1. Examination of CVS Auscultation( Heart Sounds )

2. General Considerations

3. (1) A stethoscope with bell + diaphragm

4. (2) The earpieces should fit comfortably and firmly

5. (3) The tubing should be about 25 cm long

6. (4) The tubing should be thick enough to reduce external sounds

7. To start …..

9. What to hear ? First Heart Sound (S1) Closure of M + T valves.
Beginning of ventricular systole.
Second Heart Sound (S2)
Closure of A + P valves. ( A P)
End of ventricular systole.
Splitting of the S2.

10. Timing …..

11. Abnormalities of the Heart Sounds
Alteration in Intensity.
Splitting.
Extra Heart Sounds.
Additional Sounds.
Murmurs.

12. S1 * Prolonged dias. filling (1st degree block). * MS + TS
* Red. diast. filling (HTN)
* Prolonged dias. filling (1st degree block).
* Delayed onset of sys. (LBBB).
* MR S1

13. * Systemic HTN. (A2)
* Cong. AS. (A2)
* Pulm. HTN. (p2)
* AR. S2

14. Abnormalities of the Heart Sounds
Alteration in Intensity.
Splitting.
Extra Heart Sounds.
Additional Sounds.
Murmurs.

15. P A + in expiration. LBBB, AS. Inc. N.
d.t. delay in Rt vent. emptying.
RBBB, PS, VSD, MR.
Reversed
P A + in expiration.
LBBB, AS.

16. Abnormalities of the Heart Sounds
Alteration in Intensity.
Splitting.
Extra Heart Sounds.
Additional Sounds.
Murmurs.

17. What to hear ? 4TH Heart Sound (S4) Da-lubb-dupp A stiff wall
3RD Heart Sound (S3)
Lubb-dupp-da
Slushing in
Caused by turbulent blood flow into ventricles and detected near end of first one-third of diastole (Rapid ventricular filling).
Fluid backing up , as in cardiac failure
4TH Heart Sound (S4)
Da-lubb-dupp
A stiff wall
With the atria systole
Non compliant ventricles

18. Third Heart Sound (S3) Low pitched. @ apex + LLSB. Mid-diastolic.
Triple rhythm (lub-dub-dum) (= gallop rhythm)
N: children + young people + pregnancy + athletes + fever.
Ab. : VF, AR, MR, VSD, PDA, Constrictive pericarditis.

19. Fourth Heart Sound (S4)
High pressure atrial wave reflected back from a poorly compliant ventricle.
Late diastolic, high-pitched sound.
NEVER physiological.
Ab. : AS, PS, MR, HTN, IHD, advanced age, angina or MI,

20. Abnormalities of the Heart Sounds
Alteration in Intensity.
Splitting.
Extra Heart Sounds.
Additional Sounds.
Murmurs.

21. Opening snap.
Systolic ejection click
Prosthetic heart valves.
Pericardial friction rub.

22. Pericardial friction rub
A superficial scratching sound.
Occurs at any time during the cardiac cycle.
Sign of PERICARDITIS.
Louder with sitting up and breathing out.

23. Abnormalities of the Heart Sounds
Alteration in Intensity.
Splitting.
Extra Heart Sounds.
Additional Sounds.
Murmurs.

24. Murmurs Timing. Intensity. Area of greatest intensity. Propagation.
Effect of certain maneuvers.

25. Timing Systolic: Innocent. (fever, athletes, pregnancy)
Pansys. (MR, TR, VSD)
Ejection (mid) sys. (AS, PS, ASD, severe anemia)
Late sys. (M Prolapse)
Diastolic:
Early. (AR, PR)
Mid. (MS, TS)
Others:
Presys. (MS, TS)
Continuous. (PDA + fistulae)

26. Murmurs (cont.) Timing. Intensity. Area of greatest intensity.
Propagation.
Effect of certain maneuvers.

27. Intensity 1/6 : soft + not heard @ first.
2/6: soft BUT can be detected.
3/6: moderate, NO thrill.
4/6: loud + thrill.
5/6: very loud.
6/6: very, very loud (w/o stethoscope).

28. Murmurs (cont.) Timing. Intensity. Area of greatest intensity.
Propagation.
Effect of certain maneuvers.

29. Murmurs (cont.) Timing. Intensity. Area of greatest intensity.
Propagation.
Effect of certain maneuvers.

30. Propagation PSM (MR) Lt axilla. PSM (VSD) Rt sternal edge.
ESM (AS) Carotid arteries.

31. Murmurs (cont.) Timing. Intensity. Area of greatest intensity.
Propagation.
Effect of certain maneuvers.

32. Effect of certain maneuvers
Respiration.
Valsalva maneuver.
Squatting.
Isometric exercise.

33. Lesion
Manoeuvre MR AS
MVP
Softer
Longer
Valsalva
(dec. preload)
Louder
Shorter
Squatting or leg raise
(inc. preload)
Hand grip
(inc. afterload)

34. Take home messages
Be professional.

35. Treat the pt. as one of your relatives.
Take home messages
Treat the pt. as one of your relatives.

36. Take home messages
Practice, practice, practice, and
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