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1. Cardiac Auscultation Jay L. Rubenstone, D.O., F.A.C.C.
September 2007
2. Techniques of Examination Order of Exam
Aortic Area
Pulmonic Area
Tricuspid Area
Mitral Area
4. Process of Auscultation At each auscultatory area:
1. Concentrate on 1st Heart Sound
note Intensity and Splitting
2. Concentrate on 2nd Heart Sound
note Intensity and Splitting
3. Listen for Extra Sounds in Systole
note Timing, Intensity, Pitch
6. Process of Ascultation 4. Listen for Extra Sounds in Diastole
note timing, intensity, pitch
5. Listen for Systolic Murmurs*
6. Listen for Diastolic Murmurs*
7. Other Heart Sounds
7. Process of Ascultation *If Systolic or Diastolic Murmur Present, Note:
Location
Radiation
Intensity
Pitch
Quality
8. Auscultation Timing Systolic
Early
Mid
Late
Diastolic
Early
Mid
Late (or Presystolic)
9. AuscultationLocation Interspace
Centimeters from
Midsternal
Midclavicular
Or Axillary Lines
10. AuscultationIntensity Grade 1 Very Faint
Grade 2 Quiet, but Heard Immediately
Grade 3 Moderately Loud, Not Associated with a Thrill
Grade 4 Loud, May Be Associated with a Thrill
Grade 5 Very Loud
Grade 6 May be Heard w/stethoscope off chest
11. Auscultation Radiation or Transmission
Pitch
High, Med, Low
Quality
Blowing
Rumbling
Harsh
Muscial
12. Components of S1 Mitral Valve Closure
Best Heard: Apex
Tricuspid Valve Closure
Best heard: Lower Left Sternal Boarder
13. S1 Wide Splitting
RBBB
PVC from Left Ventricle
Single Sound
Normal
LBBB
PVC from Right Ventricle
Paced Beats
14. S1 Increased Intensity
Short PR
Rapid HR
Atrial Fibrillation
Mitral Stenosis
15. S 1 Decreased Intensity
Mitral Stenosis (Immobile Leaflets)
Opposite of Causes of Increased Intensity
16. S 2 Two Components
Aortic Closure A2
Pulmonic Closure P2
Best Heard at the Base
17. S 2 Normal Splitting
Best Heard At 2nd Left Intercostal Space
During Inspiration there is Delayed Pulmonic Valve Closure
Due to Increased Capacitance of Pulmonary Bed
18. S 2 Loss of Splitting
Inaudible P2-
Adults with Increased Chest Diameter
Congenital (Tetralogy, Pulmonary Atresia Transposition)
Increased Pulmonary Valve Resistance-Pulmonary HTN
Eisenmengers Complex-Equal Pulmonary & Systemic Resistances
19. S 2 Persistent Splitting
RBBB
Pure MR
Healthy Adolescents when in Supine Position
Fixed Splitting
Atrial Septal Defect- Due to Delayed Closure of Pulmonic Valve from Increased Right-Sided Flow
20. S 2 Paradoxical Splitting- P2 before A2
LBBB
Paced Beats
Increased Intensity
A2 Systemic HTN
Dilated Aortic Root
P2 Pulmonary HTN
Dilated Pulmonary Trunk
22. Early Systolic Sounds Ejection Sound- Usually High Frequency
Aortic Valve- Aortic Stenosis, Bicuspid Aortic Valve
Pulmonary Valve-Pulmonic Stenosis Vary with Respirations
Prosthetic Valves- Mechanical, Not Bioprosthetic
23. Mid-Late Systolic Sounds
Click
High Frequency Sound Found in Mitral Valve Prolapse
Occurs Earlier with Valsalva Maneuver or Squatting to Standing
24. Early Diastolic Sounds Opening Snap of Mitral Stenosis (MS)
High Frequency-Left Lateral Decubitus Position, Apex
Occurs after S2, before S3
MS More Severe with Short A2-OS Interval
Precordial Knock
Chronic Constrictive Pericarditis
Mitral Regurgitation
Atrial Myxoma
Older Model Prosthetic Mitral Valve
26. Mid Diastolic Sounds S3
Occurs During Rapid Filling of Left Ventricle (LV) related to LV Volume
Low Frequency Best Heard
At the Apex w/Bell
Pt in Left Lateral Decubitus Position
Can Be Normal to Age 40???
Can be Pathognomonic for Congestive Heart Failure
27. Late Diastolic Sounds S4
During Atrial Phase of LV Filling
Consequence of Ventricular Stiffness
Absent in Atrial Fibrillation or Ventricular Pacing
Low Frequency Sound Best Heart
At the Apex
Pt in Left Lateral Decubitus Position
HTN, Aortic Stenosis, Ischemic Heart Disease
28. Diastolic Sounds Right Sided S3, S4
Left Lower Sternal Boarder
Intensity Varies with Respiration due to Right Heart Filling (Carvallos Sign)
Summation Gallop
Occurrence of an Over Lapping S3 and S4 due to Tachycardia
31. Systolic Murmurs Acute Mitral Regurgitation (MR) or Tricuspid Regurgitation (TR)
Mid Frequency
Not Classic Murmur
Ventricular-Septal Defect (VSD)
High Frequency (diaphram)
Atrial-Septal Defect (ASD)
Pulmonary Outflow
Not Defect Murmur
32. Systolic Murmurs Obstruction to Ventricular Outflow
Dilatation of Aortic Root or Pulmonary Trunk
Accelerated Flow into Aorta or Pulmonary Trunk
Innocent Murmurs
Some Forms of MR (Papillary Muscle Dysfunction)
33. Systolic Murmurs Aortic Valve Stenosis
Diamond Shaped, Crescendo-Decrescendo
Begins After S1 or with Aortic Ejection Sound
Ends Before S2
2nd Right Intercostal Space, Apex, can radiate to Neck
High Frequency, Harsh
Can be Musical in Quality at the Apex
34. Systolic Murmurs Pulmonic Stenosis
Similar to AS Except Relationship to P2
2nd Left Intercostal Space
35. Normal Systolic Murmurs Stills Murmur
Medium Frequency, Vibratory, Originating from Leaflets of Pulmonic Valve
Rapid Ejection into Aortic Root or Pulmonary Trunk
Pregnancy
Anemia
Fever
Thyrotoxicosis
36. Normal Systolic Murmurs Aortic Sclerosis
Most Common Innocent Murmur
37. Systolic Murmurs Mitral Valve Prolapse
High Frequency, Sometimes Honking, Crescendo Murmur
Usually Extends to S2
Classic Mid-Late Systolic Click
Occurs Earlier with Valsalva & Squatting to Standing
38. Systolic Murmurs Holosystolic
Begins with S1, Ends at S2
MR- Radiates to Left Sternal Boarder, Base or Neck, More Commonly Apex to Axilla
TR- Carvallos Sign (Inspiratory Variation)
VSD-Across Precordium
Patent Ductus Arteriosis (PDA)- Aorto-Pulmonary Connection
40. Early Diastolic Murmur Aortic Regurgitation
High Pitched, Decrescendo Murmur
Best heard at
Left Sternal Boarder with the diaphram w/Patient Leaning Forward at End Expiration
Acute, Severe AR Murmur
Can be Short, Soft and Med Pitched
Chronic, Sever AR-
Murmur Usually Long, Loud, Blowing Decrescendo, High Frequency
42. Early Diastolic Murmur Graham Steell
Murmur of Pulmonic Regurgitation as a Result of Pulmonary HTN
High Freq, Decrescendo Blowing Murmur Heard throughout Diastole
43. Mid Diastolic Murmur Mitral Stenosis (MS)
Follows Opening Snap
Low Pitch Rumble
Best Heard
Apex over LV
Using Bell of Stethoscope
Pt in Left Lateral Decubitus Position
44. Mid Diastolic Murmurs Tricuspid Stenosis
Similar to MS, except increases with Respiration (Carvallos Sign)
Best Heard at Left Lower Sternal Edge
45. Mid Diastolic Murmurs Pulmonic Regurgitation
Crescendo-Decrescendo Murmur when Primary Valvular Abnormality and Not Associated with Pumonary HTN
46. Diastolic Murmurs Late or Presystolic
Follows Atrial Systole
Implies Sinus Rhythm
Can be present in MS or Complete Heart Block
Austin Flint Murmur of Aortic Regurgitation
Bubbling Quality, Short
Consequence of Aortic Regurgitation impinging on Mitral Valve
47. Diastolic Murmurs Continuous
PDA (AortoPulmonary Connection)
Rough Thrill
A-V Fistulas
Hemodialysis Shunt
Aortic Valve Sinus to Right Ventricular Fistula
Coronary Artery Fistulas
48. Diastolic Murmurs Venous Hum
Rough in quality not actually a hum
Hepatic
Internal Jugular
During Anemia, Fever, Pregnancy and Thyrotoxicosis
49. Pericardial Friction Rub Three Phases
Mid Systolic, Mid Diastolic, Pre Systolic
Scratchy, Leathery
Best Heard
With Diaphragm of Stethoscope
Left Sternal Boarder Leaning over at End Expiration
Apposition of Abnormal Visceral and Parietal Pericardium
Confused with Hammans Sign in Post Open Heart Surgery (Crunch Sound from Mediastinal Air)
50. Innocent or Normal Murmurs-Systolic Vibratory Systolic Murmur (Stills Murmur)
Pulmonic Systolic Murmur (Pulmonary Trunk)*
Mammary Soufflé*
Peripheral Pulmonic Systolic Murmur (Pulmonary Branches)
Supraclavicular or Brachiocephalic Systolic Murmur
Aortic Systolic Murmur
*common in pregnancy
51. Innocent or Normal Murmurs-Continuous Venous Hum
Continuous Mammary Soufflé
52. Conclusions Consistent Approach to Auscultation
Knowing What to Look For
Follow Through on H&P
Confirm or Eliminate Suspicions
Knowing How to Find It
Proper Utilization of Stethoscope
Location and Quality of Heart Sounds & Murmurs