Download CVS ASCULTATION

Examination of CVS
Auscultation( Heart Sounds )
General Considerations
(1)
A stethoscope with bell + diaphragm
(2)
The earpieces should fit comfortably and firmly
(3)
The tubing should be about 25 cm long
(4)
The tubing should be thick enough to reduce
external sounds
To start …..
What to hear ?
First Heart Sound (S1)
Second Heart Sound (S2)

Closure of M + T valves.


Beginning of ventricular
systole.


Closure of A + P valves.
( A
P)
End of ventricular
systole.
Splitting of the S2.
Timing …..
Abnormalities of the Heart Sounds
1.
2.
3.
4.
5.
Alteration in Intensity.
Splitting.
Extra Heart Sounds.
Additional Sounds.
Murmurs.
* MS + TS
* Red. diast. filling (HTN)
* Prolonged dias. filling
(1st degree block).
* Delayed onset of sys.
(LBBB).
* MR
* Systemic HTN. (A2)
* Cong. AS. (A2)
* Pulm. HTN. (p2)
* AR.
Abnormalities of the Heart Sounds
1.
2.
3.
4.
5.
Alteration in Intensity.
Splitting.
Extra Heart Sounds.
Additional Sounds.
Murmurs.
Inc. N.
Reversed
•d.t. delay in Rt vent.
emptying.
•RBBB, PS, VSD, MR.
•P
A + in expiration.
•LBBB, AS.
Abnormalities of the Heart Sounds
1.
2.
3.
4.
5.
Alteration in Intensity.
Splitting.
Extra Heart Sounds.
Additional Sounds.
Murmurs.
What to hear ?
3RD Heart Sound (S3)
Lubb-dupp-da



Slushing in
Caused by turbulent
blood flow into
ventricles and detected
near end of first onethird of diastole (Rapid
ventricular filling).
Fluid backing up , as in
cardiac failure



4TH Heart Sound (S4)
Da-lubb-dupp
A stiff wall
With the atria systole
Non compliant
ventricles
Third Heart Sound (S3)
•
•
•
•
Low pitched. @ apex + LLSB.
Mid-diastolic.
Triple rhythm (lub-dub-dum) (= gallop rhythm)
N: children + young people + pregnancy +
athletes + fever.
• Ab. : VF, AR, MR, VSD, PDA, Constrictive
pericarditis.
Fourth Heart Sound (S4)
• High pressure atrial wave reflected back from
a poorly compliant ventricle.
• Late diastolic, high-pitched sound.
• NEVER physiological.
• Ab. : AS, PS, MR, HTN, IHD, advanced age,
angina or MI,
Abnormalities of the Heart Sounds
1.
2.
3.
4.
5.
Alteration in Intensity.
Splitting.
Extra Heart Sounds.
Additional Sounds.
Murmurs.
1.
2.
3.
4.
Opening snap.
Systolic ejection click
Prosthetic heart valves.
Pericardial friction rub.
Pericardial friction rub
•
•
•
•
A superficial scratching sound.
Occurs at any time during the cardiac cycle.
Sign of PERICARDITIS.
Louder with sitting up and breathing out.
Abnormalities of the Heart Sounds
1.
2.
3.
4.
5.
Alteration in Intensity.
Splitting.
Extra Heart Sounds.
Additional Sounds.
Murmurs.
Murmurs
1.
2.
3.
4.
5.
Timing.
Intensity.
Area of greatest intensity.
Propagation.
Effect of certain maneuvers.
Timing
• Systolic:
• Innocent. (fever,
athletes, pregnancy)
• Pansys. (MR, TR, VSD)
• Ejection (mid) sys. (AS,
PS, ASD, severe anemia)
• Late sys. (M Prolapse)
• Diastolic:
• Early. (AR, PR)
• Mid. (MS, TS)
• Others:
• Presys. (MS, TS)
• Continuous. (PDA +
fistulae)
Murmurs (cont.)
1.
2.
3.
4.
5.
Timing.
Intensity.
Area of greatest intensity.
Propagation.
Effect of certain maneuvers.
Intensity
•
•
•
•
•
•
1/6 : soft + not heard @ first.
2/6: soft BUT can be detected.
3/6: moderate, NO thrill.
4/6: loud + thrill.
5/6: very loud.
6/6: very, very loud (w/o stethoscope).
Murmurs (cont.)
1.
2.
3.
4.
5.
Timing.
Intensity.
Area of greatest intensity.
Propagation.
Effect of certain maneuvers.
Murmurs (cont.)
1.
2.
3.
4.
5.
Timing.
Intensity.
Area of greatest intensity.
Propagation.
Effect of certain maneuvers.
Propagation
• PSM (MR)
Lt axilla.
• PSM (VSD)
Rt sternal edge.
• ESM (AS)
Carotid arteries.
Murmurs (cont.)
1.
2.
3.
4.
5.
Timing.
Intensity.
Area of greatest intensity.
Propagation.
Effect of certain maneuvers.
Effect of certain maneuvers
•
•
•
•
Respiration.
Valsalva maneuver.
Squatting.
Isometric exercise.
Manoeuvre
Lesion
MVP
AS
MR
Valsalva
(dec.
preload)
Longer
Softer
Softer
Squatting or
leg raise
(inc. preload)
Shorter
Louder
Louder
Hand grip
(inc.
afterload)
Shorter
Shorter
Louder
Be professional.
Treat the pt.
as one of
your
relatives.
Practice,
practice,
practice, and
read