Download the normal sounds

Mona M Dawson, DNP, GNP-BC, RN / Educator
Website: (www.advancedassessmentskills.com)
[email protected]
Mona Dawson L.L.C. 325-650-4673
ADVANCED STETHOSCOPE SKILLS
GOALS
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Terminology - why, where, when, and what of sounds
Technique – most effective use; placement of stethoscope, directions to patients
Confidence
Approach - Visualize!
STETHOSCOPE
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“Stethos” – chest; “Scopin” – to view
History
How to hold -.
Use of:
Diaphragm - used to pick up high pitched sounds – firm pressure
Bell - needed to detect low pitched sounds – light pressure
Types of stethoscopes
AUSCULTATION - The study of sounds produced in the human body
SOUND - Audible vibrations created by airwaves (movement = sound)
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DURATION - how long the sound lasts
FREQUENCY - PITCH - Measured in cycles or waves per second (hertz)
Human hearing range 50 to 20,000 cycles per second
INTENSITY - LOUDNESS - Measured in decibels (height of the waves)
Affected by:
Source of sound
Distance it travels
Medium through which it travels
LAMINAR FLOW - fluid or air tends to flow in streamlines along the edge of a tube until disturbed by narrowing,
roughening of the tube, or upon reaching a critical velocity.
MASKING - adjustment period needed for ear to recognize a new type of sound.
Disclosure to Participants
Successful completion requires participation in the full presentation. Certificates of completion will be
distributed at the conclusion upon receipt of your completed evaluation form.
There is no conflict of interest or financial support for this presentation or any of the planners of the
activity by any outside agency. Commercial support for this presentation is provided solely by the
registration fee for the activity
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This continuing nursing education activity was approved by the Virginia Nurses Association Continuing
Education Approval Committee, an accredited approver by the American Nurses Credentialing Center’s
Commission on Accreditation.
ABDOMINAL SOUNDS
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Anatomy
Bowel Sounds
Bruits
Size & Shape of Organs
Spleen
Liver
Stomach
Gallbladder
Transverse Colon
Peritoneum
Small Intestines
Descending Colon
Ascending Colon
Sigmoid Colon
Bladder
Arteries
Veins
Abdominal
Aorta
Vena Cava
Iliac Arteries
Femoral
Arteries
Femoral
Veins
LANDMARKS
9 Areas
Four Quadrants
Epigastric
Abdominal
Aorta
RUQ
Right Renal
Artery
Right Iliac
Artery
Right Femoral
Artery
LUQ
4"
{
Left Hypochondriac
Right Hypochondriac
Umbilical
Left Renal
Artery
Right Lumbar
Left Lumbar
Umbilicus
Left Iliac
Artery
RLQ
LLQ
Right Inguinal
Hypogastric
Left Femoral
Artery
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Left Inguinal
ABDOMINAL SOUNDS
NORMAL BOWEL TONES - 5 to 35 gurgles per minute
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Predominantly from small intestines
Higher pitched in small intestine/
Lower pitched in large intestine
Vary with oral intake
PATHOPHYSIOLOGY
MECHANICAL BOWEL OBSTRUCTION
1.
2.
3.
4.
5.
Adhesion - Scar tissue from surgery
Tumor
Volvulus - Twisting on itself – more prevalent in elderly
Herniation through muscle wall
Intussusception – Part of intestine goes inside other part – most prevalent in infants
 High pitched tinkling sounds occurring in rushes - sounds like dripping. Associated with
distention and pain.
PARALYTIC BOWEL OBSTRUCTION (ALSO CALLED ILEUS)
1. Surgery always causes - handling of viscera
2. Peritonitis
3. Fractured spine / hemiplegia
4. Side effect of medications - thorazine class, opiates, abused drugs, anesthesia neuromuscular blockade.
 Decreased to absent sounds
BRUIT - hearing the blood flow through an artery.
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Causes can include:
High flow rates
Arteriosclerosis
Aneurysm
Pressure of a tumor
VENOUS HUM - blood is heard flowing through a vein.
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In the abdomen is abnormal, related to liver congestion:
Heard as blood flows from hepatic veins into inferior vena cava.
Venous Hum can be normal in clavicular area/ called “physiologic” or “functional” hum.
PERITONEAL FRICTION RUB - Grating sound when two layers of peritoneum rub
together. Can be caused by peritonitis or can occur after surgery.
TECHNIQUE FOR ABDOMINAL AUSCULTATION
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Warm stethoscope, explanation to patient
All 4 Quadrants, at least 1 minute if silent,
Diaphragm of stethoscope,
Do before palpation or percussion,
Listen for bruit
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AUSCULTATION ASSISTED PERCUSSION
LEVEL OF DIAPHRAGM (LUNGS) Can be determined by placing stethoscope in the back below
the level of the scapula, then tapping and listening for change in quality of sound.
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 LIVER EDGE DETERMINATION - Place stethoscope over liver. While listening, scratch on skin
towards stethoscope. Change in sound indicates change of medium through which sound travels. Technique works
for determining size of spleen as well.
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BONE-Transmit sound when tapping at one bony prominence and listening at
another, for example tapping knees and listening at pubis-based on symmetry and
comparing side to side. May be helpful in determining fracture or dislocation.
 BLADDER SIZE DETERMINATION-Place diaphragm of stethoscope over bladder and then start
tapping at or above the level of the umbilicus downward towards the bladder. Sound should change when tapping
over fluid filled bladder. May not be completely reliable due to anatomical position of bladder
BREATH SOUNDS
ANATOMY
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CONDUCTING PASSAGES
BRONCHI / BRONCHIOLES
ALVEOLI
PLEURA
BLOOD SUPPLY
Pleura
Terminal bronchiole
Alveolus
RUL
LUL
RML
RLL
Capillaries
LLL
Alveoli- Size of ½ tennis court
Oncotic pressure – keeps fluid
in blood stream (Protein particles, blood
cells)
Hydrostatic pressure
Surfactant
Interstitial space – lymph fluid
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LANDMARKS FOR DOCUMENTATION
HORIZONTAL LANDMARKS
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LOBES
FRACTIONS
APEX / BASE
ANTERIOR LOBES
POSTERIOR LOBES
T3
FOURTH RIB
LUL
RUL
X
RUL
LLL
LUL
RLL
T10
RML
LLL
RLL
SIXTH RIB
TECHNIQUE
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Instructions to patient
o Breathe in and out through mouth
o Deeper than normal
o Examiner raises and lowers arm to indicate rate & depth of respiration to patient
Diaphragm of stethoscope
Progression-always compare left to right at same horizontal and vertical landmarks
Anterior
Posterior
5
Lateral
6
4
3
1
2
2
1
3
4
Patient must be aligned straight to gravity; if rolled onto side, more blood goes to lower area, more air to upper.
Areas - Six anterior
Six posterior
Two each axillary side
Common errors - any movement around stethoscope creates sound
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THE NORMAL SOUNDS
BRONCHIAL
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Loud / high pitched
Heard throughout inspiration and expiration
Normal over trachea/largest airways
Abnormal if heard in peripheral lung fields
VESICULAR
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Softer / low pitched
Heard on inspiration and first part of expiration
Normal - heard over peripheral lung fields
BRONCHOVESICULAR
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Normal when heard over first branching of the bronchi
Heard both inspiration and expiration heard-not as loud as bronchial
Can occur in conditions causing bronchi to dilate (“Osis” type conditions)
ABNORMALITIES OF BRONCHIAL AND VESICULAR SOUNDS
1.
Hearing bronchial breath sounds in abnormal location
 Can indicate consolidation or fluid in the lung.
2. Absent - pneumothorax, airway obstruction, atelectasis, large effusion, slipping of endotracheal tube
3. Diminished - not as loud as expected. Shallow breathing, anesthesia, pain
4. Distant - sounds are present but "far away" as in emphysema
ADVENTITIOUS SOUNDS
CRACKLES
 Discontinuous
 Heard primarily on inspiration
 "Popping open" of previously closed airways
 Caused by thin fluid in airways as in pulmonary edema, CHF, early pneumonia
 Can be heard in atelectasis if patient takes deep breath - part of the lung
was collapsed, then popped open. Conditions affecting elasticity (lupus, scleraderma)
RHONCHI (Low Pitched Wheeze)
WHEEZE
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Continuous (but may be brief & not heard throughout entire cycle)
Heard on inspiration and expiration
Low pitched - caused by secretions in the airways
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Continuous
Musical quality
Most prominent on expiration
Indicates narrowing of bronchi by secretions or by constriction of the bronchi in asthma
The severity of the wheeze is NOT an indicator of the severity of the disease.
STRIDOR
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Continuous
Heard on inspiration
Indicates tracheal or laryngeal obstruction, as from croup, epiglottitis, tumor
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Can occur after extubation from swelling in larynx, or from foreign body.
PLEURAL RUB
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Grating sound
Localized
Heard on inspiration and expiration
Can occur with pleurisy, pleuritis, blebs, or infection spreading to pleura
IN DOCUMENTING LUNG SOUNDS THE FOLLOWING SHOULD BE INDICATED:
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The sound
The location
The part of the cycle
VOICE SOUNDS
 BRONCHOPHONY
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EGOPHONY
o
o
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Speaking voice is louder or clearer over area of consolidation
Literally, "Voice of goat"
"EE" sound changes to nasal "AA" over area of consolidation
WHISPERED PECTORILOQUY
o
Whispered tones are more distinct over area of consolidation
PATHOPHYSIOLOGY IN THE LUNGS
COPD - Chronic obstructive pulmonary disease. Characterized by increased resistance to airflow. Actually
has components of the following four diseases.
ASTHMA - Bronchioles become constricted, edematous, filled with mucous. Defined as bronchiolar
inflammation with hyper-responsiveness and narrowing of airways. Can be caused by intrinsic factors - reaction to an
infection or a cold, stress, exercise, bronchospasm; or extrinsic factors - allergens or irritants such as smoke or chemical
inhalation, cold winter air.
Sounds expected to be heard: HIGH PITCHED AND LOW PITCHED WHEEZE
BRONCHITIS - Excessive production of mucous by goblet cells. Chronic bronchitis has a medical
definition - productive cough for 3 consecutive months in 2 consecutive years. Increase in number of goblet cells.
Sounds expected to be heard: LOW PITCHED AND HIGH PITCHED WHEEZE
EMPHYSEMA – Obstructive pulmonary disease characterized by dilation and destruction of small lung
units from terminal bronchiole to alveolar sacs. Abnormal enlargement and air trapping in the alveoli and alveolar
ducts.
Sounds expected to be heard: DISTANT BREATH SOUNDS; POSSIBLE RUB, PNEUMO
BRONCHIECTASIS - Chronic dilation of bronchi with inflammation and excess mucous production.
Was prevalent after childhood illnesses before antibiotics were discovered. Other chronic conditions associated with
long term inflammation of the bronchi will have the same general presentation (asbestosis, silicosis, fibrosis, etc.)
Sounds expected to be heard: WHEEZES, BRONCHIAL SOUNDS OUT TOWARDS PERIPHERY
ATELECTASIS - Not a disease but a condition of "imperfect expansion" - parts of the lung are airless and
collapsed. Three factors contribute to atelectasis:
 poor lung distention,
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obstruction of airways
insufficient surfactant levels
Causes include bronchial obstruction, tumor, effusion and others.
Sounds expected to be heard: ABSENT; POSSIBLE CRACKLES
PNEUMONIA – Inflammation and infection in the lung. Affects 1% of population
annually. Infection in alveoli with fluid exudate, can also be aspiration type.
Sounds expected to be heard: CRACKLES
BRONCHIAL SOUNDS WITH VOICE SOUNDS (BRONCHOPHONY, EGOPHONY,
WHISPERED PECTORILOQUOY;
LOW & HIGH PITCHED WHEEZE
POSSIBLE PLEURAL RUB
ARDS - ADULT RESPIRATORY DISTRESS SYNDROME. Low oxygenation of the blood due
to damage of the alveolar-capillary membrane. Causes include cardiac problem, aspiration, pneumonia, other
infections, sepsis, amniotic, fat, or thrombotic embolism, inhaled toxins, drug toxicity, near drowning, chest trauma,
DIC. Treatment: Positive pressure ventilation.
Sounds expected to be heard: CRACKLES RISING QUICKLY ON CHEST; POSSIBLE WHEEZE
AIR FLOW / BLOOD FLOW
X
Normal
X
Atelectasis
x
X
P.E.
X
X
X
X
Pneumothorax
PULMONARY EMBOLISM – Vascular obstruction of pulmonary blood vessels by blood clots.
Factors associated with formation of venous emboli include:
 hypercoagulability of blood
 damage to the wall of the blood vessel
 venostasis.
Sounds expected to be heard initially: VESICULAR
Size of area affected: WIDELY VARIABLE
Pain: MAY BE A SHARP STABBING SENSATION; MAY NOT HAVE MUCH PAIN
Treatment: THROMBOLYTICS; ECMO
Sounds expected to be heard later: CRACKLES, THEN DIMINISHED, THEN RUB
PULMONARY EDEMA – Accumulation of fluid in the extravascular spaces (the interstitium) and in
the tissues in the lungs. Causes can be:
 high blood pressure
 increased permeability of membranes
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 problems with lymph drainage
 low oncotic pressure.
Sounds expected to be heard: CRACKLES
PLEURAL EFFUSION - Effusions are fluid production and seeping from &/or within the pleural space.
Transudates - low protein (CHF, nephrotic syndrome, portal vein obstruction, anemia, chemical inhalation). Exudates high protein (hemothorax, cancer, abscess, chemotherapy, lupus, Hodgkin’s, contusion, pneumonia).
Sounds expected to be heard: BRONCHIAL IF FLUID IN LUNG; ABSENT IF FLUID IN SPACE
ASPIRATION- Damage to the delicate structures of the lung. Three types of aspiration:
(1) foreign body or food particles, (2) liquid aspiration, (3) bacterial aspiration. Treatment and presentation of lung
disorder will vary by type of aspiration.
Solid : May cause atelectasis; If inhaled object lodges, may cause bronchiectasis
Gas: May cause infections if germs are inhaled; May cause ARDS if gas damages alveolar wall
Liquid: Fresh water: May be absorbed if small amount; washes out surfactant if large amount
Salt water: Can pull fluid into lung and looks like pleural effusion
Acidic fluid: Acid can break down alveolar surface – leading to ARDS
COR PULMONALE – Right heart enlargement and failure as a result of pulmonary disease. Increase in
pumping pressure of right ventricle.
Sounds expected to be heard: CRACKLES
HEART SOUNDS
ANATOMY
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SEQUENCE OF BLOOD FLOW
CHAMBERS / ATRIA AND VENTRICLES
VALVES / TRICUSPID, PULMONIC ON RIGHT
 MITRAL AND AORTIC ON LEFT
Pulmonary artery
Aorta
Pulmonary vein
Vena cava
Left atrium
Right atrium
Mitral valve
Tricuspid valve
Aortic valve
Left ventricle
Pulmonic valve
Right ventricle
Apex
CYCLE - SOUND PRODUCTION
1. Mid diastole - passive filling of ventricles
2. Late diastole - active filling of ventricles from atrial contraction
3. Early systole - S1 sound AV valves close - beginning of contraction
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4. Mid systole - ejection of blood
5. Late systole - closure of semilunar valves - S2 sound
6. Early diastole - ventricles are relaxed - passive filling resumes
THE SOUNDS
S1 - Closure of mitral and tricuspid valves (AV valves) “systole 1” Lub
S2 - Closure aortic and pulmonic valves (semilunar valves) “systole 2” Dub
VALVE AREAS
 AORTIC – 2nd intercostal space on the right side of the sternum
 PULMONIC – 2nd intercostal space on the left side of the sternum
 TRICUSPID – 3rd – 4th intercostal space left sternal border
 MITRAL - (APEX) 5th intercostal space along the mid-clavicular line
 ERB'S POINT – 3rd to 4th intercostal space medial to mid-clavicular line
Pulmonic
Aortic
Erb’s Point
Tricuspid
Mitral
S1, S2 DETERMINATION
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Timing - "1, 2, pause"
Palpation or visualization of carotid pulsation - occurs with S1
Position where the S1 or S2 sound is the most crisp and clear
TECHNIQUE
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Instructions of patient ("breathe quietly now so that I can hear your heart")
Diaphragm of stethoscope in all valve areas
Bell of stethoscope in all valve areas (For extra heart sounds determine: what? where? how?)
Inching - adjusting the positions slightly for best sound quality
Positions of the patient for cardiac auscultation
o Supine
o Left lateral recumbent
o Sitting up & slightly leaning forward
Focus - selective listening
o S1
o S2
o Systole
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o
o
Diastole
Changes with respiration, activity, or position
FACTORS AFFECTING INTENSITY AND QUALITY OF S1 / S2
1. Anatomy of chest
Thin chest wall ______________ Thicker chest wall ________________
2. Vigor of contraction – Affects S1 sound
Vigorous contraction ___________ Less vigorous contraction ___________
3. Valve position at onset of systole - Affects S1 sound
Valve wide open _______________
Valve partially shut ________________
Measured on EKG by determining _______________________
4. Pathology of valve
5. Impedance of blood
Thick blood _________________
Thinner blood ________________
6. Pressures in heart chambers or vessels – Pressure in vessels affects S2 sound
High pressure in aorta
High pressure in pulmonary artery
S1 = M1 + T1
S2 = A2 + P2
SPLIT S1 SOUND
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Mitral and tricuspid valves closing slightly apart in time
Can be normal or can be caused by partial right bundle branch block
PERSISTENT SPLITTING OF S2
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Closure of pulmonic valve is consistently delayed
Causes:
o Pulmonic stenosis
o Complete right bundle branch block
o Pacemaker placement on left ventricle
o Fixed splitting of S2 - atrial septal defect
PHYSIOLOGIC SPLIT S2
 NORMAL FINDING - Heard best at aortic or pulmonic area
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Extra blood returns to right ventricle on inspiration
Pulmonic valve closes after aortic on inspiration – S2 single sound on expiration
PARADOXICAL SPLITTING OF S2
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Closure of aortic valve is delayed. This leads to S2 splitting on expiration, single sound on
Causes:
o Aortic stenosis
o Left bundle branch block
o Placement of a right ventricular pacemaker
inspiration.
SANDERSON, N. (1975), HANDY HEART SOUND SIMULATOR. AMERICAN JOURNAL
OF CARDIOLOGY, DEC. 75 VOL. 36.
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S3 – Ventricular Gallop
Early diastolic filling sound
• May be normal in children and young adults
• Heard over the ventricles (mitral area, tricuspid area, Erb’s point)
• Factors that can cause abnormal S3
(the vibration of the muscle that occurs when the ventricle relaxes and blood
rushes in) influenced by volume & velocity of blood flowing in and by compliance of muscle wall
1. High cardiac output
Anemia
Thyrotoxicosis
*Fluid Overload
2. Excessively rapid filling
Regurgitation of blood through incompetent valve
3. Limited expansion ability
Coronary artery disease
*Congestive heart failure
Cardiomyopathy
S4 – Atrial Gallop
Late diastolic filling sound from blood ejected by atrial contraction vibrating the wall of the ventricle • May be a normal finding
• Factors that can cause abnormal S4 (the vibration of the ventricle which occurs when blood is forced in by
contraction of the atria)
1. Valvular abnormality
Pulmonic or aortic stenosis
Mitral regurgitation
2. Low compliance of muscle wall
Chronic pulmonary or systemic hypertension
Cardiomyopathy
Coronary artery disease
3. Increased cardiac output states
Thyrotoxicosis, anemia, fluid overload
DOCUMENTATION OF HEART SOUNDS: S1 S2  3,4,M ,R
SUMMATION GALLOP - S3 and S4 occurring together as one sound
QUADRUPLE RHYTHM - S1 S2 S3 S4 - all four sounds occurring in sequence
SYSTOLIC EJECTION CLICKS
(The sound of movement in the pulmonary artery or aorta when blood is ejected by the ventricle)
1.
Dilation of pulmonary artery or aorta
2.
Pulmonary or systemic hypertension
3.
Pulmonary embolism
4.
Aortic or pulmonic stenosis
5.
Forceful ventricular ejection
a. Thyrotoxicosis
b. Fever
c. Exercise
d. Anemia
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6.
7.
High pitched
Heard best at pulmonic or aortic area
MIDSYSTOLIC CLICK - Due to tension of chordae tendinae on mitral valve leaflets when valve prolapse
occurs.
 High pitched
 Heard best at mitral area
OPENING SNAP - Diastolic sound occurs just after S2 due to opening of thick, stenosed mitral valve or tricuspid
valve.
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High pitched
Heard best at mitral or tricuspid area
Factors causing MURMURS
1. Outflow obstruction - stenosis of valve
2.
High flow states – anemia thyrotoxicosis, fever, exercise
3.
Incompetent valve – regurgitation occurs (can be caused by rupture of papillary muscle, by aneurysm, or by
valve disease).
4. Dilation of pulmonary artery or aorta
5. Cardiac defect
CLASSIFICATION AND DESCRIPTION OF MURMURS
• Location - where heard best
• Radiation - for example to abdomen, axilla, neck, back
• Timing - systole or diastole
• Intensity: Scale is used to establish and maintain a baseline of patient’s condition.
I/VI - must concentrate to hear
II/VI - faint but recognized easily
III/VI - moderate loud with no thrill
IV/VI - loud with faint thrill
V/VI - loud with definite thrill
VI/VI - loud - heard with stethoscope off chest wall
• Pitch and quality
• Changes with respiration, position, activity
Systolic Murmurs:
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Aortic / Pulmonic Stenosis
Mitral / Tricuspid Regurgitation
Diastolic Murmurs:
 Aortic / Pulmonic Regurgitation
 Mitral / Tricuspid Stenosis
Mnemonic for determining which valve is involved with murmurs:
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MS ARD (Mitral Stenosis, Aortic Regurgitation – Diastolic)
MR PASS (Mitral Regurgitation, Pulmonic / Aortic Stenosis – Systolic)
PERICARDIAL FRICTION RUB
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Grating sound
Heard in pericarditis & after open heart surgery
Innocent Murmurs:
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Irregular Rhythms:
Systolic
Grade I or II
Normal S2
Heard along left sternal border
No associated clicks or snaps
Asymptomatic
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Volume changes
Sinus arrhythmia
Bigeminey
Trigeminy
Chaotic rhythm
Patent Ductus Arteriosus
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Artery between pulmonary artery and aorta that is open in utero
Generally closes on its own
Affects more girls than boys
Can occur in combination with genetic disorders such as Down’s syndrome or if the mother had rubella during
pregnancy.
Websites:
http://www.blaufuss.org/
http://www.med.ucla.edu/wilkes/intro.html
http://solutions.3m.com/wps/portal/3M/en_US/Littmann/stethoscope/education/heart-lung-sounds/
http://auscultation.com/
http://www.rale.ca/
http://www.amphl.org/home.php (site for hearing impaired equipment)
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