Module 17 : Cardiac Auscultation Flashcards
why listen to heart sounds
- cardiac auscultation is quick inexpensive method to detect and track the progression of valvular heart disease
progression of events
- doctor will hear murmur before sending patient for an Echo
- once echo is performed the doctor can correlate the present disease state with the echo findings
- if quality of murmur changes that could indicate that the disease has progressed
- new echo is then ordered
auscultation is performed with what
- stethoscope
the four heart sounds
- represent different mechanical eents
- first = S1
- second = S2
- third = S3
- fourth = S4
- normally hear S1 and S2
first heart sound S1
- lub sound
- represents MV and TV closure
- S1 composed of M1 (mitral) and T1 (tricuspid) sounds
- normally M1 precedes T1 slightly when normal conduction through bundle branches
- T1 may precede M1 with the left bundle branch block
second heart sounds S2
- dub sound
- caused by Av and PV closure
- divided into A2 and P2
- normally A2 precedes P2
- A2 and P2 widen slightly with inspiration (more right heart filling so valves stay open longer)
- a very wide split of A2 and P2 may result form RBBB pulmonic stenosis and atrial septal defect
third heart sound S3
- lub dub ta
- seldom heard heart sound
- normal in young athletes pregnancy (high preload strong early filling)
- abnormal later in life
- may signify CHF
- caused by increases volume of blood in the ventricle when the MV opens, coincides with early filling
- NOT CAUSED BY VALVES
fourth heart sound S4
- a PRESYSTOLIC heart sound (precedes S1)
- NOT A NORMAL SOUND
- REPRESENTS BLOOD BEING FORCED INTO A VERY STIFF VENTRICLE FROM TEH ATRIA
- occurs during late filling phase
- does not occur with afib
+ no result of coordinated contraction
murmurs
- sound produced by turbulent flow in the heart through valves/shunts/vessels
- ABNORMAL heart sound
- usually during systole or diastole
causes of murmurs
- turbulence
- high flow rate
- forward flow - abnormal valves
+ stenosis - back flow - regurge
- abnormal connections - VSD PDA
common valvular pathologies causes murmurs - mitral
- mitral stenosis MS
- mitral regurge MR
- mitral valve prolapse MP
common valvular pathologies causin murmurs - tricuspid
- tricuspid stenosis TS
- tricuspid regurge TR
common valvular pathologies causing murmurs - aortic
- aortic stenosis AS
- aortic regurge AR
common valvular pathologies causing murmurs - pulmonary
- pulmonary stenosis PS
- pulmonary regurge PR
clicks
- valve openings are usually silent but valvular stenosis can produce ejection click or snaps during valve opening
murmur physiology
- a valve hat fails to close properly allows regurge of blood flow wen it should not be happening
- produces a sound because o turbulent blood flow when the valve normally would be closed
6 factors to assess and describe murmurs
1) which phase (systole, diastole, pan hollow)
2) which portion of the phase (early or late)
3) location where murmur is best heard
4) radiation ? to where (carotids /axilla)
5) quality /shape of murmur (harsh/cresendo/decresendo/blowing)
6) intensity (grade 1-6)
location of murmurs
- sounds produced by the valves are best heard over a particular region of the chest
- lower apex = mitral
- more midline lower = tricuspid
- high left = pulmonic
- high right = aortic
radiation of murmurs
- sometimes radiate to other areas like carotid or axilla
crescendo / decrescendo
- helpful to to relate doppler qualities to the quality of murmur
- crescendo = increasing in pitch
- decrescendo = decrees in pitch
heart quality and shape - stenosis of semi lunar valves
- crescendo / decrescendo
heart quality and shape - stenosis of AV valves
- diastolic rumble
- lower pitch
heart quality and shape - regurge
- holophasic or pan phasic
- means through the whole cycle
timing of heart sound - systolic aortic ejection murmur (AS)
- occurs during systole between S1 and S2
- crescendo decrescendo
timing of heart sound - pan systolic murmur (mitral incompetence)
- spray sound
- even throughout cycle
timing of heart sound - pan systolic murmur aortic or pulmonary incomp
- occurs in diastole
- ## after S2
timing of heart sound - delayed diastole murmur mitral stenosis
- gap after S2 during IVRT
- early undulate diastole
timing of heart sound - continuous murmur of patent ductus arterioles
- systole and diastole
intensity of murmurs and click
- levine scale
- grade 1-6
grade 1 murmur
- lowest intensity (barely audible)
grade 2 murmur
- low intensity
grade 3 murmur
- medium intensity (no palpable thrill)
grade 4 murmur
- medium intensity (palpable thrill)
grade 5 murmur
- loud intensity (palpable thrill)
grade 6 murmur
- loudest intensity
- largest palpable thrill
- heard with stethoscope above chest
palpable thrill
- vibration felt on thrill
describing stenotic murmurs - AV/PV
- harsh quality (murmur/flow)
- radiation - to where
+ AV > carotids - closing sound may be muted or absent when valve is thickened
describing stenotic murmurs - MV TV
- diastolic
- at apex
- little radiation
- rumbling quality
stenotic murmurs - AV valves
- starts with opening snap
- low pitched/ decrescendo / rubbing
regurge murmurs - AV/PV
- diastolic
- blowing , decrescendo
regurge murmurs - MV/ TV
- pan systolic holosystolic
- mitral regurge
+ at apex
+ radiates to left axilla
+ loud - tricuspid regurge
+ pan systolic
+ left sternal border
less common murmurs
- rub
- knock
- muffled heart sounds
- ## changes with respiration/ provocative maneuvers
rub murmur
- beating of heart agains inflamed pericardium without fluid between the layers
- caused by tiny crystals in the pericardium sounds like sand paper
knock murmur
- beating of heart against hardened pericardium with fluid between the layers
- pericardium is like a hard shell from pericarditis s
muffled heart sound murmurs
- in presence of pericardial effusion
- fluid dampens the sound
Changs in respiration / provocative manoeuvres murmurs
- split S1 S2 , paradoxical splitting
- sound intensity increases with valsalva
systolic murmurs
- maybe innocent
- nervous, anxiety , functional
- if pathological they could be
+ AS pS MR TR
diastolic murmurs
- usually pathology
- AR PR MS TS
phonocardiogram
- graphic display of heart sounds and murmurs
- obsolete with event of echo can now demonstrate and quantify valvular abnormalities
- similar to stethoscope microphone on Chest
