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Auscultation By the time you listen, you should know what to hear If you don’t hear what you expect, explain it Don’t leave the bedside till you know.

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Presentation on theme: "Auscultation By the time you listen, you should know what to hear If you don’t hear what you expect, explain it Don’t leave the bedside till you know."— Presentation transcript:

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2 Auscultation

3 By the time you listen, you should know what to hear If you don’t hear what you expect, explain it Don’t leave the bedside till you know what you are hearing Never auscultate from the wrong side of the bed

4 Auscultation Use the diaphragm for high pitched sounds and murmurs Use the bell for low pitched sounds and murmurs Sequence of auscultation –upper right sternal border (URSB) –upper left sternal border (ULSB) –lower left sternal border (LLSB) –apex –apex - left lateral decubitus position –lower left sternal border (LLSB)- sitting, leaning forward, held expiration

5 Grading of Murmurs: Grade 1 - only a staff man can hear Grade 2 - audible to a resident Grade 3 - audible to a medical student Grade 4 - associated with a thrill or palpable heart sound Grade 5 - audible with the stethoscope partially off the chest Grade 6 - audible at the bed-side Auscultation

6 Characteristics of a “functional” murmur Short and soft SEM Normal S1 and S2 Normal cardiac impulse No evidence for any hemodynamic abnormality

7 Auscultation Use the diaphragm for high pitched sounds and murmurs Use the bell for low pitched sounds and murmurs Sequence of auscultation –upper right sternal border (URSB) –upper left sternal border (ULSB) –lower left sternal border (LLSB) –apex –apex - left lateral decubitus position –lower left sternal border (LLSB)- sitting, leaning forward, held expiration

8 Grading of Murmurs: Grade 1 - only a staff man can hear Grade 2 - audible to a resident Grade 3 - audible to a medical student Grade 4 - associated with a thrill or palpable heart sound Grade 5 - audible with the stethoscope partially off the chest Grade 6 - audible at the bed-side Auscultation

9 Assessing Murmurs Grading of Murmurs: Grade 1 - only a staff man can hear Grade 2 - audible to a resident Grade 3 - audible to a medical student Grade 4 - associated with a thrill or palpable heart sound Grade 5 - audible with the stethoscope partially off the chest Grade 6 - audible at the bed- side Functional Murmur: short and soft SEM Normal S1 and S2 Normal cardiac impulse No evidence for hemodynamic abnormality

10 Innocent Murmurs Common in asymptomatic adults Characterized by –Grade I – LSB –Systolic ejection pattern –Normal intensity & splitting of second sound (S2) –No other abnormal sounds or murmurs –No evidence of LVH, and no  with Valsalva S1 S2

11 Common Murmurs and Timing (click on murmur to play) Systolic Murmurs Aortic stenosis Mitral insufficiency Mitral valve prolapse Tricuspid insufficiency Diastolic Murmurs Aortic insufficiency Mitral stenosis S1 S2 S1

12 Auscultation “Aortic area” 2nd left intercostal space (URSB) –compare S1 to S2-S1 should be softer. If the same, think Mitral Stenosis –identify ejection murmur-time the peak intensity in relation to systole –identify ejection click if present

13 Auscultation “Pulmonary Area” 2nd right intercostal space (ULSB) –listen for split S2 (A2/P2) –identify the intensities of A2 and P2 –time split S2 with respiration –normally widens with inspiration, closes with expiration –wide split S2-RBBB, RV volume overload,PS, RV failure –wide fixed split = ASD –paradoxical split = LBBB, severe AS, severe LV dysfunction, pacemaker

14 Auscultation Differential diagnosis of split S2 A2/P2 A2/Pericardial knock A2/OS Sometimes 3 components heard A2/P2/OS A2/P2/PK Exclude S 3 Lower pitched Heard with bell At apex In left decubitus position

15 Auscultation Left Sternal Border Listen for early diastolic murmurs (AR/PR) Press firmly with diaphragm Listen upright with forced expiration Listen on hands and knees

16 Auscultation “Mitral Area” (LLSB) Listen for intensity of S1 –Soft-LV dysfunction, first degree heart block, pre- closure with sudden severe AR/MR –Loud-MS, sympathetic stimulation –Variable- Complete heart block with AV dissociation, Wenkebach Identify splitting of S1 –M1/T1, M1/EC(aortic or pulmonary), M1/Non-EC (MVP), S4/M1

17 Auscultation “Mitral Area” (LLSB) Identify quality,timing and intensity of systolic murmurs –ejection quality vs regurgitant quality –pansystolic vs early or mid to late systolic murmer

18 Auscultation Apex –Listen for S3 and S4 –Consider differential diagnosis of S3 A2-wide P2, A2-OS, A2-PK, A2-S3 –Identify diastolic rumble –Determine radiation of murmur e.g.. MR to axilla

19 Auscultation- Timing of A2 to OS Interval

20 Clinical Signs of LV Dysfunction Hypotension Pulsus alternans Reduced volume carotid LV apical enlargement/displace ment Sustained apex - to S2 Soft S1 Paradoxically split S2 S3 gallop (not S4 = impaired LV compliance) Mitral regurgitation Pulmonary congestion –rales

21 Clinical Signs of RV Dysfunction With Pulmonary HPT –Loud P2/palpable –PR murmer –RV lift Common findings Without Pulmonary HPT –Soft P2 –No PR –+/- RV lift RV S4 TR  CV wave RV S3 murmer  JVP  A wave Pulsatile  liver + HJR Edema + Kussmaul’s

22 Causes of RV Dysfunction LV failure Pulmonary HPT –1  –2  RV infarction Pericardial Disease –tamponade –constriction


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