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Auscultation of the Heart

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. AV 2 : left third intercostal space

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Auscultation of the Heart

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  1. Auscultation of the Heart

  2. 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

  3. II. Auscultatory order • ApexPV AV AV2 TV III. Content of auscultation • 1. Heart rate • 2. Heart rhythm • 3. Heart sound • 4. Heart murmurs

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

  5. 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

  6. 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

  7. 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

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

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

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

  11. 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

  12. 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

  13. 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

  14. 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

  15. S1: 1) Infarction • 2) MI

  16. 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

  17. 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.

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

  19. 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.

  20. 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.

  21. 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.

  22. 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.

  23. 5. Extra soundsIn diastolic period • 1) Gallop: Three or four sounds are spaced to audibly resemble the center of a horse, the extra sounds occurs after S2.

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

  25. 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.

  26. 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

  27. 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)

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

  29. Summation gallop • Overlapping of S3G and S4G while HR

  30. 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

  31. 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.

  32. 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

  33. 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

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

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

  36. Character of murmur • Location: • 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

  37. 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

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

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

  40. 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.

  41. PCG • Crescendo type • Decrescendo type • Crescendo-decrescendo type • Continuous • Regular

  42. 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

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