The following heart sounds are auscultated in mitral stenosis: i. If the leaflets are supple and elastic, a hyperactive first heart sound can be heard in the apical region, and an open heart sound can be heard in a tapping pattern. If the leaflets are calcified and stiff, this sign will disappear. When pulmonary hypertension is combined, the second heart sound in the pulmonary valve area is hyperacusis with splitting. On auscultation, the characteristic murmur of mitral stenosis is a low-pitched rumbling murmur in the apical region in late diastole, which is more limited, more pronounced in the left lateral recumbent position, and can be incremental, increasing with activity or forceful expiration, sometimes accompanied by diastolic tremor. In severe pulmonary hypertension, which can lead to relative pulmonary valve insufficiency, a decreasing high-pitched sigh-like early diastolic murmur can be heard in the second intercostal space at the left sternal border. When right ventricular enlargement causes relative tricuspid valve insufficiency, a full systolic blowing murmur can be heard between the 4th and 5th ribs of the left sternal border.