Auscultation of the Heart

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

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

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

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

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

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

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

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

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

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

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

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

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

S1: 1) Infarction 2) MI

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

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.

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

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.

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.

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.

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.

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.

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

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.

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

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)

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

Summation gallop Overlapping of S3G and S4G while HR

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

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.

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

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

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

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

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

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

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

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

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.

PCG Crescendo type Decrescendo type Crescendo-decrescendo type Continuous Regular

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

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

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

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

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

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

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

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

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

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

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

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

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

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.

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

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

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

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.

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

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

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

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

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

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

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.

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 

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

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

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