis
  • Techniques
• 1st & 2nd Heart Sounds
• 2nd & 3rd Heart Sounds
• Clicks and Snaps
• Murmurs
• Rubs
  • Demonstrations
Associated Evaluations
  • Patient HX
  • Physical Exam
  • Laboratory & Imaging
Differential Dx
Evidence Base
• Accuracy in Diagnosis of Systolic Murmurs
• Accuracy in Diagnosis of Diastolic Murmurs
• Accuracy in Diagnosis of CHF
Teaching Tips
[Skill Modules >> Heart Sounds & Murmurs >> Techniques ]

Techniques: Heart Sounds & Murmurs

Clicks and Snaps

Click to hear S3 extra heart sound. Click to hear S4 extra heart sound.
Diagram of systole / diastole for clicks & snaps.
EC=ejection click :: OS=opening snap
Ejection click

Most common early systolic sound; Results from abrupt halting of semilunar valves

Aortic ejection click:

Loud high frequency sound, associated with murmur due to same etiology
Does not vary with respiration

Best heard at apex

Clinical significance:
Causes associated with aortic valve with decreased but some residual mobility: i.e., aortic stenosis, bicuspid aortic valves and dilated aortic root; not generally heard with calcific aortic stenosis due to non-mobile valve

Pulmonic ejection click:

Early systolic ejection sound with associated murmur. Often diminishes with inspiration.

Sternal edge 2nd or 3rd ICS

Clinical significance:
Causes associated with pulmonic valve: pulmonic stenosis, pulmonary hypertension and dilated pulmonary trunk

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Opening snap

High-frequency early diastolic sound (occurs 50-100 msec after A2) associated with mitral stenosis; sound due to abrupt deceleration of mitral leaflets sound with associated murmur. Often diminishes with inspiration' accentuated in left lateral position.

Between apex and left lower sternal border

Sounds like:
RUP bu Dup rrrrrrRup Bu Dup
Correlating to s1, s2, OS, murmur of mitral stenosis,

Clinical significance:
The OS plus typical murmur indicates the murmur is due to mitral stenosis and not a flow rumble across a non-stenotic valve. The timing of the OS has been suggested as a gauge of the severity of the stenosis but has not been found to be reliable for this.

Mid-systolic click (plus late systolic murmur of mitral valve prolapse)

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Prosthetic valves
Prosthetic mitral valve sounds:

  • opening sound analogous to opening snap
  • closing sound coincides with S1

Prosthetic aortic valve sounds:

  • opening sound analogous to ejection click
  • closing sound coincides with S2

Proceed to the next technique

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