#HEART_LOCATIONS_FOR_AUSCULTATION
Aortic sound location
2nd R intercostal space
Pulmonic sound location
2nd L intercostal space
Tricuspid sound location
Lower L sternal border (4th or 5th space)
Mitral sound location
Apex (usually 5th intercostal space, loudest sound)
Erb’s point sound location
Between pulmonic and tricuspid. (Listen here first, if you hear something weird go to other locations)
Best placement of pt for listening to heart sounds?
Listening to the heart can be helped by having the patient sit up and lean forward, or having the patient roll to the left side.
Main valve sizes
Aortic is smallest. Pulmonic is the 2nd smallest. Mitral is the 2nd largest, and tricuspid is the largest.
Additional sounds during systole are
Valvular sounds
Additional sounds during diastole are
Wall sounds
S1 (Lub)
Closing of mitral valve and tricuspid valve aka the beginning of systole. (mitral valve slightly precedes tricuspid; just know that the pressure during systole in the LV is much greater than in the R so you can predict that the mitral valve closes first.) Heart makes this sound when the pressure of blood outside the heart during contraction is greater than the pressure inside the atrium. This pressure differential causes the valves to close quickly.
S2 (Dub)
Closing of aortic and pulmonary valves. (Aortic just before pulmonary). The ventricles continue to contract during systole. When the mm begins to relax and the pressures inside the heart drop below those of the pressures in the aorta and the artery to the lungs, blood flows in to make the valves close again. When those valves close, we heart the second sound.
A splitting of the sound means
the valves aren’t synchronized
Gallop
Having and S3 or S4 or both. This results in sound patterns that resemble a running horse.
Murmur
A low or high pitched sound lasting longer than normal sounds - usually created by turbulent blood flow through abnormal valves or openings. Can be systolic (before dub) or diastolic (after dub). Graded I-VI according to audibility. They’re most often caused by a stiffened valve that leaves only a narrow passage for blood to get through, or by a weak, floppy valve that allows blood to backflow. A murmur can also be caused by blood flowing turbulently through a hole in the septal wall. Heard loudest over the area affected i.e. mitral insufficiency over the apex, while pulmonic valve stenosis over the 2nd intercostal space.
Bruit
Turbulent blood flow through abnormal vessels other than the heart. [same as murmur, but murmurs are by definition only in the heart]
S3
3rd sound or “ventricular gallop.” Low in volume & frequency (pitch). Hear in the early disatolic period and is normal in children. Adults >35 it indicates CHF. NOT caused by valves, created by sudden tensing of the ventricular WALL. Best heart with the bell of the stethoscope on the apex of the heart. Helps to have the pt hold their breath, or supine or in left side-lying. It’s created when the ventricles relax and pressure from the filling blood rapidly distends the ventricle. When the stiff, non-complient ventricular wall reaches its physical limits, it suddenly tenses, and the sound is created.
S4
4th heart sound or “atrial gallop”. Low in volume and frequency. Heard in the early end-diastolic period. Can indicate HTN, CAD, or AMI [a WALL sound]. Best heard over the apex. Is heard late in diastole, just prior to S1. The presence of it creates a rhythm that sounds like the word Ten-nes-see. Here, it represents the “Ten,” S1 represents “nes,” and S2 carries the accent on the syllable “see.” It’s caused when stiff and over-distended ventricles are forced to accept blood from the atria during late diastole, when the atria exert their final squeeze, called the atrial kick.
Murmur Grades
slide 11, too lazy to type it all
Assessment of Venous Pressure
Pt inclinde 45 deg, relaxed (HR <100 bpm). ID jugular pulse wave w/ pen light. Measure heigh of wave above angle of Louis. Add 5 cm to value. <8 is normal.
Kussmaul’s Sign
rise in JVP with inspiration
Efficacy in CHF diagnosis
JVD alone: 17% sn, 98% sp. JVD with Hepatojugular reflex (provocative): 33% sn, 94% sp.
Aortic Stenosis
Systolic Ejection Murmur. Narrowing of valve [doesn’t open all the way, heart has to work harder to pump bld to the body]. Etiology: Congenital (most common in young), rheumatic heart disease, calcification in persons > 70 years. Symptoms: fainting w/ exertion, awaken at night w/ SOB, angina.
Mitral Valve Prolapse
Systolic murmur. Leakly L chamber valve with blood regurgitation [abnormal bulging of the valve when the heart contracts]. High risk: males > 50, HTN, Marfan Syndrome. Symptoms: cough, fatigue, rapid heart rate.
Austin Flint Murmur
Diastolic Murmur. Aortic valve regurgitation. Two columns of blood. L atrium to ventricle & L aorta to ventricle.
Austin Flint vs Mitral Stenosis
Austin Flint murmur is an apical diastolic rumbling murmur in patients with pure aortic regurgitation. Can be mistaken with the murmur in mitral stenosis and should be noted by the fact that an Austin Flint murmur does not have an opening snap that is found in mitral stenosis.
Friction Rub w/ Pericarditis
Systolic, Early & Late Diastolic sounds. Increased fluid between heart & surrounding sac. Etiology: CA, surgical accident, autoimmune disease (i.e. RA, lupus), bacterial infection.
5 most important things in pt exams to make a diagnosis
History,
physical,
Electrocardiogram,
x-ray,
lab
Holter Monitor
Electrodes worn for 24 hours during ADLs