Auscultation of the Heart

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Auscultation of the Heart

• Amit Shah, M.D.

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Overview

• Physical Examination Technique
• Heart sounds
• Murmurs
• Build your own murmur
• Your turn!

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Examination

• Observation
• Position
• Lean forward or LLD
• Palpation
• Feel the PMI and for a thrill or heave
• Examine the carotid and feel the systole/diastole
• Percussion
• Yeah right
• Auscultation

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Methods

• Classic location
• Aortic 2nd/3rd Rt ICS
• Pulmonic 2nd/3rd LT ICS
• Tricuspid LLSB
• Mitral Apex

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Classic locations
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Maneuvers

• Inspiration/Expiration
• Increase with Inspiration rIght sided
• Increase with Expiration lEft sided
• Valsalva drops preload
• Decreases all murmurs EXCEPT
• MVP HOCM
• Handgrip Increases SVR
• more flow AWAY from aortic valve

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Heart Sounds
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Sounds

• S1
• Closing of Mitral and Tricuspid valves
• S2
• Aortic then Pulmonic valves closure
• FIXED SPLIT ASD
• WIDE SPLIT RBBB or PS
• PARADOXICAL SPLIT LBBB or Severe AS

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Extra Sounds

• S3
• Due to tensing of chordea tendinae with expansion
  of LV
• Indicates volume overload/ DILATION
• Occurs IMMEDIATELY after S2 3 part S2
• S4
• Atrial contraction against STIFF VENTRICLE
• Occurs Before S1 sounds like split S1
• ALWAYS ABSENT ----
• A. Fib (no atrial kick)

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Murmurs

• Systolic vs Diastolic
• Diastolic ALWAYS ABNORMAL
• FEEL THE CAROTID
• Think of when blood is flowing!
• Maximal location
• Maneuvers
• Inspiration/Expiration
• Valsalva
• Handgrip
• Radiation where does the blood flow
• Grade
• gt 4 has a thrill
• Quality cred/decred vs holo vs rumble

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Murmurs

• 4 Valves
• 2 Potential murmurs
• Stenosis
• Regurge
• 8 total potential murmurs to learn
• Other
• ASD
• VSD
• PDA

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Build your own Murmur

• Aortic Stenosis
• Systolic/diastolic?
• Systolic
• Location
• R 2nd ICS
• Radiation -gt carotids
• Maneuvers
• Louder with Inspiration or Expiration?
• Expiration
• Louder with Valsalva?
• No
• Louder with Handgrip?
• No
• Quality
• Cresendo/decresendo
• ASC Aortic Stenosis Complications or
• Angina (5 year), Syncope (3 years), CHF (2 year)
• Fix to curemore important than most any other
  surg

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Key Points

• Inspiration increase rIght sided murmurs
• Expiration increases lEft sided murmurs
• All murmurs decrease with Valsalva XCPT
• HOCM MVP
• Differentiate w/ handgrip (HCMHandgrip Contracts
  Murmur)
• ALL DIASTOLIC MURMURS ARE ABN