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Heart Sounds
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Heart Sounds & Murmurs
The Stethoscope
• The Bell – used to hear low-pitched sounds– used for mid-diastolic murmur of mitral
stenosis or S3 in heart failure
• The Diaphragm– filters out low-pitched sounds– highlights high-pitched sounds– used for analyzing the second heart
sound, ejection and midsystolic clicks and for the soft but high-pitched early diastolic murmur of aortic regurgitation
Positioning
• Patients can be examined while lying supine, in the left lateral decubitus position, sitting, and leaning forward.
Listening Posts
Cardiac Cycle
Systolic vs. Diastolic
systole
S1 S2
diastole
Gallops
systole
S1 S2
S4 S3
diastole
S1 (lubb)• The 1st heart sound,
marks the beginning of systole (end of diastole).
• Related to the closure of the mitral and tricuspid valves.
• Loudest at the apex and lower left sternal border.
The first heart sound can usually be heard easily with both the bell and the diaphragm
Abnormal S1• Loud First Heart Sound
– Hyperdynamic (fever, exercise) – Mitral stenosis
– short AV intervals like Wolff-Parkinson-White syndrome
• Soft First Sound– Low cardiac output (rest, heart failure) – Tachycardia – Severe mitral reflux (caused by destruction of
valve) – long PR interval
• Variable Intensity of First Sound– Atrial fibrillation – Complete heart block
S2 (dub)• The 2nd heart sound,
marks the end of systole (beginning of diastole).
• Related to the closure of the aortic and pulmonic valves.
• Loudest at the base.
For the second heart sound the diaphragm is invaluable, with the stethoscope usually best placed at the base
Abnormal S2• Loud Second Heart Sound (aortic)
– Systemic hypertension
– Dilated aortic root
• Soft Second Heart Sound (aortic)
– Calcified aortic stenosis
• Loud Second Heart Sound (pulmonary)
– Pulmonary hypertension
S3 Heart Sound • Heard in early diastole
• Lub-dub-by cadence similar to "Kentucky“ SLOSH’-ing-in
• It can be thought of as a sound which is generated when the ventricle is forced to dilate beyond its normal range because the atrium has overloaded volume. As seen in congestive heart failure, which is the most common cause of a S3.
• May be normal physiological finding in patients less than age 30.
S3 is low frequency and thus best heard with the bell of the stethoscope at the apex while the patient is in the left lateral decubitus position. .
S4 Heart Sound• Low frequency sound in late diastole
• Le-lub-Dub cadence similar to "Tennessee" a-STIFF’-wall
• Caused by the atrial kick into a noncompliant ventricle
• Seen in patients with stiffened left ventricles, resulting from conditions such as hypertension, aortic stenosis, ischemic or hypertrophic cardiomyopathy, acute MI.
• In patient with mitral regurgitation, suggestive of acute onset of regurgitation due to the rupture of the chorda tendinae that anchor the Valvular leaflets.
It is heard best with the bell of the stethoscope at the apex.
Gallop Sounds
Gallops & Other Sounds
Sound Answer
Normal
Split S1
Split S2
S3
S4
Summation Gallop
MurmursBlood flow through a structure normally closed during systole (mitral or tricuspid valves). Regurgitation
Blood flow through a valve normally open in systole but abnormally narrowed (e.g. aortic or pulmonary). Stenosis
Increased blood flow through a normal valve High flow states like… pregnancy, fever, anemia, hypothyroidism
Due to structural cardiac abnormality and increased flow
ventricular septal defect atrial septal defect mitral regurgitation
Murmur Assessment
1. note where it is heard best and where it radiates to
2. try to discern if the murmur occurs in systole or diastole by timing it against S1 and S2
3. Note the sound of the murmur, is it blowing or grating?
4. Note the intensity of the murmur
Murmurs Made Easy
systole
S1 S2
diastole
systole
diastole
S1 S2
Murmurs 1 2 3
1. Systolic or Diastolic?
2. Blowing or Grating?
3. Open or Closed?
Murmurs 1 2 3
1. Systolic or Diastolic?
2. Blowing or Grating?
3. Open or Closed?
Systolic
What is it?(What’s my Aortic Valve doing?)
Grating
Ope
n
AORTIC STENOSIS
Murmurs 1 2 3
1. Systolic or Diastolic?
2. Blowing or Grating?
3. Open or Closed?
Systolic
What is it?(What’s my Aortic Valve doing?)
Blowin
gClosed
MITRAL INSUFFICIENCY
Murmurs 1 2 3
1. Systolic or Diastolic?
2. Blowing or Grating?
3. Open or Closed?
Diastolic
What is it?(What’s my Aortic Valve doing?)
Blowin
gClosed
AORTIC INSUFFICIENCY
Murmurs 1 2 3
1. Systolic or Diastolic?
2. Blowing or Grating?
3. Open or Closed?
Diastolic
What is it?(What’s my Aortic Valve doing?)
Grating
Ope
n
MITRAL STENOSIS
Systolic MurmursValvular
Mitral regurgitation
Tricuspid regurgitation
Aortic stenosis
Pulmonic stenosis
Nonvalvular
PDA
VSD
Systolic Valvular Murmurs
Mitral regurgitationhigh pitch pansystolic (holosystolic) murmur with blowing qualitybest heard at the apexradiation into the axilla. plateau shaped May follow MVP
Mitral valve prolapse (MVP) resulting in a mid-systolic clickafter the click, a brief crescendo-decrescendo murmur usually best at the apex
Systolic Valvular Murmurs
Tricuspid regurgitation
high pitch pansystolic blowing quality
Best at tricuspid area (4th ICS LSB)
little radiation
Systolic Valvular Murmurs
Aortic stenosis
medium to high pitch rough, harsh quality
heard best over the “aortic area” or right second intercostal space
radiation into the right neck. This radiation is such a sensitive finding that its absence should cause the physician to question the diagnosis of aortic stenosis.
Systolic Valvular Murmurs
Pulmonic stenosis
Medium to high pitch with a harsh, grinding quality
the second intercostal space along the left sternal border
radiating into the neck or the back
Patent ductus arteriosus
• PDA occurs in about 1 in 2,000 infants
• This murmur is best heard over the upper left sternal edge, associated with a thrill, and is characteristically continuous and machinery-like
Ventricular septal defect
• VSD is one of the most common congenital (present from birth) heart defects.
• It is usually best heard over the “tricuspid area”, or the lower left sternal border, with radiation to the right lower sternal border because this is the area which overlies the defect.
Atrial septal defect (ASD) is a congenital heart defect.
• ASD is present in 4 out of 100,000 people.
• Symptoms usually have manifested by age 30.
• This murmur is best heard over the “pulmonic area” of the chest, and may radiate into the back
Diastolic Murmurs
Valvular
Aortic regurgitation
Pulmonic regurgitation
mitral stenosis
tricuspid stenosis
Nonvalvular
PDA
Diastolic Valvular Murmurs
Mitral stenosis
low pitched, decrescendo pattern, quiet to loud with thrill, rough, rumble quality
best heard at the apex
Tricuspid stenosis
medium pitch quiet murmur, louder with inspiration. Rumble quality
best heard at 4th ICS LSB
Diastolic Valvular Murmurs
Aortic regurgitation
high pitch, faint to medium in intensity, decrescendo pattern, blowing quality
2nd ICS RSB & 3rd ICS LSB
Radiation to the neck
Pulmonic regurgitation
Medium pitch, faint intensity, and blowing quality
These can sound alike but only aortic regurgitation will be associated with a bounding arterial pulses…”water hammer pulse” brisk femoral pulsation
Pericardial Friction Rub
• Caused by the beating of the heart against an inflamed pericardium or lung pleura, which itself has a wide variety of etiologies.
• This sound is usually continuous, and heard diffusely over the chest.
• If the rub completely disappears when the patient holds his breath it is more likely due to pleural, not pericardial, origin.
Intensity of MurmursMurmur Grades
Grade Volume Thrill
1/6very faint, only heard with optimal conditions
no
2/6 loud enough to be obvious no
3/6 louder than grade 2 no
4/6 louder than grade 3 yes
5/6heard with the stethoscopepartially off the chest
yes
6/6heard with the stethoscopecompletely off the chest
yes
Significant or not?
• consider is the clinical scenario
• presence of symptoms such as effort syncope, chest pain, palpitations, shortness of breath, or paroxysmal nocturnal dyspnea
• some common variations of normal heart sounds without an underlying structural pathology
– Split S2 and flow murmurs
Sites for practicehttp://depts.washington.edu/physdx/heart/tech.html
http://www.med.ucla.edu/wilkes/Systolic.htm
http://www.medstudents.com.br/cardio/heartsounds/heartsou.htm
http://www.uni-duesseldorf.de/WWW/MedFak/Herz-Kreislauf-Physiologie/lehre/sounds/intro.html
Laptop has download as well. Cardiac Auscultation (heart sounds) from 3M Littmann Stethoscopes
Now you have a whole new meaning to the phrase “listen to your heart.”
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