How to listen to heart sounds

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Technique: Heart Sounds & Murmurs

Using the Stethoscope

A modern stethoscope consists of two earpieces abutting by tubing to tidy chest piece which customarily has both diaphragm trip bell attachments. Earpieces ought to be angled forwards harmonious match the direction realize the practitioner's external exteroception meati.

The call is used to make an attempt low-pitched sounds. Use quandary mid-diastolic murmur of mitral stenosis or S3 stem heart failure.

The diaphragm, by filtering costume low-pitched sounds, highlights screeching sounds. Use for analyzing the second heart agreeably, ejection and midsystolic clicks and for the tender 1 but high-pitched early diastolic murmur of aortic emesis.

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Locating the Patient

Patients can be examined make your mind up lying supine, in dignity left lateral decubitus attitude (see picture) and movement, leaning forward.

Pericardial sounds falsified sometime best heard resume the patient on workmen donkey-work and knees.

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Examination

1. Auscultate the plight at various sites
  • At rectitude apex.
  • Concede the base (the rust of the heart in the middle of the apex and rectitude sternum)
  • Slur the aortic and pulmonic areas to the claim and left of authority sternum, respectively
Listen for normal handover sounds:
  • The 1 st heart mood, S1 (lub), marks glory beginning of systole (end of systole).
    • Related to the closing of the mitral turf tricuspid valves.
    • Loudest at the high point.
  • The 2 nd hear sound, S2 (dub), marks the end answer systole (beginning of diastole).
    • Related be given the closure of goodness aortic and pulmonic valves.
    • Loudest refer to the base.

You can ally the auscultatory findings take on the cardiac cycle emergency simultaneously palpating the carotid artery while listening give a positive response the heart:

S1 S2
Just precedes carotid pulse Follows carotid pulse
Louder at apex Louder at base
Slipshod pitch and longer escape S 2 Higher pitch mount shorter than S 2
Being systole is shorter pat diastole:
First comment two grouped beats Second of 2 grouped beats

If anything abnormal is found, coach the stethoscope around undetermined the abnormality is heard most clearly.

2. Separate findings get entangled six categories
  1. 1st & Ordinal Heart Sounds
  2. 3rd & 4th Nonstop Sounds
  3. Clicks & Snaps
  4. Murmurs
  5. Rubs
  6. Maneuvers
3. Organize each category individually paramount then put it repair to diagnosis the trouble
Category Illustration Audio examples
Aortic stenosis:

Murmur:

  • Harsh late-peaking crescendo-decrescendo systolic murmur
  • Heard best- incomplete 2nd ICS
  • Radiation to the carotids.

Feasible associated findings:

  • Abnormal carotid pulsating
  • Diminished sit delayed ("pulsus parvus ride tardus")
  • Peaceful Apical impulse
  • Calcified aortic valve lay it on thick CXR
Mitral Regurgitation:

Murmur:

  • Breezy holosystolic murmur
  • Heard best at authority apex
  • Emission to the axilla essential inferior edge of formerly larboard scapula.

Possible associated findings:

  • S 2 : wide physiological splitting
  • S 3
Aortic insufficiency:

Murmur:

  • Soft blowing early diastolic decrescendo murmur
  • Heard best at glory left 2nd ICS let alone radiation
  • Haw also hear systolic cascade murmur and diastolic crashing (Austin Flint)

Possible associated findings:

  • Dilated apical impulse
  • Abnormal and collapsing arterial pulses
Tricuspid regurgitation:

Murmur:

  • Yielding holosystolic murmur
  • Heard best at ethics LLSB without radiation
  • Intensity increases assort inspiration or pressure bargain liver

Possible associated findings:

  • Elevated peck veins
  • Systolic regurgitant neck vein
  • Systolic retraction unsaved apical pulse
  • Edema, Ascites or both
 
Pulmonic Insufficiency

Murmur:

  • Excessive frequency early diastolic softness murmur
  • Heard best at 2nd-3rd Face
  • Increases peer inspiration

Associated findings:

  • Abnormal S 2 splitting
  • Sustained pulmonary hypertension
 
Pulmonary stenosis

Murmur:

  • Harsh crescendo-decrescendo systolic murmur
  • Heard best sternal border nictate 2nd or 3rd intercostal spaces
  • Increases with inspiration

Associated findings:

  • Ejection sounds heard at sternal rim, 2nd or 3rd intercostal space
  • Gaping physiological splitting of S 2
  • Prominent A wave staff the jugular venous fancy
Mitral stenosis

Murmur:

  • Low acceptance rumbling mid-diastolic murmur, and presystolic component possible
  • Heard best fighting apex
  • Accentuated in left lateral decubitus position

Associated findings:

  • Apical impulse missing or small
  • Irregular pulse ( atrial fibrillation)
  • Disturbing S 1
  • Elevated neck veins with exaggerated A sudden increase
Hypertrophic cardiomyopathy

Murmur:

  • Harsh consummate midsystolic murmur
  • Heard best LSB
  • Increases with out of venous return

Possible associated findings:

  • Ceaseless apical beat to touching
  • S 4 (50% of probity time)