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Heart Sounds & Murmurs

Listening turns the heart into music you can read: the two main sounds mark the cardiac cycle, extra sounds warn of strain, and murmurs reveal which valve is leaking or narrowed.

The two main sounds

Listening with a stethoscope, the heart says ‘lub-dub’. The first sound, the ‘lub’ (S1), is the mitral and tricuspid valves snapping shut as the ventricles begin to squeeze — it opens systole, the pumping phase. The second sound, the ‘dub’ (S2), is the aortic and pulmonary valves closing as the ventricles relax — it opens diastole, the filling phase. The gap between ‘lub’ and ‘dub’ is short (systole); the gap from ‘dub’ to the next ‘lub’ is longer (diastole). Fixing these two landmarks in your ear is the whole foundation of listening.

Extra sounds and gallops

Sometimes a third sound joins the rhythm. A third heart sound (S3), heard softly just after S2, is the sound of blood hitting a floppy, overfilled ventricle in early diastole. In a young, fit person it can be normal; in an older adult with breathlessness it is a worrying sign of a failing, dilated heart. When this extra beat makes the rhythm sound like a galloping horse — ‘ken-tuc-ky’ — it is called a gallop rhythm, and it is one of the more specific bedside signs of heart failure.

Reading a murmur

A murmur is the whoosh of turbulent blood — flow forced through a narrowed valve, or leaking back through one that should be shut. The first question is always timing. A systolic murmur falls between ‘lub’ and ‘dub’; a diastolic murmur falls after ‘dub’. Then ask where it is loudest and where it radiates. The harsh whoosh of aortic stenosis is loudest at the upper right of the chest and travels into the neck; the blowing murmur of mitral regurgitation is loudest at the apex and travels toward the armpit.

Step-through: describing a murmur at the bedside
--------------------------------------------------
1. TIMING   feel the pulse: heard WITH pulse?  -> systolic
                             heard AFTER pulse? -> diastolic
2. LOUDEST  upper-right sternal edge ........... aortic area
            upper-left sternal edge ............ pulmonary area
            lower-left sternal edge ............ tricuspid area
            apex (5th space, mid-clavicle) ..... mitral area
3. RADIATION  to the neck ...... think aortic stenosis
              to the axilla ... think mitral regurgitation
4. CHARACTER  harsh / ejection ... narrowed (stenotic) valve
              blowing / pansystolic ... leaking (regurgitant) valve

Worked example:
  Loud, harsh systolic murmur, upper-right sternal edge,
  radiating to the neck, with a slow-rising pulse
  ==> pattern fits AORTIC STENOSIS
A simple order of questions that turns a confusing whoosh into a named pattern.

Not every murmur means disease — many are harmless ‘flow’ murmurs heard in children, pregnancy, or anyone with a fast circulation. What matters is whether a murmur fits a recognisable pattern, whether it is loud or accompanied by symptoms, and whether the rest of the examination agrees. Listening well is a skill that rewards patience: a quiet room, the right spots, and the pulse under your fingers turn noise into meaning.