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)

Closure of M + T valves.

Beginning of ventricular systole.

Second Heart Sound (S2)

Closure of A + P valves. ( A P)

End of ventricular systole.

Splitting of the S2.

Timing..…

Abnormalities of the Heart Sounds

1. Alteration in Intensity.2. Splitting.3. Extra Heart Sounds.4. Additional Sounds.5. Murmurs.

Abnormalities of the Heart Sounds

1. Alteration in Intensity.2. Splitting.3. Extra Heart Sounds.4. Additional Sounds.5. Murmurs.

Abnormalities of the Heart Sounds

1. Alteration in Intensity.2. Splitting.3. Extra Heart Sounds.4. Additional Sounds.5. 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 one-third 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. Alteration in Intensity.2. Splitting.3. Extra Heart Sounds.4. Additional Sounds.5. Murmurs.

1. Opening snap.2. Systolic ejection click3. Prosthetic heart valves.4. 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. Alteration in Intensity.2. Splitting.3. Extra Heart Sounds.4. Additional Sounds.5. Murmurs.

Murmurs

1. Timing.2. Intensity.3. Area of greatest intensity.4. Propagation.5. 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. Timing.2. Intensity.3. Area of greatest intensity.4. Propagation.5. 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. Timing.2. Intensity.3. Area of greatest intensity.4. Propagation.5. Effect of certain maneuvers.

Murmurs (cont.)

1. Timing.2. Intensity.3. Area of greatest intensity.4. Propagation.5. Effect of certain maneuvers.

Propagation

• PSM (MR) Lt axilla.

• PSM (VSD) Rt sternal edge.

• ESM (AS) Carotid arteries.

Murmurs (cont.)

1. Timing.2. Intensity.3. Area of greatest intensity.4. Propagation.5. 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