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Auscultation
21
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Page 1: Auscultation

AuscultationAuscultation

Page 2: Auscultation

AuscultationAuscultation

• 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

Page 3: Auscultation

AuscultationAuscultation

• 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

Page 4: 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

AuscultationAuscultation

Page 5: Auscultation

Characteristics of a “functional” murmurCharacteristics of a

“functional” murmur

• Short and soft SEM

• Normal S1 and S2

• Normal cardiac impulse

• No evidence for any hemodynamic abnormality

Page 6: Auscultation

AuscultationAuscultation

• 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

Page 7: 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

AuscultationAuscultation

Page 8: Auscultation

Assessing Murmurs Assessing Murmurs

Grading of Murmurs:Grade 1 - only a staff man can

hearGrade 2 - audible to a residentGrade 3 - audible to a medical

studentGrade 4 - associated with a

thrill or palpable heart soundGrade 5 - audible with the

stethoscope partially off the chest

Grade 6 - audible at the bed-side

Functional Murmur:• short and soft SEM• Normal S1 and S2• Normal cardiac

impulse• No evidence for

hemodynamic abnormality

Page 9: Auscultation

Innocent MurmursInnocent Murmurs

• Common in asymptomatic adults• Characterized by

– Grade I – II @ LSB

– Systolic ejection pattern

– Normal intensity & splitting of second sound (S2)

– No other abnormal sounds or murmurs

– No evidence of LVH, and no with Valsalva

S1 S2

Page 10: Auscultation

Common Murmurs and Timing (click on murmur to play)

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

Page 11: Auscultation

AuscultationAuscultation

“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

Page 12: Auscultation

AuscultationAuscultation

“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

Page 13: Auscultation

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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

Page 14: Auscultation

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Left Sternal Border

• Listen for early diastolic murmurs (AR/PR)

• Press firmly with diaphragm

• Listen upright with forced expiration

• Listen on hands and knees

Page 15: Auscultation

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“Mitral Area” (LLSB)• Listen for intensity of S1

– Soft-LV dysfunction, first degree heart block, pre-closure 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

Page 16: Auscultation

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“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

Page 17: Auscultation

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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

Page 18: Auscultation

Auscultation-Timing of A2 to OS Interval

Auscultation-Timing of A2 to OS Interval

Say Timing seconds

Severity of MS

Other HS’s

Prrr 0.06 Severe

Pada .07-.08 Mod-severe

Pata .08-.09 Mod

Papa 0.10 Mild PK 0.1-0.110

Tu-huh

.12 A2-S3 0.12-0.18

Page 19: Auscultation

Clinical Signs of LV Dysfunction

Clinical Signs of LV Dysfunction

• Hypotension• Pulsus alternans• Reduced volume

carotid• LV apical

enlargement/displacement

• Sustained apex - to S2

• Soft S1• Paradoxically split S2• S3 gallop

(not S4 = impaired LV compliance)

• Mitral regurgitation• Pulmonary congestion

– rales

Page 20: Auscultation

Clinical Signs of RV Dysfunction

Clinical Signs of RV Dysfunction

• With Pulmonary HPT– Loud P2/palpable

– PR murmer

– RV lift

• Common

findings

• Without Pulmonary HPT– Soft P2

– No PR

– +/- RV lift

RV S4 TR CV wave

RV S3 murmer

JVP A wave Pulsatile liver

+ HJR Edema

+ Kussmaul’s

Page 21: Auscultation

Causes of RV Dysfunction

Causes of RV Dysfunction

• LV failure• Pulmonary HPT

– 1– 2

• RV infarction• Pericardial Disease

– tamponade– constriction