1. The differential diagnosis of the noise in the heart. Professor A. G
The differential diagnosis of the noise in the heart. Professor A.G. Gadaev

2. Normally, a healthy person Auscultation auscultated 2 tones:
The first tone - the tone (systolic) beginning ventricular systole, in its formation participate tone closure of the mitral and tricuspid valves, the tone of the opening of the valves of the aorta and pulmonary artery, and participates in it a muscular component of the ventricles;
The second tone (diastolic) - the tone of the closing the aortic valve and the pulmonary artery, as well as the tone of the opening of the mitral and tricuspid valves.

3. These two colors are different from each other as follows:
These two colors are different from each other as follows: ?? ● The first tone is longer than the second? ● Compared to the first tone of the second less sonority? ● First tone coincides with the apical impulse pulsing arteries and blood vessels of the neck? ● The first tone is listened better in the cardiac apex and the second tone at its base. ? ● After the first short tones auscultated systolic and diastolic long after the second pause.

4. Auscultation of the heart consists of the topographic location of the auscultation points: 1. The point of listening to the mitral valve to the left in the V intercostal space on cm medially from the mid-clavicular line apex of the heart.? 2. Point Botkin-Erba (auscultation the aortic valve) in the IV intercostal space left parasternal over the front line.? 3. The aorta - in II intercostal space on the right in front paraster-tional line 4?. Pulmonary artery - in II-III intercostal space left parasternal line at the front 4?. Tricuspid valve- at the base of the xiphoid process.? 5. Status of the heart walls -.? In the IV intercostal space in the chest Sometimes in healthy people and adolescents on the heart and its base verhuschke auscultated 3 intermittent tone.

5. DETERMINATION OF NOISE HAS HEART important differential diagnostic value, as their presence often confirms availability heart disease Depending on the time of occurrence of noise, they are divided into systolic and diastolic, the latter is divided into: systolic (appears before systole), mezodiastolichesky (appears before diastole ) and protodiastolic (occurs after diastole).

6. Depending on the type of heart disease and the presence of certain organic noise may change the hearts of the border. ? The ECG marked increase in wave amplitude P (spiky P) for right ventricular hypertrophy in II-III standard lead, with left ventricular hypertrophy increase in P wave amplitude in the I-II standard lead, increase wave amplitude R in III, aVF with right ventricular hypertrophy in V1-2 increase in the amplitude of the R wave in I, aVL, V5-6 deepening of the S-wave, while left ventricular hypertrophy in I, aVL, V5-6 increase in the amplitude of the R in III, aVF, V1-2 deepening wave S.

7. Radiographic picture of the left and right borders of the heart in direct projection
Right heart border:
A top hollow Vienna; B- right atrium.
The left heart border:
A bulging of the aortic arch;
B-pulmonary artery;
B left atrium;
T- left ventricle

8. addition to the above organic noise may occur anatomical
addition to the above organic noise may occur anatomical? Changes in valvular heart cavities and in which noise can be detected parakardialnae. ? Functional noises often systolic and well listened to the apex of the heart, they are fickle and short on character. They are not transmitted to the neck vessels, weaken or disappear during exercise. They are associated with degenerative lesions of the myocardium. Some teens systolic murmur auscultated in the period of intensive growth.

9. In the dry pericarditis usually auscultated rough systolic murmur noise pericardial friction in systole and well heard when pressing stethoscope on the chest, he was not transferred to the vessels of the neck and hair resembles the noise of friction. Pericarditis is a clinical symptom or complication of any disease. The correct diagnosis in addition to the presence of noise and basic clinical data of great importance ECG diagnostics.

13. ● When a systolic murmur in a patient, if there is no history of symptoms and objective data of rheumatism, as well as signs of left ventricular hypertrophy on electrocardiogram and echocardiogram, then soft and nezvuchnye timbre noise is functional. ? ● If with systolic murmur patient has palpitations, shortness of breath and shortness of breath on exertion or at rest, he complains of a dull pain in the heart, objectively seen from apical impulse lifts, amplified, shifted to the left, it is the signs of mitral insufficiency .

14. At the same heart defects systolic murmur gradually or rapidly growing, it can be soft or rough and is held in the armpit. ? Thus, there is a weakening of heart apex tone 1, tone 3 times appearance and emphasis auscultated 2 tones to the pulmonary artery. ? The ECG: signs of left ventricular hypertrophy and left atrial overload X-ray diffraction:.? Signs of hypertrophy of the left atrium and the left ventricle, with the progression of the disease expansion of the right ventricle to the stagnation in the lungs and a decrease in the aortic arch.

15. The presence of diastolic heart noise on top of a sign of mitral stenosis. ? Auscultation auscultated at the top and the diastolic presystolic noise, clapping I tone, with the noise of opening of the mitral valve, and forked II tone with emphasis on pulmonary artery. ? The ECG: signs GPZH and left atrium with symptoms of atrial fibrillation. ? X-ray diffraction is characterized by the expansion of the left atrium and the right ventricle, contrast esophagus deflected in an arc of small radius. ? On echocardiography: is determined by the degree of narrowing of the mitral orifice (normally 4-6 cm2). The restriction to cm2 is an indication for emergency heart surgeon consultation.

16. If the patient is auscultated systolic and diastolic murmur at the same time, it indicates the presence of him as mitral regurgitation or stenosis. ? If a child is listened to the apex of the heart and diastolic murmur in II-III intercostal space left from sternum systolic murmur, then this indicates the presence of congenital (CHD), mitral stenosis and atrial defect dammed (Lyutenbashe syndrome).

18. If at the point Botkin-Erba auscultated rough and enhanced systolic murmur, you can think about the presence of CHD, mainly of ventricular septal defect, tetralogy of Fallot, or pentad. ? If there is a sonorous and rough pansystolic noise emphasis II tone of the aorta, shortness of breath on exertion, shortness of breath, fatigue, pain in the heart and history of recurrent pneumonia, and when viewed from the detection of expansion right heart border with systolic trembling and heart hump can think of ventricular septal defect.? The ECG and X-ray determined by the signs of hypertrophy of the left and right ventricle, and atroventrikulyarnaya blockade.

19. Depending on the location of the defect defects are divided into several types: defect in the bottom of the IVS; upper and lower defect (Tolochinova disease - Roger); defect in the top of the right-hand position of the aorta (Eisenmenger complex). After the GP echocardiography can detect the presence of evil. Such patients are sent for consultation to the heart surgeon and indications are assigned to cardiac catheterization and other studies in the specialized agencies. Treatment - surgery

20. Signs notebook or pentad Fallot is the presence of: systolic murmur at Botkin-Erb and in II - III intercostal space left of the sternum, I gain tone at the top, the weakening II tone on the pulmonary artery, diffuse cyanosis, and asthma attacks. Tetralogy of Fallot is characterized by pulmonary artery stenosis, VSD, right-hand position of the aortic arch, a sharp right ventricular hypertrophy, when pentad Fallot + ASD.

21. Most often they are in a position embracing his knees (on the "squatting"), they have a shortness of breath at the slightest exertion, attacks of breathlessness and cyanosis .. Objective: the lag in physical development, diffuse cyanosis, fingers as drumsticks, and having a heart hump offset borders of the heart to the right. ? The ECG hypertrophy of the right atrium and right ventricle, signs of overload of the right atrium, the configuration of X-ray aortalnayaya heart, increase the right ventricle and the pulmonary pattern impoverishment. The diagnosis is confirmed by echocardiography.

23. The main symptoms of aortic insufficiency - diastolic murmur at the point Botkin -Erba and in II intercostal space to the right of the sternum (sometimes presystolic noise Flint), here at the aorta due to the relative aortic stenosis extra systolic murmur at the apex as a result of the relative failure of the mitral valve decreasing systolic noise attenuation I tone at the top, II of tone of the aorta and the presence of dual tone Duroziez on large vessels.

24. Ripple large vessels, capillary pulse, raises the apical impulse, shifting borders of the heart down and left. Systolic blood pressure is normal, while the diastolic low, there is a correspondingly high pulse pressure. The ECG left ventricular hypertrophy and overload, aortic configuration of the X-ray of the heart, increased left heart, increasing the ascending aorta. Fluoroscopically visible deep and rapid pulsation of the left ventricle and the aorta. The diagnosis is confirmed by echocardiography.

25. If along with the systolic and diastolic noise at Botkin-Erb, wired rough systolic murmur in the aorta, carotid arteries, in the interscapular region, neck cavities, it is possible to think about the insufficiency of aortic valve with a narrowing of the aorta.

26. In the presence of the patient's pulmonary artery stenosis in II intercostal space left of the sternum is listened rough systolic murmur. ? The ECG will be signs of right ventricular hypertrophy and blockade of CBH. ? X-ray diffraction spot observed changes in arterial narrowing. If the constriction is located near the pulmonary valve, there is a sharp increase in the right ventricle, pulmonary artery trunk extension, and its bulging with a sharp narrowing of the smaller of its branches, as well as the depletion of the lung pattern. If the constriction is located under the valves of the pulmonary artery, observed lengthening of the left pulmonary artery, at the location of the narrowing of the entire length of the pulmonary trunk - increased pulmonary pattern, and the left on the contrary depletion pattern.

28. If a patient with systolic murmur marked difference in blood pressure on the upper and lower limbs can be assumed coarctation of the aorta. Sometimes the noise is performed on the neck vessels, and interscapular region. II tone of the aorta strengthened. An objective examination, palpation, percussion there is a difference in the pulse of the upper and lower torso, seen pulsating collaterals on the ribs, sternum and armpit, as well as above the presence of blood pressure on the upper limbs and lower absence. On EKGpriznaki left ventricular hypertrophy, the increase in X-ray left heart border expansion of the aorta. In the outpatient setting is needed to confirm the diagnosis echo-Doppler.

29. If at the same blood pressure in the arms and legs, lower systolic noise on the ECG, there are signs of right ventricular hypertrophy and CBH blockade, it is possible to suspect an atrial septal defect or anomalous pulmonary veins. In atrial septal defect blood from the left side to the right and enters the cause of right ventricular hypertrophy, and stagnation in the pulmonary circulation. In the anomalous pulmonary venous drainage also auscultated systolic murmur over the pulmonary artery. This defect is usually accompanied by an atrial septal defect.

30. At insufficiency of the valves of the pulmonary artery diastolic murmur auscultated in II -III intercostal space at the left sternal border. Auscultation diastolic murmur is heard along with the emphasis II tone on the pulmonary artery. An objective examination noteworthy pronounced cyanosis, in the presence of II -III intercostal space on the left and behind the xiphoid systolic pulsation. The ECG signs of right ventricular hypertrophy and overload, increase in X-ray of the right ventricle, pulmonary artery trunk extension, its bulging and strong pulsation.

31. When listening to the left in the II -III intercostal systolic Malvinas diastolic noise is determined by the signs of the UPU - patent ductus arteriosus (defect aorto-pulmonary artery). The ECG signs of left ventricular hypertrophy, mitral configuration of X-ray of the heart, an increase of the left and right ventricle, left atrial enlargement, aortic widening, lengthening of the left pulmonary artery, its bulging and strong pulsation. Confirm the diagnosis of echocardiography (Doppler). Surgical treatment after aoartografii.

33. Availability epicenter systolic and diastolic noise at the base of the xiphoid process, or a combination thereof directs the presence of openings between the right atrium and right ventricle. If this projection auscultated systolic murmur, then we can think about the tricuspid valve. This defect in itself is rare, and flows by type of complicated mitral insufficiency. Sometimes the noise is listened epicenter of the right or left in the IV-V intercostal space.

34. The ECG hypertrophy of the right atrium and the right ventricle, the blockade right bundle Hiss beam, X-ray mitral heart configuration (often it happens as a result of mitral stenosis), an increase in the right atrium and right ventricle, swelling of the jugular veins. Using echocardiography revealed hemodynamic changes, and with the heart the size of the degree of NK.

35. Diastolic murmur at the base of the xiphoid process is listened when the tricuspid valve stenosis. This creates an obstacle the flow of blood through the narrowed opening between the right atrium and right ventricle, resulting in increased pressure in the right atrium and develop signs of venous stasis in the systemic circulation. Objectively, there is swelling of the neck veins pulsing them during diastole (shishinқirashi), enlargement of the liver, shifting borders of the heart to the right, ascites, edema of the body, the diastolic tremor at the xiphoid process.

36. Sometimes auscultated weakening II tone on the pulmonary artery
Sometimes auscultated weakening II tone on the pulmonary artery. The ECG marked hypertrophy of the right atrium (P-pulmonale), confirmed by X-ray diffraction. Keep in mind that malformations of the mitral and aortic valves are found not only in stenosis of the tricuspid valve, and other vices. Using echocardiography can detect the prevalence of this or any other blemish, and establish the degree of narrowing of the tricuspid orifice.

37. Askultativno in the presence of systolic and diastolic noise at the base of the xiphoid process and the narrowing of the opening between the right atrium and ventricle can be thought of failure 3 flapper valve. There is also an objective examination, the ECG, echocardiography and radiological signs are determined by the two vices

39. If there is noise in the heart and conduct physical examination continue to assign the patient:? ♦ ECG, chest radiography and echocardiography? ♦ If there is acquired heart disease indications for treatment in a hospital. ? ♦ If there are signs of an active process or NC assignment of measures to etiological, pathogenetic Islands symptomatic treatment ;? ♦ Regardless of the type of heart disease treatment of such patients is carried out in specialized surgical wards and hospitals. ? ♦ Remember that timely surgical interventions can save the patient's life.

40. Examples diagnosis of congenital and acquired heart diseases :
Examples diagnosis of congenital and acquired heart diseases :? ♦ Acute rheumatic fever, carditis primary, active phase, activity II. Insufficiency of the mitral valve.? ♦ Acute rheumatic fever, carditis primary, active phase, activity II. Insufficiency of the mitral valve and narrowing aortic NC II FC B. III.? ♦ UPU: the triad of Fallot - atrial septal defect, pulmonary stenosis, right ventricular hypertrophy.? ♦ UPU: patent ductus arteriosus.

41. ♦ Rheumatism active stage. Activity I
♦ Rheumatism active stage. Activity I. Recurrent rheumatic heart disease. Insufficiency of the mitral valve. Revmokardioskleroz with arrhythmia. GEN I class on lawn.? ♦ Chron. rheumatic fever. Return rheumatic heart disease. Insufficiency of the mitral valve. Revmokardioskleroz with arrhythmia. GEN I class on lawn.