AuscultifyClinical Auscultation Cases: Practice Scenarios for Heart & Lung Sounds
Recognizing a sound in isolation is the first step. The real skill is hearing a sound in the context of a patient presentation and reaching the right diagnosis. These clinical scenarios walk you through the reasoning — from chief complaint to auscultation finding to diagnosis.
Case 1: The breathless elderly man
Presentation: A 72-year-old man presents with progressive exertional dyspnea over 6 months. He reports a recent syncopal episode while climbing stairs. BP 110/85 mmHg. Pulse is slow-rising.
On auscultation: You hear a harsh crescendo-decrescendo systolic murmur loudest at the right upper sternal border, radiating to both carotids. S2 is soft and single (no split). There is an S4.
Reveal diagnosis & reasoning
Diagnosis: Severe aortic stenosis.
The classic triad — exertional dyspnea, syncope and angina — with a crescendo-decrescendo systolic murmur at RUSB radiating to the carotids. The soft S2 indicates a calcified, immobile valve. The S4 reflects LVH from chronically elevated afterload. The slow-rising pulse (pulsus parvus et tardus) confirms hemodynamically significant stenosis. This patient needs echocardiography and likely valve replacement.
Case 2: The young woman with palpitations
Presentation: A 25-year-old woman complains of intermittent palpitations and occasional sharp chest pain. She is thin and otherwise healthy. No family history of cardiac disease.
On auscultation: You hear a mid-systolic click at the apex, followed by a late systolic murmur. When you ask her to stand, the click moves earlier and the murmur becomes longer.
Reveal diagnosis & reasoning
Diagnosis: Mitral valve prolapse (MVP).
The mid-systolic click is the prolapsing mitral leaflet billowing into the left atrium. The late systolic murmur represents the mitral regurgitation that follows. Standing reduces preload, which makes the ventricle smaller — the prolapse occurs earlier, so the click moves toward S1 and the murmur lengthens. Squatting would do the opposite. MVP is the most common valvular abnormality in young adults and is usually benign.
Case 3: The child with a murmur at a routine checkup
Presentation: A 4-year-old boy is brought in for a well-child visit. His mother mentions the previous doctor heard a murmur. He is active, growing well, with no exercise intolerance or cyanosis.
On auscultation: You hear a grade 2/6 low-pitched, musical, vibratory systolic murmur at the lower left sternal border. It disappears when the child sits up and becomes louder when supine. No diastolic component. Normal S1 and S2.
Reveal diagnosis & reasoning
Diagnosis: Still's murmur (innocent murmur).
Still's murmur is the most common innocent murmur in children aged 3–6. It's musical/vibratory (not harsh), systolic only, grade ≤3, with no radiation or associated symptoms. It changes with position (louder supine, softer upright) and disappears with maneuvers. Normal S2 splitting rules out ASD. No referral needed — reassure the parents. See our pediatric auscultation guide for more on innocent vs pathological murmurs.
Case 4: The ICU patient with new-onset crackles
Presentation: A 65-year-old woman, day 3 post-CABG, develops increasing oxygen requirements. SpO2 drops from 96% to 89% on 4L nasal cannula. She has bilateral lower extremity edema and elevated JVP.
On auscultation: Bilateral fine crackles at both lung bases that do not clear with coughing. An S3 gallop is audible at the apex with the bell.
Reveal diagnosis & reasoning
Diagnosis: Acute decompensated heart failure with pulmonary edema.
The bilateral basal crackles represent fluid in the alveoli — pulmonary edema. The S3 gallop in a 65-year-old indicates volume overload and elevated filling pressures. Combined with elevated JVP and lower extremity edema, this is a classic presentation of fluid overload post-cardiac surgery. The crackles don't clear with coughing (distinguishing them from secretion-related crackles). Management: diuresis, fluid restriction, possibly afterload reduction.
Case 5: The medical student with a stiff neck and fever
Presentation: A 22-year-old presents with 3 days of fever, malaise and sharp central chest pain that worsens on inspiration and improves when leaning forward. Recent viral upper respiratory infection.
On auscultation: You hear a scratchy, high-pitched sound with three components at the left sternal border. It's louder when the patient sits forward.
Reveal diagnosis & reasoning
Diagnosis: Acute pericarditis with pericardial friction rub.
The three-component scratchy sound is a pericardial friction rub — caused by inflamed pericardial surfaces rubbing together during atrial systole, ventricular systole and early diastolic filling. The positional chest pain (worse supine, better leaning forward) is classic. Post-viral pericarditis is the most common cause in young adults. The rub may come and go — if you suspect pericarditis, auscultate repeatedly. ECG will show diffuse ST elevation with PR depression.
Case 6: The smoker with progressive dyspnea
Presentation: A 58-year-old man with a 40-pack-year smoking history presents with worsening dyspnea over 2 years. He has a barrel-shaped chest and uses accessory muscles. Prolonged expiratory phase.
On auscultation: Globally diminished breath sounds with scattered expiratory wheezes and a prolonged expiratory phase. No crackles.
Reveal diagnosis & reasoning
Diagnosis: COPD (emphysema predominant).
The diminished breath sounds reflect hyperinflation — air-trapping pushes the diaphragm down and increases the distance between airways and the stethoscope. The scattered expiratory wheezes indicate airflow limitation. The prolonged expiratory phase is a hallmark of obstructive disease. The barrel chest confirms chronic hyperinflation. Note: absence of crackles helps distinguish from pulmonary fibrosis (which has fine inspiratory crackles). Spirometry will confirm with a reduced FEV1/FVC ratio.
Case 7: The immigrant with dyspnea and a diastolic rumble
Presentation: A 35-year-old woman from South Asia presents with progressive dyspnea and palpitations. She has a malar flush and an irregularly irregular pulse.
On auscultation: In the left lateral decubitus position with the bell at the apex, you hear a low-pitched diastolic rumble preceded by a high-pitched snap. The first heart sound is loud.
Reveal diagnosis & reasoning
Diagnosis: Mitral stenosis (rheumatic) with atrial fibrillation.
The low-pitched diastolic rumble at the apex is mitral stenosis — the stenotic valve creates turbulent flow from LA to LV during diastole. The opening snap is the stiff valve leaflets being forced open. The loud S1 indicates the valve leaflets are still mobile (not yet calcified). The irregularly irregular pulse is atrial fibrillation — a common complication as the left atrium dilates. Rheumatic heart disease is the most common cause worldwide. Echo will confirm valve area and gradient.
Case 8: The neonate with cyanosis during feeding
Presentation: A 3-day-old infant becomes cyanotic during feeding. SpO2 is 78% on room air. The baby is tachypneic with subcostal retractions.
On auscultation: You hear a harsh systolic ejection murmur at the left upper sternal border. S2 is single (no split).
Reveal diagnosis & reasoning
Diagnosis: Tetralogy of Fallot.
The four components — VSD, right ventricular outflow tract obstruction, overriding aorta and RVH — produce a harsh systolic ejection murmur from the RVOT obstruction. The single S2 occurs because the pulmonic component (P2) is diminished or absent due to reduced flow through the pulmonic valve. Cyanosis during feeding (increased oxygen demand) with low SpO2 confirms a right-to-left shunt. Paradoxically, more severe obstruction = quieter murmur (less flow crosses the RVOT). This is a surgical emergency requiring urgent cardiology consultation.
How to use cases for learning
- Read the presentation first — form a differential before reading the auscultation findings.
- Predict the sound — based on your differential, what would you expect to hear?
- Compare your prediction to the finding — did the sound match? If not, revisit the pathophysiology.
- Then listen to the actual sound — cases teach the reasoning, but you need to hear the sounds to build pattern recognition.
Hear the sounds from these cases
Reading a case is step one — hearing the aortic stenosis murmur, the pericardial rub, the fine crackles is what makes the diagnosis stick. Auscultify has 200+ real clinical recordings of every sound in these cases. Use Source Check mode to practice identifying sounds in clinical context, or Heart Sounds and Lung Sounds modes to drill individual findings until they're automatic.
Practice with real recordings →