Technique: Heart Sounds & Murmurs - University of Washington

Use for mid-diastolic murmur of mitral stenosis or S3 in heart failure. ... Soft holosystolic murmur; Heard best at the LLSB without radiation ...  [HeartSounds&Murmurs]    |  Liver&Ascites    |  NeckVeins    |  Pulmonary    |  Thyroid    Examination   • Techniques • 1st&2ndHeartSounds • 2nd&3rdHeartSounds • ClicksandSnaps • Murmurs • Rubs   • Demonstrations Historical Pathophysiology AssociatedEvaluations   • PatientHX   • PhysicalExam   • Laboratory&Imaging DifferentialDx EvidenceBase • AccuracyinDiagnosisofSystolicMurmurs • AccuracyinDiagnosisofDiastolicMurmurs • AccuracyinDiagnosisofCHF References TeachingTips [SkillModules >> HeartSounds&Murmurs >> Techniques ] Technique:HeartSounds& Murmurs UsingtheStethoscope Amodernstethoscopeconsistsoftwoearpiecesconnectedbytubingtoachestpiecewhichusuallyhasbothdiaphragmandbellattachments.Earpiecesshouldbeangledforwardstomatchthedirectionofthepractitioner'sexternalauditorymeati. Thebellisusedtohearlow-pitchedsounds.Useformid-diastolicmurmurofmitralstenosisorS3inheartfailure. Thediaphragm,byfilteringoutlow-pitchedsounds,highlightshigh-pitchedsounds.Useforanalyzingthesecondheartsound,ejectionandmidsystolicclicksandforthesoftbuthigh-pitchedearlydiastolicmurmurofaorticregurgitation. backtotop PositioningthePatient Patientscanbeexaminedwhilelyingsupine,intheleftlateraldecubitusposition(seepicture)andsitting,leaningforward. Pericardialsoundsaresometimebestheardwiththepatientonhandsandknees. backtotop Examination 1.Auscultatetheheartatvarioussites Attheapex. Atthebase(thepartoftheheartbetweentheapexandthesternum) Intheaorticandpulmonaryareastotherightandleftofthesternum,respectively Listenfornormalheartsounds: The1stheartsound,S1(lub),marksthebeginningofsystole(endofsystole). Relatedtotheclosureofthemitralandtricuspidvalves. Loudestattheapex. The2ndhearsound,S2(dub),markstheendofsystole(beginningofdiastole). Relatedtotheclosureoftheaorticandpulmonicvalves. Loudestatthebase. Youcanrelatetheauscultatoryfindingstothecardiaccyclebysimultaneouslypalpatingthecarotidarterywhilelisteningtotheheart: S1 S2 Justprecedescarotidpulse Followscarotidpulse Louderatapex Louderatbase LowerpitchandlongerthanS2 HigherpitchandshorterthanS2 Becausesystoleisshorterthandiastole: Firstoftwogroupedbeats Secondof2groupedbeats Ifanythingabnormalisfound,movethestethoscopearounduntiltheabnormalityisheardmostclearly. 2.Separatefindingsintosixcategories 1st&2ndHeartSounds 3rd&4thHeartSounds Clicks&Snaps Murmurs Rubs Maneuvers 3.Analyzeeachcategoryindividuallyandthenputittogethertodiagnosistheproblem Category Definition Audioexamples Aorticstenosis: Murmur: Harshlate-peakingcrescendo-decrescendosystolicmurmur Heardbest-left2ndICS Radiationtothecarotids. Possibleassociatedfindings: Abnormalcarotidpulse Diminishedanddelayed("pulsusparvusandtardus") SustainedApicalimpulse CalcifiedaorticvalveonCXR MitralRegurgitation: Murmur: Blowingholosystolicmurmur Heardbestattheapex Radiationtotheaxillaandinferioredgeofleftscapula. Possibleassociatedfindings: S2: widephysiologicsplitting S3 Aorticinsufficiency: Murmur: Softblowingearlydiastolicdecrescendomurmur Heardbestattheleft2ndICSwithoutradiation Mayalsohearsystolicflowmurmuranddiastolicrumble(AustinFlint) Possibleassociatedfindings: Dilatedapicalimpulse Abnormalandcollapsingarterialpulses Tricuspidregurgitation: Murmur: Softholosystolicmurmur HeardbestattheLLSBwithoutradiation Intensityincreaseswithinspirationorpressureoverliver Possibleassociatedfindings: Elevatedneckveins Systolicregurgitantneckvein Systolicretractionofapicalpulse Edema,Ascitesorboth   PulmonicInsufficiency Murmur: Highfrequencyearlydiastolicdecrescendomurmur Heardbestat2nd-3rdICS Increaseswithinspiration Associatedfindings: AbnormalS2 splitting Sustainedpulmonaryhypertension   Pulmonarystenosis Murmur: Harshcrescendo-decrescendosystolicmurmur Heardbeststernalborderbat2ndor3rdintercostalspaces Increaseswithinspiration Associatedfindings: Ejectionsoundsheardatsternaledge,2ndor3rdintercostalspace WidephysiologicalsplittingofS2 ProminentAwaveofthejugularvenouspulse Mitralstenosis Murmur: Lowfrequencyrumblingmid-diastolicmurmur,withpresystoliccomponent possible Heardbestatapex Accentuatedinleftlateraldecubitusposition Associatedfindings: Apicalimpulseabsentorsmall Irregularpulse(atrialfibrillation) LoudS1 ElevatedneckveinswithexaggeratedAwave Hypertrophiccardiomyopathy Murmur: Harshqualitymidsystolicmurmur HeardbestLSB Increaseswithdecreasedvenousreturn Possibleassociatedfindings: Sustainedapicalbeattopalpation S4(50%ofthetime)   backtotop