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Auscultation- Essential and Irreplaceable

Qualities of Sound. Frequency (CPS = Hz) Perceived as pitchAmplitude Perceived as loudnessHarmonics Perceived as qualityDynamics Perceived as loudness changes . Pitch

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Auscultation- Essential and Irreplaceable

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    1. Auscultation- Essential and Irreplaceable Stewart L Nunn MD University Distinguished Professor Medicine/Cardiology The University of Tennessee

    2. Qualities of Sound Frequency (CPS = Hz) Perceived as pitch Amplitude Perceived as loudness Harmonics Perceived as quality Dynamics Perceived as loudness changes

    3. Pitch (Hz) Pitch is important in auscultation Most energy in heart sounds is low-frequency (20-150 Hz) Most energy in murmurs is mid frequency (80-500 Hz) The stethoscope bell gets all sounds The diaphragm without a surround only gets sounds above ~100Hz

    4. Loudness (Amplitude) Fletcher-Munson curve = at low volume, low frequencies are hard to hear and are perceived as low volume even if amplitude is high Extremely low frequency sounds – S3 and S4 – are difficult to hear even at substantial amplitude Selection of stethoscope head is critical – the diaphragm filters out sound below 100Hz and gets rid of S3 and S4

    5. Quality (Harmonics) Murmurs that sound smooth (“blowing”) have many frequencies that are all about the same amplitude (white noise) Harsh murmurs have multiple inharmonic peaks that produce a grinding sound Murmurs that are predominantly one frequency have a distinct pitch and are called musical All these categories have diagnostically useful implications

    6. Dynamics Chreshendo – dechreshendo (AS) <> Decreshendo (AR) > Pansystolic, unvarying (MR)

    7. Stethoscope Factors The stethoscope bell gets all sounds if pressed lightly and is tunable by pressing harder and turning it into a diaphragm The diaphragm (without a surround) only gets sounds above ~100Hz and is not suitable for the study of low-frequency heart sounds but is ideal for murmurs which are higher-frequency

    8. Bell

    9. Diaphragm

    10. Heart Sounds S1 is caused by closure of the mitral and tricuspid valves and is quieter in LV dysfunction S2 is caused by closure of the aortic and pulmonic valves and the involved component is quieter when there is calcification and louder when there is hypertension S2 normally splits with inspiration and its behavior is a rich source of information S3 is caused by early diastolic ventricular filling S4 is caused by presystolic atrial contraction delivering blood in to a nearly filled ventricle

    19. Murmurs Murmurs are described by timing (systolic or diastolic), by dynamics (creshendo, decreshendo, pansystolic), by quality (harsh,blowing) and loudness

    20. Aortic Stenosis

    21. AS/AR

    22. Mitral Regurgitation

    23. MVP Click/Murmur

    25. Recorded Sounds and Murmurs

    26. Sequence of exam 1 Patient sitting Look at neck veins for pressure and waves (a, v and y descent) Listen for carotid bruits and radiated murmurs Feel precordium for lifts and thrills Listen with diaphragm for heart sounds and rhythm Listen with diaphragm for murmurs in all locations Listen specifically for aortic regurgitation along upper LSB with patient leaning forward and exhaled and diaphragm pressed hard

    27. Sequence of Exam 2 Patient recumbant Listen mostly with bell for normal and abnormal heart sounds Study in a focused way S1 and S2 Listen for other sounds in systole Listen in a focused way for S3 and S4 Listen at apex with bell and diaphragm for mitral regurgitation Listen at apex with bell for mitral diastolic rumble in appropriate patients

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