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2. The Stethoscope
The Bell
The Diaphragm
o
used for analyzing the second heart sound, ejection and midsystolic
clicks and for the soft but high-pitched early diastolic murmur of aortic
regurgitation
3. Positioning
Patients can be examined while lying supine, in the left lateral decubitus
position, sitting, and leaning forward.
4. Listening Posts
5. Cardiac Cycle
6. Systolic vs. Diastolic systole S1 S2 diastole
7. Gallops systole S1 S2 S4 S3 diastole
8. S1 (lubb)
The 1st heart sound, marks the beginning of systole (end of diastole).
The first heart sound can usually be heard easily with both the bell and the diaphragm
9. Abnormal S1
Loud First Heart Sound
Mitral stenosis
Tachycardia
long PR interval
Atrial fibrillation
10. S2 (dub)
The 2nd heart sound, marks the end of systole (beginning of diastole).
For the second heart sound the diaphragm is invaluable, with the stethoscope usually
best placed at the base
11. Abnormal S2
Loud Second Heart Sound (aortic)
Systemic hypertension
Pulmonary hypertension
S3 is low frequency and thus best heard with the bell of the stethoscope at the apex
while the patient is in the left lateral decubitus position. .
13. S4 Heart Sound
Low frequency sound in late diastole
Seen in patients with stiffened left ventricles, resulting from conditions such as
hypertension, aortic stenosis, ischemic or hypertrophic cardiomyopathy, acute
MI.
Blood flow through a valve normally open in systole but abnormally narrowed
(e.g. aortic or pulmonary). Stenosis
Increased blood flow through a normal valve High flow states like pregnancy,
fever, anemia, hypothyroidism
mitral regurgitation
Blowing or Grating?
Open or Closed?
19. Murmurs 1 2 3
Systolic or Diastolic?
Blowing or Grating?
Open or Closed?
Systolic What is it? (Whats my Aortic Valve doing?) Grating Open AORTIC
STENOSIS
20. Murmurs 1 2 3
Systolic or Diastolic?
Blowing or Grating?
Open or Closed?
Systolic What is it? (Whats my Aortic Valve doing?) Blowing Closed MITRAL
INSUFFICIENCY
21. Murmurs 1 2 3
Systolic or Diastolic?
Blowing or Grating?
Open or Closed?
Diastolic What is it? (Whats my Aortic Valve doing?) Blowing Closed AORTIC
INSUFFICIENCY
22. Murmurs 1 2 3
Systolic or Diastolic?
Blowing or Grating?
Open or Closed?
Diastolic What is it? (Whats my Aortic Valve doing?) Grating Open MITRAL
STENOSIS
23. Systolic Murmurs
Valvular
Mitral regurgitation
Tricuspid regurgitation
Aortic stenosis
Pulmonic stenosis
Nonvalvular
o
PDA
VSD
plateau shaped
little radiation
heard best over the aortic area or right second intercostal space
radiation into the right neck. This radiation is such a sensitive finding
that its absence should cause the physician to question the diagnosis of
aortic stenosis.
This murmur is best heard over the upper left sternal edge, associated with a
thrill, and is characteristically continuous and machinery-like
It is usually best heard over the tricuspid area, or the lower left sternal border,
with radiation to the right lower sternal border because this is the area which
overlies the defect.
This murmur is best heard over the pulmonic area of the chest, and may
radiate into the back
Aortic regurgitation
Pulmonic regurgitation
mitral stenosis
tricuspid stenosis
Nonvalvular
o
PDA
low pitched, decrescendo pattern, quiet to loud with thrill, rough, rumble
quality
Tricuspid stenosis
o
Pulmonic regurgitation
o
These can sound alike but only aortic regurgitation will be associated with a bounding
arterial pulseswater hammer pulse brisk femoral pulsation
34. Pericardial Friction Rub
Caused by the beating of the heart against an inflamed pericardium or lung
pleura, which itself has a wide variety of etiologies.
This sound is usually continuous, and heard diffusely over the chest.
If the rub completely disappears when the patient holds his breath it is more
likely due to pleural, not pericardial, origin.
35. Intensity of Murmurs Murmur Grades Grade Volume Thrill 1/6 very faint, only
heard with optimal conditions no 2/6 loud enough to be obvious no 3/6 louder than
grade 2 no 4/6 louder than grade 3 yes 5/6 heard with the stethoscope partially off the
chest yes 6/6 heard with the stethoscope completely off the chest yes
http://www.med.ucla.edu/wilkes/Systolic.htm
http://www.medstudents.com.br/cardio/heartsounds/heartsou.htm
http://www.uni-duesseldorf.de/WWW/MedFak/Herz-KreislaufPhysiologie/lehre/sounds/intro.html
38. Now you have a whole new meaning to the phrase listen to your heart.