In vivo analysis techniques - Auscultation of body sounds

IN VIVO ANALYSIS TECHNIQUES - AUSCULTATION OF BODY SOUNDS

Table of contents :

chest auscultation

lung auscultation
heart auscultation

auscultation of peripheral pulses

abdomen auscultation

percussion => percussion sounds
auscultation : the act of listening for auscultatory sounds within the body (such as heart sounds, Korotkoff sounds, breath sounds, or adventitious sounds), chiefly for ascertaining the condition of the lungs, heart, pleura, abdomen and other organs, and for the study of the sounds of the fetal heart (obstetric auscultation).

souffle / bruit de soufflet [Fr. “sound of a bellows”] : a soft, blowing, auscultatory sound

false bruit : one due to pressure by the stethoscope, or derived from the circulation in the ear of the auscultator

direct or immediate auscultation : auscultation performed without the stethoscope.
Korúnyi's auscultation or percussion : auscultatory percussion done by tapping with one forefinger the second joint of the other forefinger applied perpendicularly to the part
mediate auscultation : auscultation performed by the aid of a stethoscope interposed between the ear and the part being examined.

monoauricular auscultation
biauricular auscultation

stethoscope (a.k.a. campana in Italy) : the skin acts as the resonance membrane (better for low sounds (n = 20-200 Hz : 2^nd, 3^rd and 4^th cardiac tones, cardiac and arterial murmurs)

telestethoscope : a combination of stethoscope and electrical amplification by which persons at a distance from the patient can hear the heart and lung sounds, as in demonstrating to a class or to a medical audience

phonendoscope : a stethoscopic device that intensifies auscultatory sounds, consisting of a shallow metal cup closed by a diaphragm. It contains a diaphragm for band selection and amplification during resonance (better for high sounds (n = 100-500 Hz : 1^st cardiac tone). The eartubes are permanently set at an anatomically correct angle. The eartips should point in a forward direction as you insert them into your ear canals. To reduce spring tension in the headset, hold each eartube at the bend near the eartip and gradually pull apart until fully extended. To increase spring tension, grasp the headset at the yoke with one hand where the eartubes enter the tubing and squeeze until the tubing on one eartube touches the other. Repeat as necessary. Snap-tight eartips are pushed on to the end of the eartube and snapped firmly into place for personal safety and optimum performance. If sterilization is required, the stethoscope should be EO sterilized using the cold cycle in a 3M Steri-Vac Gas Sterilizer followed by aeration for 36 hours in a 3M Steri-Vac Aeration Cabinet.
stethophonendoscope has both stethoscope and phonendoscope on opposite sides

stethophonendoscope with tunable diaphragm, which enables single-sided chestpiece operation

to listen to low-frequencie sounds, you can use either the traditional open bell or tunable diaphragm using very light contact pressure. Although both high and low frequency sounds will pass through in this mode, with light pressure the low frequency sounds will dominate the sounds you hear and mask the higher frequencies
to accentuate the higher frequency sounds, using the tunable diaphragm, press firmly on the chestpiece. The tunable diaphragm will move inward and contact the attenuator ring underneath. As you press on the chestpiece, you will hear the diminished amplitude of the low frequency sounds and the clarity of any high frequency sounds

chest auscultation

lung auscultation : pulmonary sounds

physiological breath sounds : auscultatory sounds heard in relation to the patient's breathing; they are usually listened for over a lung or a bronchus. Types include bronchial, bronchovesicular, vesicular, and cavernous breath sounds

tracheal murmur (on the neck, during terminal inspiration and initial expiration)
bronchial breath sounds / bronchial breathing / bronchial or tubular respiration : breath sounds with a high pitch like that of blowing through a tube. Generated in bronchi, loss in alveoli as air allow transmission only of sounds with 200 < n < 400 Hz. In healthy persons they are heard over the normal manubrium sterni on auscultation during whole respiration. When heard elsewhere they are pathologic and may indicate areas of adjacent consolidated or compressed lung
bronchovesicular breath sounds or respiration : breath sounds intermediate between bronchial and vesicular with similar duration and quality during whole inspiration and initial expiration. They are heard normally over lung hyli : near the anterior part of the first two intercostal spaces and on the back between the scapulae. When heard over the lung they usually indicate an area of partial consolidation
vesicular breath sounds or resonance / normal breath sound (NBS) (generated in prealveolar structures, low-pitched sounds heard on auscultation over the whole chest during whole inspiration (generated from turbolent air flow in segmental and lobar bronchi) and first half of expiration (generated from central airways); intensity is decreased in pulmonary emphysema)
xiphisternal crunching sound : a peculiar sound, of unknown origin, frequently heard (20% of healthy men) over the lower sternum and xiphoid process.
voice sounds : auscultatory sounds heard over the lungs or airways when the patient speaks; increased resonance indicates consolidation or an airless lung underlying an effusion. Types include :

bronchophony : the normal voice sounds heard over a healthy large bronchus
pectoriloquy / pectorophony : voice sounds of increased resonance heard through the chest wall

bronchophony / bronchiloquy : an abnormal voice sounds heard over the lung, with the voice transmitted unusually clearly and with a high pitch; it is a type of pectoriloquy, indicating solidification of the lung tissue
aphonic pectoriloquy / Baccelli's sign : the sound of the whispered voice transmitted through a serous, but not through a purulent, exudate within the pleura
whispered or whispering pectoriloquy, bronchophony, resonance or voice : the transmission of the sound of whispered words through the walls of the chest, heard upon auscultation and indicating an area of consolidation

egophony / bronchoegophony / egobronchophony / tragophonia / tragophony / voix de Polichinelle : increased resonance of voice sounds, with a high-pitched nasal or bleating quality, heard especially over lung tissue that is compressed or consolidated by pleural effusion
laryngophony : a voice sound heard over the larynx
tracheophony : a voice sound heard over the trachea
amphoric or cavernous voice / amphoriloquy / amphorophony : a type of pectoriloquy consisting of hollow voice sounds heard over a lung cavity when the patient speaks

pathological sounds

bronchial murmurs in places other than sternum handle
Aetiology : decreased air content

soft bronchial murmur

pleural effusion

hard bronchial murmur

additional lung sounds (ALS) / adventitious sounds : abnormal auscultatory sounds heard over the lungs in some stage(s) of respiratory cycle. Details can be better detected with time-expanded waveforms (TEW).

discontinuous additional lung sounds (DALS) / crackles / rales (a.k.a. crepitii in Italy) (lasting < 200 or 250 ms - usually 20 ms) : a series of short nonmusical noises, heard primarily during during inspiration

low tonality or gross sounds : coarse crackle or wet noise or heavy-breathing (a.k.a. crepitio a bassa tonalità o grossolano or rantolo mucoso in Italy) during initial inspiration; initial deflection width (IDW) = 1.25 ms; 2 cycle duration (2CD) = 9.32 ms. They are due to air gurgling through intrabronchial secretions in larger airways.

large bronchi coarse crackle (bronchitis )
intermediate bronchi coarse crackle (bronchiolitis or bronchiectasia )
small bronchi coarse crackle (initial (crepitatio indux) or terminal (crepitatio redux) alveolar pneumonia or alveolar pulmonary oedema )

high tonality or keen sounds : fine crackle (a.k.a. crepitio ad alta tonalità o fini or crepitazione in Italy) during the mid-terminal inspiration. They are due to sequential sudden openings of previously closed smaller airways.

amphoric rale / bottle sound : a coarse, musical, and tinkling rale caused by the splashing of fluid in a cavity connected with a bronchus
atelectatic, border or marginal rale : a nonpathologic rale that is dissipated by deep breathing or coughing and is best observed at the margin of a lung. This type is frequently heard in those who breathe feebly and superficially, when on deep inspiration the moist walls of the unexpanded alveoli are suddenly forced apart by the entering air; after a few deep inspirations these rales are lost
cellophane rale : one resembling the rustling of cellophane, heard in interstitial pulmonary fibrosis.
consonating or metallic rale : a clear, ringing sound produced in bronchial tubes that are surrounded by consolidation tissues.

cavernous rale : a hollow and metallic rale caused by the alternate expansion and contraction of a pulmonary cavity during respiration.

dry rale : originally, a rale with a whistling or squeaking quality produced by the presence of viscid secretions in the bronchial tubes or by spastic contraction of the tube walls. Because it seemed contradictory to refer to such a rale as “dry,” the term is now more often used to describe fine crackles associated with many types of interstitial lung disease, including idiopathic pulmonary fibrosis.
moist rale : any of numerous rales produced by the presence of liquid in the bronchial tubes.

bubbling or mucous rale : a moist rale heard when air passes through areas of bronchi that contain mucus.

gurgling rale : a very coarse type of bubbling rale.

clicking rale : a small, sticky moist rale heard in inspiration, caused by the passage of air through secretions in the smaller bronchi.
crackling or subcrepitant rale : a fine, moist rale heard in conditions that are associated with liquid in the smaller tubes
crepitant or vesicular rale / crepitus : a very fine rale, resembling the sound produced by rubbing a lock of hair between the fingers or by particles of salt thrown on fire; heard at the end of inspiration

guttural rale : a rale produced in the throat.
tracheal rale : a rale produced in the trachea.

continuous additional lung sounds (CALS) (lasting > 200 or 250 ms, first inspiratory ==increase in bronchoconstriction==> also expiratory); initial deflection width (IDW) = 0.92 ms; 2 cycle duration (2CD) = 6.02 ms. They are due to vibration of bronchial walls and intrabronchial fluid at a critical flow rate generated at a critical bronchial diameter.

low tonality, n_dominant ~ 200 Hz : (sonorous) rhonchus (a.k.a. ronco (sonoro or russante in Italy), a dry, low-pitched, snorelike noise, produced in the throat or bronchial tube due to a partial obstruction such as by secretions
high tonality, n_dominant ~ 400 Hz : wheeze / sibilant or whistling rhonchus (a.k.a. sibilo, ronco sibilante, or gemito in Italy), a whistling noise with a high pitch, thought to be generated by gas flowing through narrowed airways

asthmoid respiration : wheezing respiration like that of bronchial asthma
asthmatoid wheeze : a sound similar to the wheezing of an asthmatic, heard in cases of foreign body in the trachea or bronchus.

Aetiology

obstructive lung diseases

pleural or pleuritic friction rub : a rub produced by friction between the visceral and costal pleurae

Aetiology

: pleural effusion

vesiculocavernous respiration : cavernous breath sounds with a vesicular quality, indicating a cavity surrounded by healthy lung tissue.
vicarious respiration : increased action in one lung when that of the other lung is diminished.
cavernous breath sounds or respiration : abnormal breath sounds marked by a peculiar prolonged hollow resonance, usually due to an underlying cavity in the lung
bronchocavernous respiration : breath sounds intermediate in character between bronchial and cavernous, heard over a lung cavity with solidified lung tissue adjacent to it.
amphoric respiration : respiration characterized by amphoric resonance, heard over pulmonary cavities or pneumothorax.
metallic sound : a sound having a metallic quality heard especially over cavities in the chest
Shibley's sign : in the presence of consolidation of the lung or a collection of fluid in the pleural cavity, all spoken vowels are heard through the stethoscope as “ah.”
resonance : a vocal sound as heard in auscultation

cough resonance : a peculiar auscultatory sound elicited by coughing
vesiculotympanitic or wooden resonance : a resonance, heard upon auscultation, that is partly vesicular and partly tympanitic
vocal resonance (VR) : the sound of ordinary speech as heard through the chest wall.

heart auscultation

auscultation areas : precordial region : a part of the anterior surface of the body covering the heart and the epigastric fossa or pit of the stomach

mitral area : at the crossing between left hemiclavear line and 4^th-5^th intercostal space
tricuspid area : at the crossing between left or right marginosternal line and 4^th intercostal space
mesocardiac area : at the crossing between left marginosternal line and 4^th or 5^th intercostal space
pulmonary area : at the crossing between left marginosternal line and 2^nd intercostal space (Louis' angle)
aortic area : at the crossing between right marginosternal line and 2^nd intercostal space (Louis' angle)
aortic accessory area or Erb's point : at the crossing between left marginosternal line and 3^rd intercostal space

sounds : amplitude is maximal on the auscultation area of the generating valve.

tones arise from closure of valves or filling of ventricles : their intensity relates to

initial distance between the strips

increased in tachyarrhytmia, when EDV decreases
decreased in bradyarrhythmia, when EDV increases

tissue resistance

increased in fibrosis and calcifications

clicks arise from opening of valves
murmurs arise from transformation of laminary flow into turbolent flow and last until a DP exists. They can be classified according to :

cardiac souffle : any cardiac or vascular murmur of a blowing quality.
aetiology

functional
organic

timing

systolic

protosystolic
mesosystolic
telesystolic
pansystolic or holosystolic

diastolic

protodiastolic
mesodiastolic
telediastolic or presystolic or atriosystolic
pandiastolic or holodiastolic

[continuous murmurs (although the flow is stopped between closure of atrioventricular valves and opening of semilunar valves (isovolumetric systole) and between closure of semilunar valves and opening of atrioventricular valves (isovolumetric diastole))

Gibson's murmur / locomotive puff, due to patent ductus arteriosus (PDA)
arterovenous fistulae

aortic Valsalva's sinus => right atrium
bronchial artery => pulmonary vein
coronary artery => left atrium
in systemic circulation

hemodyalisis

systodiastolic murmurs : due to contemporaneous presence of at least 2 different murmurs]

Levine scale :

I : lowest intensity, difficult to hear even by expert listeners
II : low intensity, but usually audible by all listeners
III : medium intensity, easy to hear even by inexperienced listeners, but without a palpable thrill
IV : medium intensity with a palpable thrill
V : loud intensity with a palpable thrill. Audible even with the stethoscope placed on the chest with the edge of the diaphragm
VI : loudest intensity with a palpable thrill. Audible even with the stethoscope raised above the chest.

summary of normal (and [additive]) sounds and murmurs audible in a complete cardiac cycle and their cause(s) :

flapping sound : the peculiar sound made by the closure of the heart valves.
tick-tack sounds : the heart sounds of a pendulum rhythm

systole

1^stheart sound or tone (S₁) : the heart sound occurring during closure of atrioventricular valves, lasting 140 ms; it is dull, firm, prolonged, and is heard as a “lubb” sound. It begins with an inaudible, low-frequency vibration (M) occurring at the onset of ventricular systole, followed by 2 intense, high-frequency vibratory bursts associated with mitral and tricuspid valve closure (M₁ and T₁, respectively), and ending with several variable low-intensity vibrations. Splitting of M₁ and T₁ is normally = 20 ms and is not usually discernible in normal adults.

bruit de canon [Fr. “sound of cannon”] : an abnormally loud first heart sound, heard intermittently in complete heart block when atrial contraction just precedes ventricular contraction.

Splitting of S₁ is audible only if they are separated by > 40 ms

advance in closure of mitral valve

left ventricle extrasystole

delay in closure of tricuspid valve :

[ejection clicks or sounds : high-pitched clicking sounds occurring shortly after the first heart sound, at the time of maximal opening of the semilunar valves

protosystolic clicks

aortic ejection click or sound

abnormality of structure (e.g. fusion of spires) or function of the aortic valve (valvular aortic ejection click or sound). Not produced if valve is fibrotic
abnormality of structure (e.g. ascending aorta aneurysm, systemic arterial hypertension, aortic coartaction) or function of the aorta (vascular aortic ejection click or sound)

pulmonary ejection click or sound

abnormality of structure (e.g. fusion of spires) or function of the pulmonary valve (valvular pulmonary ejection click or sound)
abnormality of structure or function of the pulmonary artery (vascular pulmonary ejection click or sound)]

mesotelesystolic or regurgitation click : mitral valve prolapse
[systolic regurgitation bruit or murmurs (backward turbolence), rectangule-shaped, lasting up to 2^nd tone

mitral valve failure (common)

pansystolic or holosystolic, due to chronic left cardiomegaly
protomesosystolic

acute mitral valve failure : during acute left CHF atrial walls have no time to increase compliance. Increase of left intratrial pressure during telesystole prevents regurgitation but leads to pulmonary arterial hypertension .

mesotelesystolic (preceded by a regurgitation click)

severe mitral valve prolapse into the atrium only when ventricle pressure becomes high

tricuspid valve failure (rare)

pansystolic or holosystolic, due to right cardiomegaly (Rivero-Carvallo's sign : augmentation of intensity at the end of inspiration)
protomesosystolic

ventricular septal defect (VSD) : Roger's bruit or murmur / bruit de Roger : a loud long systolic murmur heard in the 3rd intercostal space to the left of the sternum, characteristic of a small ventricular septal defect

[systolic ejection bruit or murmurs (forward turbolence on a semilunar valve), beginning after a latency from 1^st tone, increasing and decreasing up to disappearing before the 2^nd tone ("diamond-shaped").

physiological or functional (protomesosystolic)

increase of EDV due to :

thin chest wall (closer to the 1^st tone)

pathological (closer to the 2^nd tone)]

aortic valve stenosis (common)
pulmonary valve stenosis (rare)

2^nd hearth sound or tone (S₂) : the heart sound occurring during closure of the 2 semilunar valves at the beginning of diastole, and heard as a “dupp”sound lasting 110 ms, generally merged on expiration but split on inspiration in normal adults. It consists of 2 sharp, high frequency vibrations representing :

aortic second sound (A₂) the audible vibrations related to the closure of the aortic valve
pulmonic second sound (P₂) the audible vibrations related to the closure of the pulmonary valve

mitral valve stenosis

during inspiration the gap increases as

increase in capacitance of pulmonary circulation decreases blood return in left atrium => decreased left EDV => less time is needed to empty left ventricle => advanced closure of aortic valve
decrease in intrathoracic pressure increases blood return in right atrium => increased EDV => more time is needed to empty right ventricle => delayed closure of pulmonary valve

during expiration the gap disappears as

decrease in capacitance of pulmonary circulation increases blood return in left atrium => increased left EDV => more time is needed to empty left ventricle => delayed closure of aortic valve
increase in intrathoracic pressure decreases blood return in right atrium => decreased EDV => less time is needed to empty right ventricle => advanced closure of pulmonary valve

[The splitting becomes pathological ...

bruit de rappel [Fr. “sound of a drum beating to arms”] : a double sound as of 2 beats of a drum, describing splitting of the second heart sound or a second sound followed by an opening snap.

... if it ...

is too large during inspiration (large splitting of S₂)

excessive advance in closure of aortic valve

mitral valve failure

excessive delay in closure of pulmonary valve

is audible also during expiration (fixed splitting of S₂)

excessive delay in closure of pulmonary valve

atrial septal defect (ASD)

disappears during inspiration and increases during expiration (reversed splitting of S₂)

semilunar valves stenosis

diastole

[diastolic regurgitation murmurs] (backward turbolence on a semilunar valve)

aortic valve failure (eventually leading also to presystolic murmur)
pulmonary valve failure due to pulmonary arterial hypertension (Graham-Steel murmur)

[opening clicks (opening of an atrioventricular valve)

mitral valve opening click

mitral valve stenosis

tricuspid valve opening click

pericardial knock : an early diastolic sound resembling an S3 gallop but earlier and due to sudden deceleration of ventricular filling at capacity in cases of constrictive pericarditis .
[3^rd heart sound or tone (S₃) : the heart sound associated with low frequency vibrations of the ventricular walls during rapid ventricular filling in early diastole

Physiological before age 30 or in patients with thin chest wall.

left ventricle failure (increased filling pressure due to increased ESV)
mitral valve failure
ventricular septal defect (VSD)]

S₃, ventricular

or protodiastolic gallop rhythm /

bruit de galop

[filling or mesodiastolic or delayed diastolic murmurs (ventricle filling)

mitral valve stenosis or diastolic rolling (common)
tricuspid valve stenosis or diastolic rolling (rare)
increased flow through atrioventricular valves (only protodiastolic)

increased mitral flow : hyperkinetic circulations
increased tricuspid flow : atrial septal defect (ASD)]

[4^th heart sound or tone / atrial sound (S₄) : the heart sound associated with atrial contraction, occurring during the presystolic phase of diastole

congestive heart failure (CHF)

increased filling pressure due to increased ESV
increased stiffness of ventricle walls

It is rarely audible in normal hearts but when accentuated is usually called an S₄, atrial, presystolic or telediastolic gallop rhythm / bruit de galop

If both 3^rd and 4^th tones are audible : atrioventricular gallop. If they are fused : sum gallop]

[presystolic or atriosystolic murmur] (terminal ventricle filling at atrial systole)

severe aortic valve failure , leading to functional mitral valve stenosis (Austin-Flint murmur)

pericardial friction rub : a scraping or grating noise heard with the heart beat, usually a to-and-fro sound, associated with pericarditis or other pathological condition of the pericardium.

Effects of physiologic and pharmacologic intervention on the intensity of heart murmurs and sounds

respiration :

inspiration => decrease of intrathoracic pressure => increase of blood return to right atrium => increase of intensity of right tones and murmurs
expiration => increase of intrathoracic pressure => increase of blood return to left atrium => increase of intensity of left tones and murmurs

Valsalva manuever : most murmurs decrease in length and intensity. 2 exceptions are the systolic murmurs of hypertrophic cardiomyopathy (HCM), which usually becomes much louder, and that of mitral valve prolapse (MVP), which becomes longer and often louder. Following release of the Valsalva maneuver, right-sided murmurs tend to return to control intensity earlier than left-sided murmurs

after ventricular premature beat (VPB) or atrial fibrillation (AF) murmurs originating at normal or stenotic semilunar valves increase in the cardiac cycle following a VPB or in the cycle after a long cycle length in AF. By contrast, systolic murmurs due to AV valve regurgitation either do not change, or diminish (papillary muscle dysfunction, or become shorter (MVP)
positional changes : with standing, most murmurs diminish, 2 exceptions being the murmur of HCM, which becomes louder, and that of MVP, which lengthens and often is intensified.
with squatting, most murmurs become louder, but those of HCM and MVP usually soften and may disappear
passive leg raising usually produces the same results

exercise : murmurs due to blood flow across normal or obstructed valves (e.g., PS, MS) become louder with both isotonic and submaximal isometric (handgrip) exercise. Murmurs of MR, VSD and AR also increase with handgrip exercise. However, the murmur of HCM often decreases with near maximum handgrip exercise. Left-sided S₄ and S₃ are often accentuated by exercise, particularly when due to ischemic heart disease
pharmacological interventions :

during the initial relative hypotension following amyl nitrite inhalation, murmurs of MR, VSD, and AR decrese, while murmurs of aortic stenosis or sclerosis increase. During the later tachycardia phase, murmurs of MS and right-sided lesions also increase. The response in MVP often is biphasic (first softer and then louder than control)
the arterial constrictor phenylephrine tends to produce the opposite effects

transient arterial occlusion : transient external compression if both arms by bilateral cuff inflation to 20 mmHg over peak systolic pressure augments the murmur of MR, VSD and AR, but not murmurs due to other causes.

Algorithm for patients with cardiac murmur over age 40 years

systolic murmur =>

grade I + II and midsystolic =>

asymptomatic and no associated findings =>

normal ECG and chest X-ray => no further work-up
abnormal ECG or chest X-ray => echocardiography => cardiac consult if appropriate

other signs or symptoms of cardiac disease => echocardiography => cardiac consult if appropriate

grade III or >, holosystolic or late systolic

diastolic or continuous murmur => echocardiography => cardiac consult if appropriate

Web resources

Normal and abnormal heart sounds

mammary souffle : a functional cardiac murmur with a blowing sound, heard over the breasts in late pregnancy and during lactation; it may be either restricted to systole or continuous.
aneurysmal bruit : a blowing sound heard over an aneurysm
timbre métallique / Potain's sign / bruit de tabourka [Fr. “sound of drum”] : a high-pitched tympanic second sound heard in dilatation of the aorta. When heard in persons < 55 years of age it has been considered suggestive of syphilitic aortitis
bruit de tambour [Fr. “sound of drum”] : a ringing sound heard in syphilitic aortic regurgitation
bruit de claquement [Fr. “sound of clapping”] : a snapping sound caused by the sudden contact of parts.
bruit de craquement [Fr. “a sound of crackling”] : a crackling pericardial or pleural bruit.
bruit de cuir neuf [Fr. “sound of new leather”] : a creaking noise; usually a sign of pericarditis or pleurisy .
bruit de froissement [Fr. “sound of clashing”] : a clashing noise of varying origin.
bruit de frolement [Fr. “sound of rustling”] : a rustling murmur from a pericardial or pleural friction rub.
bruit de lime [Fr. “sound of a file”] : a cardiac sound resembling filing.
bruit de moulin [Fr. “sound of a mill”] : a splashing or waterwheel sound synchronous with systole, sometimes audible at some distance from the patient, variously attributed to cardiac, pericardiac, or mediastinal causes.
bruit de parchemin [Fr. “sound of parchment”] : a sound as of 2 pieces of parchment rubbed together, of valvular cardiac origin.
bruit de piaulement [Fr. “sound of whining”] : a cardiac murmur like the mewing of a cat.
bruit de rape [Fr. “sound of a grater”] : a rasping, cardiac, valvular murmur.
bruit de scie [Fr. “sound of a saw”] : a cardiac murmur resembling the sound of a saw.

auscultation of peripheral pulses : with the first 3 fingers of the hand

peripheral arterial pressure pulses : the rhythmic expansion of an artery caused directly by systole, palpable with the finger

[temporal pulse] (giant cell arteritis (GCA))
[ophthalmic pulse] (aneurysm of ophthalmic artery )
preauricular pulse
occipital pulse : laterally to the occipital foramen when the head is flexed
carotid pulse : the pulse in the carotid artery; tracings of it can be used in timing the phases of the cardiac cycle
[suprasternal pulsation : arterial pulsation in the region of the suprasternal notch, due to dilatation and/or elongation of the aortic arch or to aneurysm ]
axillary pulse
brachial pulse : one felt over the brachial artery at the inner aspect of the elbow.
radial pulse : that felt over the radial artery
ulnar pulse : that felt over the ulnar artery
epigastric or abdominal pulse : the pulse over the abdominal aorta (palpable only in thin patients)
common iliac pulse : above the mid of inguinal ligament (palpable only in thin patients)
femoral pulse : one felt over the femoral artery, laterally to the femoral vein in the femoral triangle , at the mid of the line joining the upper anterior iliac spine to the pubic tubercle (see also Palma's syndrome )

[systolic murmur : partial stenosis
continuos murmur : severe stenosis]

popliteal pulse : one palpated over the popliteal artery in the popliteal fossa, most easily detected when the patient is lying prone with the knee flexed about 45°
anterior tibial pulse : one felt over the anterior tibial artery just anterior to the lateral malleolus on the outer aspect of the ankle

pedideal or dorsalis pedis pulse : one felt over the dorsal artery of the foot on the dorsum of the foot between the first and second metatarsal bones (at the 2/3 of a line joining the medial malleolus to the big toe); in 8-10% of the population it cannot be detected.

posterior tibial pulse : one felt over the posterior tibial artery just posterior to the medial malleolus on the inner aspect of the ankle

venous pulse : the pulsation which occurs in a vein, usually observed at the right jugular vein just above the sternoclavicular junction.

jugular pulse : a venous pulse seen or felt over the internal jugular vein

A : a positive wave due to contraction of the right atrium;

giant a waves : abnormally tall a waves in tracings of the jugular venous pulse; they occur

when either inflow resistance to or outflow resistance from the right ventricle is increased
when atrial contractions occur out of phase in rhythm disturbances, during the period the tricuspid valve is closed (cannon a waves).

C : a positive deflection due to bulging of the tricuspid valve toward the atria at the onset of ventricular contraction;
X : a negative deflection due to atrial relaxation;
V : a positive deflection due to filling of the right atrium against the closed tricuspid valve during ventricular contraction;
Y : a negative deflection due to emptying of the right atrium upon ventricular relaxation.

respiratory pulse : one observed normally in the superficial cervical veins after rapid exercise or at other times of increased respiration
retrosternal pulse : a venous pulse perceptible just above the suprasternal notch.
atrial venous or atriovenous pulse : a venous pulse in the neck having an accentuated a wave during atrial systole, owing to increased force of contraction of the right atrium; a characteristic of tricuspid valve stenosis .
centripetal venous pulse : an abnormal venous pulse caused by a systolic volume expansion that passes from the arteries through the capillaries and venules into the larger veins
venous hum / humming-top murmur / bruit de diable [Fr. “sound of humming top”] : a continuous blowing, singing, or humming murmur heard on auscultation over the right jugular vein in the sitting or erect position; it is an innocent sign that is obliterated on assumption of the recumbent position or on exerting pressure over the vein

Jaquet's apparatus

Qualities of pulse

frequency
rhythm
strength
tension
duration
equality :
simmetry :

anacrotic pulse : one in which the ascending limb of the tracing shows a transient drop in amplitude, or a notch.
catacrotic pulse : one in which the descending limb of the tracing has a notch
catacrotic wave : the wave of a tracing of a catacrotic pulse.

dicrotic notch : a small downward deflection in the arterial pulse or pressure contour immediately following closure of the aortic valve and preceding the dicrotic wave; sometimes used as a marker for the end of systole or the ejection period.

dicrotic or recoil wave : the second portion of the arterial pulse or arterial pressure recording after the dicrotic notch, attributed to the reflected impulse of closure of the aortic valves
tricrotic wave : a third wave in the sphygmographic curve in addition to the tidal and dicrotic waves, occurring during systole.
Traube-Hering waves : rhythmical rises and falls in the arterial pressure, attributed to rhythmical activity of the vasoconstrictor center.
Mayer waves : regular variations in blood pressure over intervals longer than those of Traube-Hering waves, associated with pathologic mechanisms such as abnormal oscillations in the baroreceptor system or activation of vasopressor reflexes.
papillary or percussion wave : the chief ascending portion of a sphygmographic tracing.

anacrotic wave : the wave on a tracing of an anacrotic pulse.
anadicrotic wave : the wave on a tracing of an anadicrotic pulse.
atrial pressure waves : the 3 elevations commonly seen on the graphic representation of the cardiac cycle, known as the a wave, c wave, and v wave

a wave : in a tracing of the venous pulse, a positive deflection representing contraction of the right atrium, occurring just prior to the carotid arterial pulse and first heart sound
c wave : in a tracing of the venous pulse, a small positive deflection representing the bulging back toward the atria of the tricuspid valve at the onset of ventricular contraction
v wave : in a tracing of the venous pulse, a positive deflection representing the filling of the right atrium against the closed tricuspid valve during ventricular contraction

x wave : in a tracing of the venous pulse, a negative deflection representing relaxation of the atria
y wave : in a tracing of the venous pulse, a negative deflection representing emptying of the right atrium upon right ventricular relaxation and opening of the tricuspid valve

monocrotic pulse : one in which the tracing has just one waveform per beat of the artery.
polycrotic pulse : one whose tracing shows secondary pulse waves

dicrotic pulse : a pulse whose tracing has 2 peaks instead of the usual one, the second one coming during diastole as an exaggeration of the dicrotic wave

catadicrotic pulse : one in which the descending limb of the tracing has a notch between 2 small additional waveforms

catadicrotic wave : the wave of a tracing of a catadicrotic pulse

anadicrotic pulse : one in which the ascending limb of the tracing has 2 waveforms separated by a notch, signifying a transient drop in amplitude.

tricrotic pulse : one in which the tracing shows 3 expansions of the artery in one beat

anatricrotic pulse : one in which the ascending limb of the tracing shows 3 small additional waves or notches
catatricrotic pulse : one in which the descending limb of the tracing has 2 notches between 3 small waveforms.

bigeminal pulse : a pulse in which beats occur as 2 in rapid succession separated from the following pair by a longer interval; it is usually related to regularly occurring ventricular premature beats
trigeminal pulse : one with a pause after every third beat
quadrigeminal pulse : one with a pause after every fourth beat
atrial liver pulse : a presystolic pulse corresponding to the atrial venous pulse, sometimes occurring in tricuspid valve stenosis
frequent or quick pulse / pulsus frequens : one faster in rate than normal
abrupt, quick or short pulse / pulsus celer : one that strikes the finger smartly and leaves it quickly
infrequent, slow, or vagus pulse / pulsus tardus : one with less than the usual number of pulsations per minute
funic pulse : the arterial tide in the umbilical cord
intermittent pulse / dropped-beat pulse : one in which various beats are dropped
allorhythmic or irregular pulse : one in which the beats occur at irregular intervals
labile pulse : a pulse that is normal when the patient is resting but increased by sitting, standing, or exercise
filiform or thready pulse / pulsus filiformis : one that is very fine and scarcely perceptible
low-tension pulse / formicant or soft pulse / pulsus formicans, mollis, parvus, or vacuus : a pulse with sudden onset, short duration, low amplitude, and quick decline, easily obliterated by pressure
bounding, full, tense or strong pulse / pulsus fortis, magnus, or plenus : a forcible pulse of high amplitude

high-tension pulse : one characterized by a gradual impulse, long duration, slow subsidence, and a firm, cordy state of the artery between the beats

jerky, sharp or vibrating pulse : a type of pulse that is both quick and strong

Corrigan's pulse / cannonball, collapsing, pistol-shot, trip-hammer, or water-hammer pulse : a jerky pulse with a full expansion, followed by a sudden collapse, occurring in aortic regurgitation
febrile pulse : a type of pulse that is both strong and quick, seen in fever.

nail pulse : the pulsation of blood under the nails; sometimes demonstrated by the onychograph.
Kussmaul's paradoxical pulse or sign / pulsus paradoxus : accentuation of a normal physiological phenomenon : hyposphigmia of radial pulse that markedly decreases in size up to disappearance during forced deep inspiration, as that which often occurs in constrictive pericarditis
reversed paradoxical pulse : a rise in arterial pressure during inspiration, seen in hypertrophic obstructive cardiomyopathy (HOCM) and some cases of tricuspid insufficiency and atrioventricular dissociation.
plateau pulse : a pulse which is slowly rising and sustained.
Quincke's pulse or sign : alternate blanching and flushing of the skin that may be elicited in several ways, e.g., by observing the nail bed or skin at the root of the nail while pressing on the end of the nail. Caused by pulsation of subpapillary arteriolar and venous plexuses, it is sometimes seen in aortic insufficiency and other disorders, but may occur in normal persons under certain conditions. It was originally thought to be due to pulsation of the capillaries, hence the name capillary pulse
Riegel's pulse : a pulse which is diminished in size during expiration
running pulse : a pulse with small irregular excursions
unequal pulse : a pulse in which some of the beats are strong and others weak
vermicular pulse : a small rapid pulse giving to the finger a sensation of wormlike movement
wiry pulse : a small, tense pulse
pulsus alternans / alternating pulse : a pulse in which there is regular alternation of weak and strong beats without changes in cycle length, usually indicative of serious myocardial disease.
hemisphygmia : a condition in which there appear to be twice as many pulse beats as heart beats, such as

pulsus biferiens or bisferiens / biferious or bisferious pulse : a pulse with two strong systolic peaks separated by a midsystolic dip, usually seen in pure aortic regurgitation and aortic regurgitation with stenosis

pulsus differens : inequality of the pulse observable at corresponding sites on either side of the body
pulsus magnus et celer : one that is both strong and quick; see febrile pulse and jerky pulse
pulsus parvus et tardus : a slow pulse that is also low-tension
expansile pulsation : a pulsation that expands with each beat of the pulse; it reflects an increase in volume of a mass, usually an aneurysm

entoptic pulse : the subjective sensation of seeing in the dark a flash of light at each heart beat.

abdomen ausculation :

hippocratic, shaking or succussion sounds : splashing sounds heard on succussion over a distended stomach and in hydropneumothorax
bruit de clapotement [Fr. “sound of rippling”] : a splashing sound indicative of dilatation of the stomach when pressure is put on the wall of the abdomen
Verstraeten's bruit : an abnormal sound heard in auscultation over the lower border of the liver in cachectic patients
splenic souffle : a sound said to be sometimes audible over a diseased spleen.
funic, funicular umbilical souffle : a hissing souffle synchronous with the fetal heart sounds, and supposed to be produced in the umbilical cord.
placental souffle / bruit placentaire [Fr. “placental sound”] : a souffle supposed to be produced by the blood current in the placenta.
uterine souffle : a sound made by the blood within the arteries of the gravid uterus.

phonocardiography (=> phonocardiogram) : the graphic representation of heart sounds, murmurs, or any acoustic phenomena emanating from the heart; in clinical use, the term usually includes recording of the pulse tracings (carotid, apex, and jugular venous) for completeness, and is often combined with other noninvasive methods such as echocardiography. If combined to EKG, apicocardiogram / apicogram, carotideal sphygmogram / carotidogram, hepatogram or jugular phlebogram is a.k.a. (phono)mechanocardiography => (phono)mechanocardiogram.

intracardiac phonocardiography : the graphic registration of sounds produced by action of the heart by means of a phonocatheter passed into one of the heart chambers (intracardiac phonocatheterization)

phonacoscopy : combined auscultation and percussion by means of a bell-shaped resonating chamber containing a percussion hammer, which is held on the anterior thoracic wall while the examiner listens at the back of the thorax
phonoangiography : the recording and analysis of arterial bruits to estimate the extent of arterial stenosis
phonoauscultation : auscultation in which a tuning fork is placed over the organ to be examined and its vibrations are listened to through a stethoscope placed over the same organ
phonomyography : the recording of muscle sounds by an oscillograph to which the sounds are transmitted by a microphone placed over the muscle
phonorenogram : a graphic representation by means of a paper recording of pulsations of the renal artery obtained by use of a phonocatheter passed through a ureter into the pelvis of the kidney
phonoscopy : 1. the delimiting of solid and hollow organs (liver, heart, lungs, etc.) by listening with a stethoscope while percussion is made in the vicinity. 2. the use of the phonoscope.
phonoselectoscope : an instrument for auscultation by means of which the lower (normal) range of the pulmonary sounds are eliminated, thus emphasizing the higher-pitched pathologic elements
phonostethograph : an instrument by which the chest sounds are amplified, filtered, and recorded