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 in 30-45 minutes.
Lesson #1: Coarctation of the Aorta
This is an example of coarctation of the aorta, a congenital abnormality. This first heart sound is normal. The second heart sound is intensified. There is diamond shaped murmur occupying most of systole and a high-pitched decrescendo murmur in the first half of diastole. In the anatomy video you can see a constriction in the descending aorta which is responsible for the systolic murmur. There is regurgitant flow from the aorta into the left ventricle which causes the diastolic murmur. The left ventricle wall thickness is increased due to aortic pressure elevation caused by the aortic coarctation.
Lesson #2: Patent Ductus Arteriosus
This is an example of patent ductus arteriosus heard at the pulmonic position. Before birth, the two major arteries—the aorta and the pulmonary artery—are connected by a blood vessel called the ductus arteriosus. Shortly after birth the patent ductus closes and turns into a ligament. However, in certain abnormal circumstances the patent ductus remains open allowing blood to flow from the aorta into the pulmonary artery causing a strain on the right ventricle. The first heart sound is normal. The second heart sound is obscured by a continuous crescendo-decrescendo murmur which runs from the beginning of systole to the end of diastole peaking at the second heart sound. In the anatomy video you can see an enlarged left atrium and left ventricle and turbulent blood flow from the aorta to the pulmonary artery through the patent ductus.
Lesson #3: Atrial Septal Defect
This is an auscultation example of an atrial septal defect as heard at the pulmonic position. Atrial Septal Defect is a congenital condition associated with abnormal blood flow between the left atrium and the right atrium. Before birth there is a large connection between right and left atria. During development of the fetus the connection gradually disappears. However, in some cases the opening persists and is known as an atrial septal defect. Both the first and second heart sounds are split. The second heart sound splitting is fixed at 80 milliseconds. There is a brief diamond shaped murmur in early systole and another brief diamond shaped murmur in early diastole In the anatomy video you see an enlarged right atrium and right ventricle. You see turbulent blood flow across the tricuspid valve between the right atrium and the right ventricle (the diastolic murmur). This is caused by blood flow from the left atrium into the right atrium through the atrial septal defect. There is further turbulent flow into the pulmonary artery causing the systolic murmur.
Lesson #4: Ventricular Septal Defect
This is an example of ventricular septal defect as heard at the tricuspid position. Ventricular Septal Defect is a congenital condition associated with abnormal blood flow between the left ventricle and the right ventricle. During fetal development a wall develops creating a right and left ventricle. In a percentage of individuals a defect in the wall persists allowing blood flow from the left ventricle into the right ventricle. This condition is known as a ventricular septal defect. The first heart sound is normal. The second heart sound is unsplit. There is a third heart sound followed by a short diamond shaped diastolic murmur. A medium pitched murmur fills all of systole. In the anatomy video you see an enlarged right ventricle and an enlarged left atrium. You see turbulent blood flow from the left ventricle into the right ventricle through the up portion of the septum (the systolic murmur). There is further turbulent flow into the left ventricle from the left atrium causing the diastolic murmur. This is caused by VSD induced increased blood flow across the mitral valve.
Lesson #5: Tetralogy of Fallot
This is an example of Tetralogy of Fallot heard at the tricuspid position. Tetralogy of Fallot is a congenital condition often called Blue Baby Syndrome. It is characterized by four abnormalities: - pulmonic stenosis - increased thickening of the right ventricle - a ventricular septal defect - overriding aorta The first and second heart sounds are normal and unsplit. There is an aortic ejection click in systole. There is a diamond shaped murmur following the click and ending well before the second heart sound. In the anatomy video you can see turbulent flow from the right ventricle into the pulmonary artery across the stenotic pulmonic valve and turbulent flow from the left ventricle to the right ventricle (the ventricular septal defect). The right ventricular wall is thickened. If you listen at the tricuspid position, you are hearing the ventricular septal defect. If you listen at the pulmonic area, you are hearing the pulmonic stenosis. Both create diamond shaped systolic murmurs.
Lesson #6: Ebstein's Anomaly
This is an example of Ebstein's Anomaly as heard at the tricuspid area. The first heart sound is increased due to thickening of the tricuspid valve leaflets. The second heart sound is normal. A rectangular murmur of tricuspid regurgitation fills all of systole. An opening snap occurs 100 milliseconds into diastole followed by a decrescendo-crescendo murmur of mitral stenosis. These findings are all a manifestation of downward displacement of the tricuspid valve into the right ventricle In the anatomy video you can see the enlarged right atrium and the small right ventricle. The upward plume from the right ventricle to the right atrium represents the systolic murmur. The downward plume from the right atrium to the right ventricle represents the diastolic murmur. This abnormality is congenital in nature.
Heart Sounds and Murmurs Across the Lifespan (with CD)
by Dr Barbara Ann Erickson
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
- 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
Laennec Publishing; 1st edition (January 1, 2009)