CARDIAC AUSCULTATION

STATION LEARNING OBJECTIVES Understand and describe the correct use of the stethoscope. Describe the normal (1st & 2nd) heart sounds. Describe and accurately demonstrate the four auscultatory areas. Understand the timing of systolic and diastolic murmurs and recognise the difference between a pansystolic and an ejection systolic murmur and the conditions with which they are associated.

The STETHOSCOPE The BELL: amplifies low pitched sounds The DIAPHRAGM: intensifies high-pitched sounds and normal heart sounds

AUSCULTATION AREAS Mitral area 4th ICS L Tricuspid area 5th ICS L Pulmonary 2nd ICS L Aortic 2nd ICS L

What do you need to consider during auscultation ? the nature and intensity of the 1st and 2nd heart sounds extra heart sounds (3rd & 4th) any additional sounds such as snaps murmurs pericardial rub

MURMURS Timing - ?systolic ?diastolic Area of greatest intensity Loudness & pitch Dynamic manoeuvres

TIMING SYSTOLIC: pansystolic eg. mitral regurgitation ejection systolic eg. aortic stenosis DIASTOLIC: early diastolic mid-diastolic eg. mitral stenosis Continuous: heard throughout systole & diastole Pericardial friction rub: scratching sound due to inflamed pericardial surfaces rubbing against each other pericarditis louder on sitting up & expiration

Dynamic Manoeuvres Respiration Right sided murmurs are exaggerated on inspiration (increased venous return therefore increased blood flow to the right side of the heart) Left sided murmurs are exaggerated on expiration Valsalva - forceful expiration against a closed glottis Mitral regurgitation and Aortic Stenosis become softer Mitral valve prolapse & HOCM become louder Exercise Mitral stenosis murmurs are enhanced with exercise Position Left lateral: murmur of mitral stenosis exaggerated Leaning forward: murmur of aortic regurgitation exaggerated

PANSYSTOLIC MURMUR OF MITRAL REGURG. Acknowledgements: Macleod’s Clinical Examination, 10th Ed, pg 96 Click here to listen to an example of a pansystolic murmur

EJECTION SYSTOLIC MURMUR OF Aortic Stenosis Acknowledgements: Macleod’s Clinical Examination, 10th Ed, pg 96 Click to hear a murmur associated with AS