1. Auscultation of the Heart

2. I. Auscultatory Valve Area
1. MV: apex, fifth left intercostal
space, medial to the
midclavicular line
2. PV: second left intercostal space
3. AV: second right intercostal space
4. AV2: left third intercostal space
5. TV: lower part of sternal
6. Other part

3. III. Content of auscultation
II. Auscultatory order
ApexPV AV AV2 TV
III. Content of auscultation
1. Heart rate
2. Heart rhythm
3. Heart sound
4. Heart murmurs

4. 1. HR Varies with age, sex. Physical activity and emotional status
Normal adult: 60-80/min
Sinus tachycardia: >100/min
Sinus bradycardia: 60/min

5. 2. Heart rhythm 1) Sinus arrhythmia 2) Premature beat:
A sudden extrasystole of the heart
in the basic of normal heart rhythm
S1; S2
Pulse absent
Ectopic point at atrial, AV node, ventricle

6. 3) Atrial fibrillation:
Mechanism: a very high frequency impulse
coming from the atrial ectopic
point, in multi-reentry
Three inconsistence: ventricular rhythm
S1 intensity
Heart rate; pulse

8. 3. Heart sound: S1, S2, S3, S4
S1: S1 indicates the beginning of the ventricular
constraction
1) Vibration of the closure of A-V valve
2) Opening of the semilunar valve
3) Acceleration of the blood in arteries

9. S1: Character of auscultation
1) Area: apex
2) Pitch
3) Lasting time:
4) Together with apex impulse

10. S2: Vibration of the closure of AV, PV,
during the beginning of ventricular
diastole,
Indicates the beginning of ventricular
diastole

11. S2: Character of auscultation
1) Area: loudest at the basic
2) Pitch 
3) Lasting time

12. The differentiate between S1~S2
1) S1 apex pitch , lasting time
S2 basic, pitch  lasting time 
2) Duration: S1__S2 S2__S1
3) Apical pulse

13. S3: Mechanism:
In early diastole filling blood moves from
atrium to ventricle, Produces the vibration
of ventricle wall
Character: at apex or superinternal of apex
0.12~0.18'' after S2
frequency  intensity
S4: Occur late in diastole, with effective
atrial contraction 0.11'' prior to S1

14. 4. Abnormal of heart sound
Change in loudness
Both S1 and S2
: Thinner chest wall
Activity of the heart increased
: Fat, edema,
Pericardial effusion, heart failure

15. Change in S1: S1 depends on: myocardial contraction
filling degree of ventricle
elastic and position of the valve
S1: 1) MS
2) Tachycardia: in high fever, the
diastolic period was shortened

16. S1: 1) Infarction
2) MI

17. Change of S2: S2 depends on (1) the pressure within the great vessel
(2) the situation of semiluner
valves
A2: hypertension
P2 : pulmonary hypertension in MS, MI
A2: AS ,AI
P2 : PS, PI

18. Change in quality of heart sound
When the myocardial muscle is damaged severely, S1 is similar to S2. The heart sound like a pendular—pendular rhythm.Usuallyaccompany with tachycardia—embryocardia.

19. Splitting of heart sounds
Splitting of S1: it is due to closure of MV and TV asynchronously loudest over the apex in RBBB

20. Splitting of S2: 1) In normal person, physiologic splitting
due to the closure of AV and PV asynchronously in inspiration
2) In pathological situation
delay of emptying time of one side of the heart
such as ASD,MS.

21. 3) The influence of respiration
in inspiration: the pressure within the thorax, venous return to RV, so empty time to be delayed, PV closure more later.

22. 4) Paradoxical splitting of S2
the abnormal is within the left heart,(AS), the emptying time of LV is delayed, the order of valve closure is reversed. In inspiration, the two components then more closer together or may be single.

23. 5)Fixed splitting of S2:
in ASD, S2 is widely split over the PV area with little or no change in the degree of splitting in either phase of respiration.

24. 5. Extra sounds In diastolic period
1) Gallop:
Three or four sounds are spaced to audibly resemble the center of a horse, the extra sounds occurs after S2.

25. Protodiastolic gallop rhythm
S3 gallop, ventricular gallop rhythm.
S1 + S2 + pathologic S3

26. In early diastole, the blood through into ventricle from atrium in failing myocardium, the ventricular wall tension is poor, produce vibration. Reflex that the ventricular function
Auscultation character of S3 gallop:
lower in pitch
After S2
Best hear at apex
Loudest at the end of expiration.

27. S3 gallop: differ from normal S3
Occur in severe organic heart disease
HR>100 bpm
The interval time between S1 and S2 are almost equal, mimicking quality, normal S3 is nearer from S2
Normal S3 will disappear in standing or sitting position

28. Late diastolic gallop S4 gallop, atrium gallop
At late diastole, related to atrial contraction.
In LVEDP  compliance Artial contraction
occur precede S1, far from S2
low-pitch; best heard at apex
Tensity: end of expiration(from LA)
end of inspiration (from RA)

29. Occur in pressure overload,LVH, in myocardial damaged , LV compliance , such as BP, IHSS, CHD.

30. Summation gallop
Overlapping of S3G and S4G while HR

31. 2) Opening snap
In MS
In early diastole of LV, the blood from LALV, the opening MV suddenly stopped make itself vibration
After S2. Brief in duration.
High in pitch. Indicate a flexible valve

32. 3) Pericardial knock
In constrictive pericarditis after inflamation, pericardial constricted, limit the diastole of ventricle was limited, produce the vibration of ventrcular wall.
0.1  after S2,
Loudest at apex.

33. 6. Extra sound in systolic period:
1) Early systolic ejection sound
Dilated great vessel, hypertention with in it.
After S1, high in pitch.
PV area: PS , PH inspiration, expiration 
AV area: BP ,AS

35. 2) Middle and late systolic clicks
In MVP
Valve, tandae chordea redudent, floppy
Click: after S1, close to S2
best heard at apex
lower in pitch

37. Heart murmur H M is abnormal sound Produce by vibration
Within the heart or large arteries.

38. Mechanism Blood velocity Blood vascosity
Valve: narrowed or incompetent; organic or relative
Abnormal connection
Vibration of loose structure
Diameter of vessel or 

41. Character of murmur Location: Timing:
Murmur of valvular origin are usually best heard over their respective valve area
Timing:
Murmurs are timed according to the phase of cardiac cycle during which they occur.
SM, DM , CM.
Early, middle, late

44. Quality Depend on: frequency and intensity of sound wave
Related to: pathology and hemodynamic changes of the heart
Soft, harsh, musical.
SM: blowing, harsh, musical (seagull)
DM: blowing, sigh-like, rumbling.
CM: machine-like, hum

45. Radiation: transmitted direction
With the bloodstream by which they are produced or propagated from their point of origin in many directions AS MR MS

46. Intensity: Related to : The severity of abnormal
The velocity of blood flow
The pressure gradient of valve
The myocardial contraction

47. Six-point scale of for grading the intensity of heart murmur
Grade Ⅰ: basely audible
Grade Ⅱ: usually readily heard
Grade Ⅲ: loud
Grade Ⅳ: quite loud
Grade Ⅴ: even most pronounced
Grade Ⅵ: may be heard with the stethoscope
removed from the chest wall.

48. PCG Crescendo type Decrescendo type Crescendo-decrescendo type
Continuous
Regular

50. Physiological maneuver
1) Change the body position
Left recumbent: MS
Sitting, leaning forward: AI
Squatting from standing, supine position,
raising two legs may increase venous
return, SV CO
Murmur of MI, AI
Murmur of IHSS

51. 2) Respiration
Deep inspiration: thorax pressure
venous return, pulmonary circulation
clockwise rotation of heart make murmur
of TI, TS ,PI
Expiration:
Valsalva maneuver: thorax pressure
venous return M of IHSS

52. 3) Exercise:
HR
Blood volume
Blood velocity
make the murmur of MS

53. The clinical value of heart murmur
1. Important in diagnosis
2. Organic M : MS
Relative M: valve , supporting tissues
of the valve abnormal
Functional M: increased flow across
a normal valve

54. 1. Systolic murmur 1) MV area : produced by MI Organic: RHD, MVP
Character: pan systolic
Harsh, Loud >3/6
Radiate to the left axilla
Maneuver insp exp

55. Relative murmur: Dilated LV
BP
Acute rheumatic fever
Severe anemia
Character:
Functional M: Valve(-) blood flow faster
Fever
Anemia
Hyperthyroidism

56. 2) AV area—AS
Organic: RHD
Character: Harsh, crescendo-decrescendo,
radiateneck, Thrill, S2
Relative: Arteriosclerosis, Dilation of aorta, HP

57. 3) PV area
Most are functional:
Relative: ASD, PA dilation
Organic: congenital PS

58. 4) TV area—TI
Most are relative, duo to dilate of RV
character like MI, but increased in
inspiration, organic SM are rare
5) Other position
VSD: harsh and loud
Third-forth intercostal space
Left to the sternal border
Thrill

59. 2. Diastolic murmur 1) MV area Organic: RHD—MS, Apex
Mid-late diastolic
Rumbling, decrescendo-crescendo
Thrill, S1, OS

60. AI; Austin-Flint murmur
Relative:
LVH;
AI; Austin-Flint murmur

61. 2) AV area – AI rheumatic
decrescendo, sigh-like
best heard at aortic second area
radiate to the left side of the lower part of sternal

62. 3) PV area
Most are produced by relative PI
4) TV area
It is rare in clinical

63. Continuous murmur In patent ductus Arteriosus
Begins after S1, crescendo, peak intensity at S2, envelop S2, decreased at early-middle diastole producing a large diamond sharp.
Harsh, mimic the sound of machine rotating
Best heart at second intercostal space,
left to sternal artery-vein fistula.

65. Pericardial friction sound
It is produced by the rubbing on each other of the parietal and visceral surfaces of the roughened pericardium.
During pericarditis
In both systolic and diastolic
Systolic component predominates
Sometime only in systole

67. Harsh,
Resemble massage the ear using the finger
Best heard at 3th-4th in intercostal space
Left to the sternal border
Common cause is pericarditis (TB, non-specific, rheumatic)
Also can been heard in AMI, uremia, SLE

68. Major symptom and sign of common diseases in circulatory system
Mitral Stenosis (MS)
Rheumatic
Commissural thickening, adherent fusion
Orifice of MV stenosis,blood flow from LA LV was limited.
LAP, LAH, Pulmonary V and capillary pressure  dilatation, stasis, PAP  RV over load  RV failure
LV filling  CO

70. Symptoms:
Exertional dyspnea, cough, hemoptysis
Paroxysmal noctunnal dyspnea
Signs:
Mitral face, apical pulse left side
Diastolic thrill at apex
Cardiac waist prominence
Diastolic murmur at apex
OS S1  P2  splitting
Graham-Steel murmur.

73. Mitral Insufficiency(MI)
Etiology: Rheumatic
Non-rheumatic
Organic
Relative: duo to the LV enlargement.
in systolic period, blood flow from
LVLA LA filling degree P
In diastolic period, LV accepts
more blood→dilation
CO

75. Symptom: fatigue , palpitation, dyspnea
Sign :
Apical pulseleft, lower
Apical beat heavy
Cardiac dullness enlargedleft
Pausystolic, murmur at apex
Radiate to left axilla, subscapular
P2 spitting S1

76. Aortic Stenosis (AS)
Rheumatic, atherosclerosis, congenital Narrowed orifice of AV, the resistence of LV to output the blood
LV contractility, LVH
Aorta P blood flow in coronary A and peripheral A
Symptom: palpitation, fatigue, angina, syncope

78. Sign:
Apical impulse, to left
Systolic thrill in AV area, pulse
Cardiac dullnessleft
Ejection SM in AV area, radiate to neck
A2 splitting paradoxically

79. Aortic insufficiency(AI)
Rheumatic, arteriosclerosis, infective endocarditis, syphilis,
In AI, LV receives both blood from LA, AOvolume overloadLV dilationrelative MI, relative MS
Diastolic pressure, pulse pressure
Symptom: palpitation, angina

81. Sign:
Apical impulseleft, inferiorly
Cardiac dullness enlargedleft, inferiorly
Boot-shaped shadow –cardiac waist
DM in AV2 area apex
S1, A2
Relative MI—SM at apex
Relative MS—Austin Flint, DM

84. Peripheral vascular sign:
pulse pressure water hammer pulse, carotic pulsation, Musset sign(moving head with each heart beat),capillary pulsation, pistol shot sound, Duroziez M.

85. Pericardial Effusion
Inflammatory (TB, purulent) non inflammatory (rheumatism, uremia)
Pericardial cavity P, limit the dilation of heart, blood flow from systemic venous to the RV, RV filling  output 

88. Symptom:
Depends on the volume and the velocity of effusion producing.
Pericardial compression, dyspnea.
Infection: fever, fatigue
Cough, dysphagia
Sign:
Cardiac impulse
Apical pulsation
Cardiac dullness enlarged,
coincide with position

89. Pericardial friction rub
Heart sound
In massive effusion: neck vein engagement, inspiration
Paradoxical pulse, venous pressure
Ewart sign: the lung was pressed by the effusion,
in the area of left scapula inferior angle with dullness, vocal fremitue, bronchovesicular breath sound

90. Thank you!