2I. Auscultatory Valve Area 1. MV: apex, fifth left intercostalspace, medial to themidclavicular line2. PV: second left intercostal space3. AV: second right intercostal space4. AV2: left third intercostal space5. TV: lower part of sternal6. Other part
3III. Content of auscultation II. Auscultatory orderApexPV AV AV2 TVIII. Content of auscultation1. Heart rate2. Heart rhythm3. Heart sound4. Heart murmurs
41. HR Varies with age, sex. Physical activity and emotional status Normal adult: 60-80/minSinus tachycardia: >100/minSinus bradycardia: 60/min
52. Heart rhythm 1) Sinus arrhythmia 2) Premature beat: A sudden extrasystole of the heartin the basic of normal heart rhythmS1; S2Pulse absentEctopic point at atrial, AV node, ventricle
63) Atrial fibrillation: Mechanism: a very high frequency impulsecoming from the atrial ectopicpoint, in multi-reentryThree inconsistence: ventricular rhythmS1 intensityHeart rate; pulse
83. Heart sound: S1, S2, S3, S4S1: S1 indicates the beginning of the ventricularconstraction1) Vibration of the closure of A-V valve2) Opening of the semilunar valve3) Acceleration of the blood in arteries
9S1: Character of auscultation 1) Area: apex2) Pitch3) Lasting time:4) Together with apex impulse
10S2: Vibration of the closure of AV, PV, during the beginning of ventriculardiastole,Indicates the beginning of ventriculardiastole
11S2: Character of auscultation 1) Area: loudest at the basic2) Pitch 3) Lasting time
13S3: Mechanism:In early diastole filling blood moves fromatrium to ventricle, Produces the vibrationof ventricle wallCharacter: at apex or superinternal of apex0.12~0.18'' after S2frequency intensityS4: Occur late in diastole, with effectiveatrial contraction 0.11'' prior to S1
144. Abnormal of heart sound Change in loudnessBoth S1 and S2: Thinner chest wallActivity of the heart increased: Fat, edema,Pericardial effusion, heart failure
15Change in S1: S1 depends on: myocardial contraction filling degree of ventricleelastic and position of the valveS1: 1) MS2) Tachycardia: in high fever, thediastolic period was shortened
17Change of S2: S2 depends on (1) the pressure within the great vessel (2) the situation of semilunervalvesA2: hypertensionP2 : pulmonary hypertension in MS, MIA2: AS ,AIP2 : PS, PI
18Change 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.
19Splitting of heart sounds Splitting of S1: it is due to closure of MV and TV asynchronously loudest over the apex in RBBB
20Splitting of S2: 1) In normal person, physiologic splitting due to the closure of AV and PV asynchronously in inspiration2) In pathological situationdelay of emptying time of one side of the heartsuch as ASD,MS.
213) 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.
224) 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.
235)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.
245. 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.
26In early diastole, the blood through into ventricle from atrium in failing myocardium, the ventricular wall tension is poor, produce vibration. Reflex that the ventricular functionAuscultation character of S3 gallop:lower in pitchAfter S2Best hear at apexLoudest at the end of expiration.
27S3 gallop: differ from normal S3 Occur in severe organic heart diseaseHR>100 bpmThe interval time between S1 and S2 are almost equal, mimicking quality, normal S3 is nearer from S2Normal S3 will disappear in standing or sitting position
28Late diastolic gallop S4 gallop, atrium gallop At late diastole, related to atrial contraction.In LVEDP compliance Artial contractionoccur precede S1, far from S2low-pitch; best heard at apexTensity: end of expiration(from LA)end of inspiration (from RA)
29Occur in pressure overload,LVH, in myocardial damaged , LV compliance , such as BP, IHSS, CHD.
30Summation gallopOverlapping of S3G and S4G while HR
312) Opening snapIn MSIn early diastole of LV, the blood from LALV, the opening MV suddenly stopped make itself vibrationAfter S2. Brief in duration.High in pitch. Indicate a flexible valve
323) Pericardial knockIn 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.
336. Extra sound in systolic period: 1) Early systolic ejection soundDilated great vessel, hypertention with in it.After S1, high in pitch.PV area: PS , PH inspiration, expiration AV area: BP ,AS
41Character of murmur Location: Timing: Murmur of valvular origin are usually best heard over their respective valve areaTiming:Murmurs are timed according to the phase of cardiac cycle during which they occur.SM, DM , CM.Early, middle, late
44Quality Depend on: frequency and intensity of sound wave Related to: pathology and hemodynamic changes of the heartSoft, harsh, musical.SM: blowing, harsh, musical (seagull)DM: blowing, sigh-like, rumbling.CM: machine-like, hum
45Radiation: transmitted direction With the bloodstream by which they are produced or propagated from their point of origin in many directionsASMRMS
46Intensity: Related to : The severity of abnormal The velocity of blood flowThe pressure gradient of valveThe myocardial contraction
47Six-point scale of for grading the intensity of heart murmur Grade Ⅰ: basely audibleGrade Ⅱ: usually readily heardGrade Ⅲ: loudGrade Ⅳ: quite loudGrade Ⅴ: even most pronouncedGrade Ⅵ: may be heard with the stethoscoperemoved from the chest wall.
48PCG Crescendo type Decrescendo type Crescendo-decrescendo type ContinuousRegular
50Physiological maneuver 1) Change the body positionLeft recumbent: MSSitting, leaning forward: AISquatting from standing, supine position,raising two legs may increase venousreturn, SV COMurmur of MI, AIMurmur of IHSS
512) RespirationDeep inspiration: thorax pressurevenous return, pulmonary circulationclockwise rotation of heart make murmurof TI, TS ,PIExpiration:Valsalva maneuver: thorax pressurevenous return M of IHSS
523) Exercise:HRBlood volumeBlood velocitymake the murmur of MS
53The clinical value of heart murmur 1. Important in diagnosis2. Organic M : MSRelative M: valve , supporting tissuesof the valve abnormalFunctional M: increased flow acrossa normal valve
541. Systolic murmur 1) MV area : produced by MI Organic: RHD, MVP Character: pan systolicHarsh, Loud >3/6Radiate to the left axillaManeuver insp exp
562) AV area—ASOrganic: RHDCharacter: Harsh, crescendo-decrescendo,radiateneck, Thrill, S2Relative: Arteriosclerosis, Dilation of aorta,HP
573) PV areaMost are functional:Relative: ASD, PA dilationOrganic: congenital PS
584) TV area—TIMost are relative, duo to dilate of RVcharacter like MI, but increased ininspiration, organic SM are rare5) Other positionVSD: harsh and loudThird-forth intercostal spaceLeft to the sternal borderThrill
592. Diastolic murmur 1) MV area Organic: RHD—MS, Apex Mid-late diastolicRumbling, decrescendo-crescendoThrill, S1, OS
612) AV area – AI rheumaticdecrescendo, sigh-likebest heard at aortic second arearadiate to the left side of the lower part of sternal
623) PV areaMost are produced by relative PI4) TV areaIt is rare in clinical
63Continuous 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 rotatingBest heart at second intercostal space,left to sternal artery-vein fistula.
65Pericardial friction sound It is produced by the rubbing on each other of the parietal and visceral surfaces of the roughened pericardium.During pericarditisIn both systolic and diastolicSystolic component predominatesSometime only in systole
67Harsh,Resemble massage the ear using the fingerBest heard at 3th-4th in intercostal spaceLeft to the sternal borderCommon cause is pericarditis (TB, non-specific, rheumatic)Also can been heard in AMI, uremia, SLE
68Major symptom and sign of common diseases in circulatory system Mitral Stenosis (MS)RheumaticCommissural thickening, adherent fusionOrifice of MV stenosis,blood flow from LA LV was limited.LAP, LAH, Pulmonary V and capillary pressure dilatation, stasis, PAP RV over load RV failureLV filling CO
75Symptom: fatigue , palpitation, dyspnea Sign :Apical pulseleft, lowerApical beat heavyCardiac dullness enlargedleftPausystolic, murmur at apexRadiate to left axilla, subscapularP2 spitting S1
76Aortic Stenosis (AS)Rheumatic, atherosclerosis, congenital Narrowed orifice of AV, the resistence of LV to output the bloodLV contractility, LVHAorta P blood flow in coronary A and peripheral ASymptom: palpitation, fatigue, angina, syncope
84Peripheral vascular sign: pulse pressure water hammer pulse, carotic pulsation, Musset sign(moving head with each heart beat),capillary pulsation, pistol shot sound, Duroziez M.
85Pericardial EffusionInflammatory (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
88Symptom:Depends on the volume and the velocity of effusion producing.Pericardial compression, dyspnea.Infection: fever, fatigueCough, dysphagiaSign:Cardiac impulseApical pulsationCardiac dullness enlarged,coincide with position
89Pericardial friction rub Heart soundIn massive effusion: neck vein engagement, inspirationParadoxical pulse, venous pressureEwart sign: the lung was pressed by the effusion,in the area of left scapula inferior angle with dullness, vocal fremitue, bronchovesicular breath sound