Transcript Auscultation - Continuing Medical Implementation Inc.

Auscultation
Auscultation
• By the time you listen, you should know
what to hear
• If you don’t hear what you expect, explain it
• Don’t leave the bedside till you know what
you are hearing
• Never auscultate from the wrong side of the
bed
Auscultation
• Use the diaphragm for high pitched sounds and
murmurs
• Use the bell for low pitched sounds and murmurs
• Sequence of auscultation
–
–
–
–
–
–
upper right sternal border (URSB)
upper left sternal border (ULSB)
lower left sternal border (LLSB)
apex
apex - left lateral decubitus position
lower left sternal border (LLSB)- sitting, leaning
forward, held expiration
Auscultation
Grading of Murmurs:
Grade 1 - only a staff man can hear
Grade 2 - audible to a resident
Grade 3 - audible to a medical student
Grade 4 - associated with a thrill or palpable heart sound
Grade 5 - audible with the stethoscope partially off the
chest
Grade 6 - audible at the bed-side
Characteristics of a
“functional” murmur
•
•
•
•
Short and soft SEM
Normal S1 and S2
Normal cardiac impulse
No evidence for any hemodynamic
abnormality
Auscultation
• Use the diaphragm for high pitched sounds and
murmurs
• Use the bell for low pitched sounds and murmurs
• Sequence of auscultation
–
–
–
–
–
–
upper right sternal border (URSB)
upper left sternal border (ULSB)
lower left sternal border (LLSB)
apex
apex - left lateral decubitus position
lower left sternal border (LLSB)- sitting, leaning
forward, held expiration
Auscultation
Grading of Murmurs:
Grade 1 - only a staff man can hear
Grade 2 - audible to a resident
Grade 3 - audible to a medical student
Grade 4 - associated with a thrill or palpable heart sound
Grade 5 - audible with the stethoscope partially off the
chest
Grade 6 - audible at the bed-side
Assessing Murmurs
Grading of Murmurs:
Grade 1 - only a staff man can
hear
Grade 2 - audible to a resident
Grade 3 - audible to a medical
student
Grade 4 - associated with a
thrill or palpable heart
sound
Grade 5 - audible with the
stethoscope partially off the
chest
Grade 6 - audible at the bedside
Functional Murmur:
• short and soft SEM
• Normal S1 and S2
• Normal cardiac
impulse
• No evidence for
hemodynamic
abnormality
Innocent Murmurs
• Common in asymptomatic adults
• Characterized by
– Grade I – II @ LSB
– Systolic ejection pattern
S1
S2
– Normal intensity & splitting of second sound (S2)
– No other abnormal sounds or murmurs
– No evidence of LVH, and no  with Valsalva
Common Murmurs and
Timing (click on murmur to play)
Systolic Murmurs
• Aortic stenosis
• Mitral insufficiency
• Mitral valve prolapse
• Tricuspid insufficiency
Diastolic Murmurs
• Aortic insufficiency
• Mitral stenosis
S1
S2
S1
Auscultation
“Aortic area”
• 2nd left intercostal space (URSB)
– compare S1 to S2-S1 should be softer. If the same,
think Mitral Stenosis
– identify ejection murmur-time the peak intensity in
relation to systole
– identify ejection click if present
Auscultation
“Pulmonary Area”
• 2nd right intercostal space (ULSB)
– listen for split S2 (A2/P2)
– identify the intensities of A2 and P2
– time split S2 with respiration
–
–
–
–
normally widens with inspiration, closes with expiration
wide split S2-RBBB, RV volume overload,PS, RV failure
wide fixed split = ASD
paradoxical split = LBBB, severe AS, severe LV
dysfunction, pacemaker
Auscultation
Differential diagnosis of
split S2
• A2/P2
• A2/Pericardial knock
• A2/OS
Sometimes 3
components heard
• A2/P2/OS
• A2/P2/PK
Exclude S3
• Lower pitched
• Heard with bell
• At apex
• In left decubitus
position
Auscultation
Left Sternal Border
• Listen for early diastolic murmurs (AR/PR)
• Press firmly with diaphragm
• Listen upright with forced expiration
• Listen on hands and knees
Auscultation
“Mitral Area” (LLSB)
• Listen for intensity of S1
– Soft-LV dysfunction, first degree heart block, preclosure with sudden severe AR/MR
– Loud-MS, sympathetic stimulation
– Variable- Complete heart block with AV dissociation,
Wenkebach
• Identify splitting of S1
– M1/T1, M1/EC(aortic or pulmonary) , M1/Non-EC
(MVP), S4/M1
Auscultation
“Mitral Area” (LLSB)
• Identify quality,timing and intensity of
systolic murmurs
– ejection quality
vs regurgitant
quality
– pansystolic vs early or mid to late
systolic murmer
Auscultation
Apex
– Listen for S3
and S4
– Consider differential diagnosis of S3
• A2-wide P2, A2-OS, A2-PK, A2-S3
– Identify diastolic rumble
– Determine radiation of murmur e.g.. MR to
axilla
AuscultationTiming of A2 to OS Interval
Say
Prrr
Timing Severity Other
seconds of MS HS’s
 0.06 Severe
Pada
.07-.08
Pata
.08-.09
Modsevere
Mod
Papa
 0.10
Mild
Tuhuh
 .12
PK
0.1-0.110
A2-S3
0.12-0.18
Clinical Signs of LV
Dysfunction
• Hypotension
• Pulsus alternans
• Reduced volume
carotid
• LV apical
enlargement/displace
ment
• Sustained apex - to S2
• Soft S1
• Paradoxically split S2
• S3 gallop
(not S4 = impaired
LV compliance)
• Mitral regurgitation
• Pulmonary congestion
– rales
Clinical Signs of RV
Dysfunction
• With Pulmonary HPT
– Loud P2/palpable
– PR murmer
– RV lift
• Common
findings
RV S4
RV S3
• Without Pulmonary HPT
– Soft P2
– No PR
– +/- RV lift
TR  CV wave
murmer
 JVP A wave
Pulsatile liver
+ HJR
Edema
+ Kussmaul’s
Causes of RV
Dysfunction
• LV failure
• Pulmonary HPT
– 1
– 2
• RV infarction
• Pericardial Disease
– tamponade
– constriction