cvs - auscultation

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4. INTRODUCTION
 Auscultation ( based on latin verb auscultare “to listen”) is
listening to the internal sounds of the body
 Usually using a stethescope
 Auscultation is performed for the purpose of examining the
circulatory and respiratory systems (heart and breathe sounds),
as well as the git (bowel sounds)
 The term introduced by Rene theophile hyacinthe laennec in
1816
 Laennecs contribution were refining the procedure, linking
sounds with specific pathological changes in the chest , and
inventing a suitable instrument (the stethescope) in the process
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5.  Dr.DAVID LITTMAN made
several improvement to
improve sound quality and
reduce weight in 1960s
 Originally there was an
distinction between
 immediate
auscultation(unaided)
 mediate auscultation (using
an instrument)
 Auscultation is a skill that
requires substantial clinical
experience , a fine
stethescope and good
listening skills.
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7. AUSCULTATION OF THE HEART AND BLOOD
VESSELS
 Closure of the heart valves
 Movement of the myocardium and great vessels
 Flow of blood into ventricles and across normal and
abnormal valves
 Able to ausultate with the help of stethescope
 Events takes place in the heart are best heard over the
precordium
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8. IMPORTANCE OF STETHESCOPE
The bell and diaphragm of the stethescope accentuate
sounds of different pitches
The bell emphazises low pitched sounds , such as normal
heart sounds eg.diastolic murmur of aortic regurgitation
The diaphragm filters these sounds and helps to identify
high pitched sounds, eg.early diastolic murmur of aortic
regurgitation or pericardial friction rub
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10. GOALS OF AUSCULTATION
The intensity of S1 in all areas
The intensity of S2 in all areas
The characterization of any Systolic
sounds
The characterisation of any Diastolic
sounds
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11. Develop a routine for auscultation and overlook subtle
abnormalities. Identify:
1.The 1st and 2nd heart sounds
2.Extra heart sounds (3rd and 4th , heard in diastole)
3.Additional sounds ,eg. Clicks and snaps
4.Pericardial rub
5.Murmurs in systole or diastole
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12. AUSCULTATORY AREAS OF HEART
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13. AUSCULTATORY AREAS OF HEART
1.MITRAL AREA : Over the area of normal apex beat
( 5th left intercostal space 1.5 cm internal to
the mid clavicular line )
2.TRICUSPID AREA 5th left intercostal space close to the sternum
3.AORTIC AREA 2nd right intercostal space close to the
sternum
4.SECOND AORTIC AREA 3rd left intercostal space close to the sternum
5.PULMONARY AREA 2nd left intercostal space close to the sternum
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14. SURFACE MARKINGS
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15. DIAGRAM
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16. POINTS TO BE NOTED IN
AUSCULTATION
1.HEART SOUNDS
 character
 Intensity
 Rhythm
2.MURMUR
 If present their character , intensity, and propagation
3.RELATIONSHIP OF AUSULTATORY EVENTS WITH THE
RESPIRATORY CYCLE
4.CHANGE WITH ALTERATION IN POSITION OF PATIENT
AND EXCERCISES
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17. NORMAL AUSCULTATORY EVENTS
FIRST HEART
SOUND
By the closure of
mitral and
tricuspid valves
Synchronise with
the end of diastole
and the onset of
ventricular systole
Low
pitched
Resembles the
sound “lub”
Best heard over
mitral area
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18. ABNORMALITIES OF INENSITIES IN FIRST
HEART SOUND
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19. ABNORMALITIES OF INTENSITIES IN FIRST
HEART SOUND
 LOUD Hyperdynamic circulation
Mitral stenosis
Tachycardia
Short P-R interval
Large stroke volume
Atrial myxoma (rare)
 QUEIT Low cardiac output (rest, heart failure)
Severe mitral reflux (caused by destruction of valve )
Long P-R interval (first degree heart block)
Poor left ventricular function
Rheumatic mitral regurgitation
 VARIABLE
INTENSITY
Atrial fibrillation
Complete heart block
extrasystoles
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20. SECOND HEART
SOUND:
By the closures of
aortic and
pulmonary valves
Synchronise with
the end of systole
and ventricular
diastole
Sound is sharp, high
pitched and shorter
in duration.
Resembles the
sound “dub”
Best heard over
aortic area.
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21. SPLITTING OF S2
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22. REVERSED SPLITTING
Aortic stenosis Left bundle branch block
FIXED SPLITTING
Atrial septal defect
SPLIT
WIDENS IN INSPIRATION
(enhanced physiological
splitting )
Right bundle
branch block
Pulmonary
stenosis

23. ABNORMALITIES OF SECOND HEART SOUND
• SYSTEMIC HYPERTENSION
• PULMONARY HYPERTENSION
LOUD
• LOW CARDIAC OUTPUT
• AORTIC STENOSIS
• AORTIC REGURGITATION
QUIET
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24. FIRST HEART SOUND SECOND HEART SOUND
 Cause Vibration of AV valves due to
closure
Vibration of semi lunar valves
due to closure
 Occurance Beginning of ventricular
systole
During early ventricular
diastole and protodiastole
 Coincides with R wave of ecg T wave of ecg
 Nature lub dub
 Duration 0.11-0.17sec longer 0.10-0.14sec shorter
 Frequency 25-45 cycles/sec 50 cycles/sec
 Significance 1.Loudness indicates force of
contraction of heart
2.Clear sound indicates proper
closing of av valves
1.Loudness indicates- blood
pressure
2.Clear sound indicates the
proper closing of semilunar
valve
 Best heard at Mitral area Pulmonary area 24

25. THIRD HEART SOUND
Heard during early
part of diastole
Produced by
rapid inflow of
blood from atria
into the ventricles
Low pitched
Soft sound
Heard at mitral
area and also
medial to it
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26. CAUSES OF THIRD HEART SOUND
1.PHYSIOLOGICAL
Healthy young adults
Pregnancy
Athletes
Fever
2.PATHOLOGICAL
Large, poorly contracting
left ventricle
Mitral regurgitation
Ventricular septal defect
Dialated cardiomyopathy
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27. INTERPRETATION
• In cardiac failure and cardiomyopathy ,
presence of abnormal 3rd heart sound may
denote diastolic dysfunction of the
ventricular myocardium
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28. FOURTH HEART SOUND
Caused by Atrial
contraction
Essential training
needed for this
Soft and low
pitched
Occurs in late
Diastole
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29. INTERPRETATIONS
Fourth heart sound becomes
prominent in conditions like
 Ventricular hypertrophy( due
to htn)
 Cardiomyopathy (out flow
obstruction)
 Positioning the patient on
their left side while you listen
may improve the yeild of this
examination.
 The presence of both s3 and
s4 simultaneously is reffered
as SUMMATION GALLOP.
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30. ADDITIONAL SOUNDS OR HEART
CLICKS
 Opening snap(early
diastole)
Heard in mitral (rarely tricuspid)
stenosis
best heard at apex.just after 2nd heart
sound
 Ejection clicks(early systole) Congenital pulmonary or aortic
stenosis,after 1st heart sound
 Midsystolic clicks (late
systolic murmur)
Mitral valve prolapse
(high pitched and best heard at apex)
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31.  MECHANICAL HEART VALVES:
• Can make a sound when they close and open
• Closure sound is normally louder especially with modern
valves
• High pitched, Metallic, often palpable
• May be heard without a stethescope
• Mechanical mitral valve replacement makes:
• Metallic 1st heart sound, sound like opening snap.
• Mechanical aortic valves:
• Metallic second heart sound
• Opening sound like ejection click.
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33. DESCRIBING A HEART MURMUR
1. TIMING
 Murmers are longer than heart sounds
 It can distinguish by simultaneous palpation of the
carotid arterial pulse
 Systolic, diastolic, continous
2. SHAPE
 Crescendo
 Decrescendo
 Crescendo-decrescendo
 plateau
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34. 3.LOCATION OF MAXIMUM INTENSITY
 Is determined by the site where the murmur originates
 Eg. A,P,T,M listening areas
4.CHARACTER AND PITCH
 Quality of murmur is subjective
 Harsh, blowing, musical , rumbling
5.RADIATION
 Reflects the intensity of the murmur and the direction of
blood flow.
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35. 6. DURATION
• MIDSYSTOLIC MURMUR OR EJECTION MURMUR :Murmur that
start a little while after 1st heart sound, increases in mid systole
and dies out before the 2nd heart sound
• LATE SYSTOLIC MURMUR :If if the murmur occupies in later half
of systole .
• PANSYSTOLIC MURMUR. Murmur commencing with 1st heart
sound and continuing throughout the systole upto the second
sound
• EARLY DIASTOLIC MURMUR:Diastolic murmur that start along
with the 2nd heart sound
• MID DIASTOLIC MURMUR :Murmurs start in mid diastole
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36. 5.INTENSITY AND GRADING OF MURMURS
5.INTENSITY AND GRADING OF MURMURS
GRADE 1 HEARD BY AN EXPERT IN OPTIMUM
CONDITIONS
GRADE 2 HEARD BY NON EXPERT IN
OPTIMUM CONDITIONS
GRADE 3 EASILY HEARD, NO THRILL
GRADE 4 LOUD MURMUR WITH A THRILL
GRADE 5 VERY LOUD OFTEN HEARD OVER
WIDE AREA WITH THRILL.
GRADE 6 EXTREMELY LOUD,HEARD
WITHOUT STETHESCOPE 36

37. SYSTOLIC MURMURS
1.EJECTION SYSTOLIC MURMUR
Increased flow through
normal valves
Innocent murmurs(fever,
athletes,pregnancy)
atrial septal defect(pulmonary flow
murmur)
Severe aneamia
Normal or reduced flow
through stenotic valve
Aortic stenosis
Pulmonary stenosis
Other causes of flow
murmurs
hypertrophic obstructive
cardiomyopathy( obstruction at sub
valvular level)
Aortic regurgitation(aortic flow murmur)
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38. 2.PANSYSTOLIC MURMUR (HOLOSYSTOLIC
MURMURS)
• Caused by a systolic leak from a high to a
lower pressure chamber
• Loud
• Blowing in character
CAUSES
• Mitral regurgitation
• Tricuspid regurgitation
• Ventricular septal defect
• Leaking mitral or tricuspid prosthesis
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39. DIASTOLIC MURMURS
 Almost always indicate heart disease
TWO BASIC TYPES
1.Early decrescendo diastolic murmurs
• Signify regurgitant flow through an incompetent semilunar
valve
Eg. Aortic regurgitation
2.Rumbling diastolic murmurs in mid or late diastole
• Suggest stenosis of an av valve
• Eg. Mitral stenosis 39

40. MID DIASTOLIC MURMUR
• Mainly caused by mitral stenosis
• Low pitched
• Rumbling sound which may follow an opening snap
• best heard with bell of stethescope at the apex with the
patient rolled to the left side.
• Murmur will be more prominent by listening after exercise
• Sounds like “lup-ta-ta-rru” rru mid diastolic murmur
• Austin flint murmur- mid diastolic murmur that accompanies
aortic regurgitation
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41. CONTINOUS MURMURS
• Begin in systole , peak near S2, and continue into all or part
of diastole
1. CERVICAL VENOUS HUM
• Audible in kids, can be abolished by compression over the
ijv
2. MAMMARY SOUFFLE
• Represents augmented arterial flow through engorged
breast
• Becomes audible during late 3 rd trimester and lactation
3. PATENT DUCTUS ARTERIOSUS
• Has a harsh, machinery like quality
4. CORONARY ARTERIO VENOUS FISTULA
5. RUPTURED SINUS OF VALSALVA ANEURYSM
6. AORTIC SEPTAL DEFECT
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43.  PERICARDIAL RUB:
• Heard over the precordium as a leather cracking sound
• Better heard towards the upper part of precordium
• Rub may be coarse/fine and squeaky
• Pressure with stethescope enhances rub
 VENOUS HUM
• Continous sound heard over major veins when blood flow is
increased.
• May be heard over the root of neck (jugular vein) in
anemia,this is known as bruii-de-diable (devils murmur)
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44.  ARTERIAL BRUIT
NORMAL
ARTERIES
BLOOD FLOW
INCREASED
LUMEN
NARROWED
CAROTID
STENOSIS
PRIMARY
THYROTOXI
COSIS
SYSTOLIC BRUIT
NECK-CAROTID
ARTERIES,
VERTEBRAL
ARTERIES
RENAL ARTERY
RENAL ARTERY
STENOSIS
INTERCOSTAL
ARTERY
COARCTATION
OF AORTA
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45. DYNAMIC AUSCULTATION
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46. CARDIAC AUSCULTATION:THE BEST SITES FOR
HEARING ABNORMALITY
Cardiac apex 1st,3rd and 4th heart sounds, mid diastolic murmur of mitral
stenosis, pan systolic murmur of mitral regurgitation, opening
snap of mitral stenosis
Lower left sternal border Early diastolic murmur of aortic regurgitation and pansystolic
murmur of tricuspid regurgitation
Upper left sternal border 2nd HS ,pv murmurs, pansystolic murmur vsd
Upper rt sternal border Systolic ejection (outflow) murmurs , eg. Aortic stenosis,
hypertrophic obstructive cardiomyopathy
Left axilla Radiation of the pansystolic murmur of mitral regurgitation
Below left clavicle Contionous “machinery” murmur of a persistent ductus
arteriosus 46

47. INTERPRETING FINDINGS
1.EXAMINE THIS PATIENT WITH SUDDEN ONSET OF CHEST PAIN
Feel the pulse for
• Bradycardia (heart block)
• Tachycardia (supraventricular tachycardia)
• Irregularity (atrial fibrillation, multiple ventricular
extrasystoles)
• Palpate carotid and femoral pulses
• Measure the bp
• Look for jvp( raised in heart failure)
• Examine the trachea nd cardiac apex beat for mediastinal
beat (tension pneumothorax)
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48. • Palpate the epigastrrium for tenderness
• Gastro oesophageal reflux
• Peptic ulcer
• oesophagitis
• Listen to the heart for extra heart sounds or gallop ( heart
failure)
• Pansystolic murmur radiating to the left axilla ( mitral
regurgitation due to papillary muscle rupture post
myocardial infarction)
• Pansytolic murmur at the left sternal edge (vsd post
myocardial infarction
• Pericardial friction rub (pericarditis)
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49. CONCLUSION
• Cardiac auscultation is a critical part of the clinical examination
and like most skills requires repetition and clinical experience to
make accurate diagnosis.
• Indeed prior to the echocardiography, physicians where
totally reliant on their stethescope and auscultatory skills to
accurately diagnose and characterize cardiac murmurs.
• With advance in technology , there has been considerable
development of traditional stethescope.
• Eg electronic stethescope have ability to amplify the heart
sounds, filter sound frequency and eliminate background noise.
• Technological innovations , such as electronic stethescope,
multimedia applications and patients stimulators are now
available to assist in the teaching of cardiac auscultation.
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50. .
• While technological advancements , such as ecg , may wee
have contributed to the demise of cardiac ausultation,
technology in the form of integrated electronic auscultation
may well revive its place in clinical medicine.
• combined approach , which maintains clinical exposure,
utilising clinical experience , but incorporates technological
innovation to reinforce learning, may be the best way
forward.
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51. RESEARCH ARTICLE
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52. REFERENCES
• Dr Michael swash, Dr michael glynn, hutchinsons clinical methods,
22nd edition , oxford, 2007.pge no; 79-81.
• Dr kv krishnadas , text book of clinical methods and laboratory
investigations, third edition, newdelhi, 2005, page no 191-200.
• Dr kv krishnadas, text book of clinical methods and laboratory, 4th
dition, new delhi,2007,
• Dr Graham douglas, Dr Fiona nicol, Dr Colin robertson, Macleods
clinical examination, 12th edition, oxford, 2009, page no:128-135.
• Dr Douglas . L.mann, Dr Douglas.p.zipes, Dr Peter libby,
robert.o.bonow, dr eugene braunwald, braunwalds heart disease a
textbook of cardiovascular medicine, 10th edition, 2015, pageno:
98-102
• Dr Dennis.l. kasper, Dr Stephen .L.Hauser, Dr Larry jameson,
harrisons principles of internal medicine, 19th edition, 2015, 1442-
1444
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