Transcript 04_Symptoms and syndromes based on the data of auscultation of a

“Symptoms and syndromes based on
the data of auscultation of a heart"
prof. S.M. Andreychyn
• Method of examination based on listening to sounds
which are created during activity of a heart
• Auscultation may be:
• Direct (immediate).
• Indirect (mediate).
Auscultation of a heart
Auscultation introduced into medical
practice french clinician Rene Laennekom
The first device for auscultation
was a stetoscope
First binaural stethoscope
First phonendoscope
A modern
stethophonendoscope
Auscultative phenomena which are called heart
sounds are created due to vibrations of anatomical
structures of a heart during its activity
Heart valves
The mechanism of formation of heart tones
Formation of heart tone-atrial component of the heart; b-valve
components of I tone; c-components of muscle tone, vascular
components I tone; e-formation second tone; / III toneformation
Heart valves projection on the thorax
Sequence of auscultation
• The mitral valve - at the heart
apex;
• the aortic valve - in the second
intercostal space to the right of
the sternum),
• the pulmonary valve - in the
second intercostal space, to the
left of the sternum,
• tricuspid valve - at the base of
the xyphoid process,
• the aortic valve again at the
Botkin-Erb point.
• Sounds associated with the mitral valve
pathology are well heard when the
patient lies on his left side, since the
heart apex is at its nearest position to the
chest wall.
• Aortic valve defects are best heard when
the patient is in the upright posture or
when he lies on his right side.
• The heart sounds are better heard if the
patient is asked to inhale deeply and
then exhale deeply and keep breath for
short periods of time so that the
respiratory sounds should not interfere
with auscultation of the heart.
Rules for auscultation of the heart.
Each of the four heart valves can best be heard at specific anatomic locations on the
chest wall. While there may be some variation from patient to patient, listen to the
heart beat at each of these areas:
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Aortic (2nd right interspace)
Pulmonic (2nd left interspace)
Tricuspid (Lower left sternal border)
Mitral (Apex)
Standards for cardiac auscultation
Points of auscultation of a heart
Sequence of auscultation
• 1 - The First Heart Sound is simultaneous to the carotid pulse.Its identification is the
first obligate step on cardiac auscultation.
• 2 - The Second Heart Sound must be analyzed,with the membrane of the stethoscope,
at the pulmonary area,where its two components are best identified. Observe its
respiratory variations and splitting.
• 3 - The Third Heart Sound is usually best heard at cardiac apex, in the partial left
lateral decubitus position, with the bell of the stethoscope.
• 4 - The Fourth Heart Sound is best heard with the bell of the stethoscope, at cardiac
apex (left origin) or tricuspid area (right origin).
• 5 - In Systole we can hear early systolic ejection sounds (aortic or pulmonary
stenosis), nonejection mid- to late- systolic clicks (prolapse, extracardiac), and also
holosystolic (mitral or tricuspid regurgitations or interventricular communication),
protomesosystolic ejection (innocent or aortic or pulmonary stenosis) and
mesotelesystolic (prolapse) murmurs.
Basic Rules on Cardiac Auscultation
Scheme of weakening (а) and intensification (б) of both
heart sounds
• I heart sound:
-the valve component, i.e. vibrations of the cusps of the atrioventricula
valves during the isometric contraction phase
-the muscular one due to the myocardial isometric contraction
-the vascular one. This is due to vibrations of the nearest portions of the
aorta and the pulmonary trunk caused by their distention with the blood
during the ejection phase
-atrial one is generated by vibrations caused by atrial contractions
• II heart sound:
The second sound is generated by vibrations arising at the early diastole
when the semilunar cusps of the aortic valve and the pulmonary trunk are
shut (the valve component) and by vibration of the walls at the point of
origination of these vessels (the vascular component).
Differential symptoms of heart tones
Differentiation of І and ІІ heart sounds in tachycardia is
performed by assessment of carotic artery pulsation
• This instructional techniques designed to create optimal
conditions for auscuiltation and detailed analysis of each
of the 4 heart valves.
Special rules auscultation of the heart
• Auscultated in 1-point (the tip of the heart) during breathhold exhale when standing, lying on his back on the left
side.
Mitral valve
Auscultated in the 2nd and 5th spots in breath-hold at
expiration, in standing, lying on his back, on the right
side, sitting with torso forward.
Aortic valve
Listen in 3-point and stood at breath-hold at
expiration in the supine position and on the left
side.
Pulmonary artery valves
• Auscultated in 4-th point in standing, lying on spynii on
the right side with breath-hold at expiration.
Tricuspid valve
• 1. Listening tones. General characteristics of tones: the
sound is normal, loud, relaxed, do not listen.
• 2. Characteristics of the first tone: standard, enhanced,
weakened, bifurcate.
• 3. Characteristics of the second tone: standard, enhanced,
weakened, hoof, no. Give separately for aortic valve (A)
and pulmonary valve (LA).
• 4. Accent II Tone: A tone on the second louder than the
second tone on tone II or LA to LA louder than the
second tone on A.
Analysis of heart sounds
• 1. Norm - And louder tone of the second tone at the top and xiphoid
process.
• 2. Amplification and tone observed in mitral stenosis, thyrotoxicosis.
Tone slapping, resulting from insufficient blood the left ventricle.
• 3. Relaxation - due to deposition of the valve and the weakening of
the muscle components (MN, TN, AN) infarction.
• No - instead I hear the tone systolic murmur. Sometimes in heart
failure, atrial fibrillation.
• 4. Bifurcation and tone: atrioventricular valves are closed
simultaneously.
Characteristics of the first
tone
Weakening of the first tone
• 1. Normal - second tone from the heart for louder and tone.
• 2. weakening - due to a decrease in the mobility of the valve leaflets
of incomplete closing in diastole. Sometimes when defects (AN, PN).
• 3. No - instead the second tone be heard noise. The resulting total
estate valves valves.
• 4. Strengthening second tone of the aorta (second point) - due to
increased blood pressure in a large circulation or sklarozom aortic
wall.
• 5. Strengthening second tone on the pulmonary artery (3rd point) due to hypertension in the pulmonary circulation.
• 6. Splitting of the second tone - a violation of intraventricular
conduction or pidvyshennya pressure in the pulmonary artery.
Characteristics of the second tone
Weakening of the second tone
• 1. Tons of normal volume.
• Cardiac captured without tension at the first hearing apposition
stethoscope listening to a point.
• 2. Strengthening both heart tones.
• Observed at:
• - Weight loss in asthenics;
• - With fever (high temperature);
• - When tereotoksykozi;
• - In mitral stenosis;
• - Anemia;
• - Exertion.
General characteristics of heart tones
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3. Weakening of both heart tones.
For auscultation of heart tones needed to focus and auditory stress.
Observed at:
- Obesity III-IV century.
- The athletes.
- In exudative pericarditis;
- With myocarditis and other diseases of the myocardium;
- In the aortic heart defects;
- With emphysema;
- Vascular insufficiency.
• 5. Additional colors: the third tone, fourth tone TVMK
(II-OS), halopnyy tons (GT).
• 6. Heart Rhythm Tone: binomial (normal), threefold: the
rhythm of quail (IT + + TVMK IIT), gallop (IT + IIT +
GT).
• 7. Heart rhythm: right, extrasystoles, atrial fibrillation,
bradycardia, sinuauricular block, paroxysmal tachycardia.
• 8. Intracardiac murmurs: systolic and diastolic.
Characteristics of each noise: volume, tone, character,
location. implementation, functional, organic.
• 9. Extracardiac murmur: pericardial friction,
kardiopulmonalni, pleuropericardial, vascular.
•Occurs in protodiastoli during the rapid filling of the ventricles with blood
from hitting a large volume of blood flowing in the ventricle, its wall.
•Quiet often intermittent sound, listen over 0.12 s after the second tone.
•Observed in children, adolescents, sporstmeniv at MN Academy
ІII tone
• Occurs before systole during atrial contraction in the active phase of
ventricular filling with blood. Vibrations are caused by ventricular infarction
due to loss of tone.
• Dull, quick sound, listen to systole, like splitting and tone.
• Observed in diseases infarction, heart failure.
ІV tone
• Intensification of S3 or S4 sounds gives a three-sound or even four- threesound rhythm, known as the gallop rhythm (because it resembles the
galloping of a horse). The rrhythm indicates heavy lesions of cardiac muscle
(inflammatory, degenerative, toxic), it is called as " cry of a heart for help".
• The gallop rrhythm is conditionally divides into protodiastolic (intensified
III sound arises up though 0,12-0,2 sec. after second sound),
mesodiastolic(at tachicardia descend coalescence of III and IV sounds and it
is accepted at auscultation as a single sound) and presystolic (is conditioned
by pathological IV cardiac sound).
• Triple rrhythm
(Rhithmus coeturnici)
• The rhythm consists of intensified I sound, II heart sound (weakened) and opening
snap sound
Heart melodies
Triple rhytm
The mitral valve opening sound
• The mitral valve opening sound (opening snup) is heard at the
heart apex of patients with mitral stenosis 0.07-0.13 s
following the second sound, during diastole.
• Extra-pericardial-sound can occur in pericardial adhesion. It
originates during diastole, 0.08-0.14 s after the second sound,
and is generated by the vibrating pericardium during the rapid
dilatation of the ventricles at the beginning of diastole.
• A gallop rhythm refers to a (usually abnormal) rhythm of the heart on
auscultation.[1] It includes three or four sounds,[2] thus resembling the
sounds of a gallop.
• The normal heart rhythm contains two audible heart sounds called S1 and S2
that give the well-known "lub-dub" rhythm; they are caused by the closing of
valves in the heart.
• A gallop rhythm contains another sound, called S3 or S4, dependent upon
where in the cycle this added sound comes.
• It can also contain both of these sounds forming a quadruple gallop, and in
situations of very fast heart rate can produce a summation gallop where S3
and S4 occur so close as to be indistinguishable.
Gallops rhytm
• Intracardial murmurs:
• Organic and functional (relative),
• Systolic and diastolic,
• Ejection and regurgitation murmurs,
• They are also different in character, intensity, duration.
• Extracardial (pericarial friction murmur and pleuropericardial murmur)
Cardiac murmurs
•A. Organic
• - Damage to the valves, chordae, papillary muscles, MN, TN;
• - Narrowing of the aortic orifice (AU) and pulmonary embolism (PS);
• - Perf IBE.
•B. functional
•- Ventricular cavity dilation with the appearance of relative MN, TN;
•- Acceleration of blood flow relative AC, PS;
•- Expansion of the aorta and pulmonary artery.
Systolic murmurs
• A. Organic
• - Damage to valves: aortic (AN), pulmonary (PN);
• - Narrowing of the valve openings: mitral (MS), tricuspid
(TC).
• B. Functional
• - Expansion of the ascending aorta and pulmonary trunk
with the appearance of relative AN and PN.
Diastolic murmurs
The quality of murmurs is hard to define.
Terms such as harsh, blowing, musical,
rumbling, high or low pitched arc used.
• Duration
• The murmurs of mitral (and tricuspid)
regurgitation start simultaneously with the first
heart sound and continue throughout systole
(pansystolic). The ejection systolic murmur of
aortic or pulmonary stenosis begins after the
first heart sound, reaches maximal intensity in
midsystole and stops before the second heart
sound.
• Character and pitch
Properties of murmurs
• At an auscultation it is necessary
to determine:
• 1) relation of murmur to the phase
of cardiac cycle (systole or
diastole);
• 2) properties of murmur, its
character, intensity, duration;
• 3) localization of murmur, i.e.
place of the best auscultation;
• 4) condution of murmur
(irradiation).
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Ejection systolic murmur
Increased flow through normal valves
•'Innocent systolic murmur':
fever
athletes (bradycardia -> large stroke volume)
pregnancy (cardiac output maximum at 15 weeks)
Atrial septal defect (pulmonary flow murmur)
Severe anaemia
Normal or reduced flow though stenotic valve
Aortic stenosis
Pulmonary stenosis
Other causes of flow murmurs
Hypertrophic obstructive cardiomyopathy (obstruction at subvalvular level)
Aortic regurgitation (aortic flow murmur)
Causes of systolic murmurs
• Auscultated best left edge of the relative dullness of the heart;
• Can be combined with noise pleural friction,
• The intensity varies in different phases of breathing becomes stronger
on inspiration.
Pleuropericardial murmur
Phonocardiogram
Thanks you for your attention!