Auscultation Of The Heart

The entire precordium is systematically investigated, typically starting with the apical regions, and the patient in the left lateral side. The patient then subsequently turns on the back and the auscultation is cephalad continued along the left sternal limit in each ICR, caudally along the right sternum limitation. The clinician also auscultated the left axilla and above the clavicles. The patient is sitting upright in the auscultation of the back, then leans forward to facilitate the auscultation of aortic and pulmonary diastolic noise or the Perikardreibung.

The auscultation of the heart requires an excellent hearing and the ability to distinguish subtle differences in the amount and the time. Doctors with hearing loss can use reinforcing stethoscopes. High frequency sounds are best heard with the diaphragm of the stethoscope. Low-frequency sounds are best heard with the bell. When using the horn very little pressure should be applied. Excessive pressure transforms the underlying skin in a membrane and deletes from very low frequency tones. The entire precordium is systematically investigated, typically starting with the apical regions, and the patient in the left lateral side. The patient then subsequently turns on the back and the auscultation is cephalad continued along the left sternal limit in each ICR, caudally along the right sternum limitation. The clinician also auscultated the left axilla and above the clavicles. The patient is sitting upright in the auscultation of the back, then leans forward to facilitate the auscultation of aortic and pulmonary diastolic noise or the Perikardreibung. Among the more saturated auscultatory findings include heart sounds murmurs friction sounds heart sounds are short, transient sounds created by the opening and closing of the heart valves. They are divided into systolic and diastolic heart sounds. Heart sounds are caused by turbulent blood flow and are longer than heart sounds. You can systolic, diastolic, or continuous. They are on the intensity (see table: heart murmur intensity) graded and described on their location and on when they occur within the cardiac cycle. Heart murmur intensity level Description 1 Barely audible two shallow, but good to hear three sound without zipping 4 According to buzz 5 According with minimal contact of stethoscope and chest According 6 without contact of stethoscope and chest rubbing noise is high-frequency scratch tones, often having 2 or 3 separate components. In tachycardia, the sound can be almost continuously. The clinician focuses successively on each phase of the cardiac cycle to notice any heart sound and every heart murmur. The volume level, duration and the time allocation of heart sounds and the intervals between them are analyzed and often allow an accurate diagnosis. A diagram of the major auscultatory and palpatory findings of Präkordiums should be routinely drawn into the patient record in every examination of the cardiovascular system (diagram of physical findings in a patient with aortic stenosis and mitral regurgitation). With such a graph, the findings of any investigation can be compared. Diagram of physical findings in a patient with aortic stenosis and mitral regurgitation sounds, character, intensity and charisma are presented. The sound of the shutter pulmonischen exceeds that of the aortic occlusion. The left ventricular (LV) thrust and the right ventricular (RV) increase (wide arrows) are identified. A fourth heart sound (S4) and systolic thrill (TS) are available. a = aorta closure clay; p = pulmonary closure clay; S1 = 1 heart sound; S2 = second heart sound; 3/6 = degree of crescendo diminuendo noise (irradiated on both sides of the neck); 2/6 = degree of pansystolischen apical crescendo noise; 1 + = slight precordial increase in RV hypertrophy (arrow shows the direction of rise); 2 + = moderate LV-thrust (arrow indicates the direction of thrust). Systolic heart sounds to the systolic heart sounds include the following: 1. heart sound (S1) clicking sounds S1 and the second heart sound (S2, a diastolic heart sound) are normal constituents of the cardiac cycle. S1 occurs just at the start of systole and is primarily driven by Mitralklappenschluss, but may also include components of Trikuspidalklappenschlusses. He is often split and high frequency. S1 is particularly loud at a mitral valve stenosis. He can be quiet at a mitral regurgitation or missing due to the sclerosis and rigidity of the valve leaflet, but is often heard clearly at a mitral insufficiency due to myxomatous degeneration of Mitralapparates or due to abnormal ventricular myocardium (z. B. papillary muscle, ventricular dilatation). Clicks occur only during systole. They are distinguished from S1 and S2 due to their higher frequency and shorter duration. Some clicks occur at different times during systole, when the hemodynamic changes. Clicks may occur singly or multiply. Clicks in congenital aortic valve – arise or pulmonary valve – the thinking goes – by an abnormal Ventrikelwandspannung. These clicks occur early in systole (very close to S1) and are not changed by the hemodynamics. Similar clicks occur with severe pulmonary hypertension. Clicks with mitral – or Trikuspidalklappenprolaps, typically occurring in the middle or Spätsystole arise – one thinks – by the abnormal voltage redundant or elongated chordae or valve leaflets. Clicking noises due myxomatous degeneration of the valve can occur at any time during the systole, but shift direction S1 during maneuvers that temporarily reduce the ventricular filling (z. B. Standing, Valsalva maneuver). If the ventricular filling is increased (eg. As in a lying position), the shifting direction S2 clicking sounds, especially in a mitral valve prolapse. From unknown causes the characteristics of clicking noises may vary greatly between studies and even be present and then missing again. A S1 splitting is normal in many patients; it is believed to be due to the closing of the mitral valve and the subsequent sound of Aortenausstoßes. var player panel = $ (MManual.utils.getCurrentScript ()) Closest ( ‘player..’); ko.applyBindings ({MediaUrl ‘/-/media/manual/professional/sounds/split_1st_heart_sound_de.mp3?la=de&thn=0&mw=350’, Mime Type: ‘audio / wav’}, playerPanel.get (0)); Splitting of the first heart sound recording provided by Jules Constant, M.D. A high pressure in the pulmonary artery can expand the pulmonary artery, stretching the valve ring, causing a click when the stretched valve leaflets open quickly. var player panel = $ (MManual.utils.getCurrentScript ()) Closest ( ‘player..’); ko.applyBindings ({MediaUrl ‘/-/media/manual/professional/sounds/pulmonary_ejection_click_de.mp3?la=de&thn=0&mw=350’, Mime Type: ‘audio / wav’}, playerPanel.get (0)); Pulmonary Auswerfklicken recording provided by Jules Constant, M.D. Sound of S1-S2 at rest ( “out”) and S1-A2 P2bei inspiration ( “in”). S2 splits on inspiration because the pressure in the thorax decreases, draws more blood into the right ventricle and the Pulmonalklappenverschluss shifts. var player panel = $ (MManual.utils.getCurrentScript ()) Closest ( ‘player..’); ko.applyBindings ({MediaUrl ‘/-/media/manual/professional/sounds/split_2nd_heart_sound_de.mp3?la=de&thn=0&mw=350’, Mime Type: ‘audio / wav’}, playerPanel.get (0)); Splitting of the second heart sound recording provided by Jules Constant, M.D. Diastolic heart sounds to diastolic heart sounds include the following: 2nd, 3rd, and 4th heart sounds (S2, S3, and S4) diastolic knocking sounds Mitralklappengeräusche Unlike systolic heart sounds are low frequency diastolic heart sounds. They are softer in intensity and last longer. Except for these S2 heart sounds are abnormal in adults usually, although a S3 until the age of 40 years and during pregnancy may be physiological. S2tritt at the beginning of the diastole because of the aortic valve and Pulmonalklappenschlusses. The Aortenklappenschluss normally precedes the Pulmonalklappenschluss except when the former occurs very late or very early the latter. The Aortenklappenschluss is late with a left bundle branch block or aortic stenosis. The Pulmonalklappenschluss is early in some forms of Präexzitationsphänomens. A delayed Pulmonalklappenschluss can (eg. As in atrial septal defect from the frequent type 2) caused by increased blood flow through the right ventricle, or at a complete right bundle branch block. An increased right ventricular blood flow in an atrial septal defect deletes from the normal breath-dependent change of aortic and Pulmonalklappenschlusses, whereby a fixed split S2 is formed. Left-right shunts with normal right ventricular volume flow (z. B. with membranous ventricular septal defects) do not cause fixed cleavage. A single S2 may occur when the aortic valve insufficient or difficult stenotic and atresia of the aortic valve (at the truncus arteriosus, when a common flap is present). Noise in paradoxical splitting, d. H. S1 P2 A2iM idle state ( “out”) and S1-S2 during inspiration ( “in”). A left bundle branch block delays the aortic valve closure, so that the splitting is audible in quiet; Inspiration reduces the pressure in the thorax, thereby drawing more blood into the right ventricle and the Pulmonalklappenverschluss is moved until it overlaps of A2 and the splitting is no longer audible. var player panel = $ (MManual.utils.getCurrentScript ()) Closest ( ‘player..’); ko.applyBindings ({MediaUrl: ‘{} merckwebpuburl /split_2nd_heart_sound_left_bundle_branch_block_de.swf&mw=350’, Mime Type: ‘audio / wav’}, playerPanel.get (0)); Splitting of the second heart sound provided by Jules Constant in LBBB Up, M.D. Noise in further splitting, d. H. S1-A2-P2im idle state ( “out”) having a still further A2-P2 interval during inspiration ( “in”). A right bundle branch block delays the Pulmonalklappenverschluss so that the S2 splitting is audible in quiet. Inspiration reduces the pressure in the thorax, thereby drawing more blood into the right ventricle and the Pulmonalklappenverschluss is moved so that the normal split is on. var player panel = $ (MManual.utils.getCurrentScript ()) Closest ( ‘player..’); ko.applyBindings ({MediaUrl ‘/-/media/manual/professional/sounds/split_2nd_heart_sound_right_bundle_branch_block_de.mp3?la=de&thn=0&mw=350’, Mime Type: ‘audio / wav’}, playerPanel.get (0)); Splitting of the second heart sound in the right bundle branch block recording provided by Jules Constant, M.D. Noise at a fixed S2Aufspaltung, d. H. S1-A2-P2 in the idle state ( “out”) and inspiration ( “in”). The split is determined, as the flow volume is increased by the right ventricle, making the normal delay of Pulmonalklappenverschlusses for inspiration omitted. var player panel = $ (MManual.utils.getCurrentScript ()) Closest ( ‘player..’); ko.applyBindings ({MediaUrl ‘/-/media/manual/professional/sounds/split_2nd_heart_sound_atrial_septal_defect_de.mp3?la=de&thn=0&mw=350’, Mime Type: ‘audio / wav’}, playerPanel.get (0)); Splitting of the second heart sound with atrial septal recording provided by Jules Constant, M.D. Noise of S1-S2-S3. var player panel = $ (MManual.utils.getCurrentScript ()) Closest ( ‘player..’); ko.applyBindings ({MediaUrl ‘/-/media/manual/professional/sounds/third_heart_sound_de.mp3?la=de&thn=0&mw=350’, Mime Type: ‘audio / wav’}, playerPanel.get (0)); 3. heart sound recording provided by Jules Constant, M.D. Noise of S4-S1-S2. var player panel = $ (MManual.utils.getCurrentScript ()) Closest ( ‘player..’); ko.applyBindings ({MediaUrl ‘/-/media/manual/professional/sounds/fourth_heart_sound_de.mp3?la=de&thn=0&mw=350’, Mime Type: ‘audio / wav’}, playerPanel.get (0)); 4. heart sound recording provided by Jules Constant, M.D. Noise of S4-S1-S2-S3in rapid succession. var player panel = $ (MManual.utils.getCurrentScript ()) Closest ( ‘player..’); ko.applyBindings ({MediaUrl ‘/-/media/manual/professional/sounds/summation_gallop_de.mp3?la=de&thn=0&mw=350’, Mime Type: ‘audio / wav’}, playerPanel.get (0)); Summation gallop recording provided by Jules Constant, M.D. A diastolic knocking has a loud S3, which is due to a constrictive pericarditis. var player panel = $ (MManual.utils.getCurrentScript ()) Closest ( ‘player..’); ko.applyBindings ({MediaUrl ‘/-/media/manual/professional/sounds/diastolic_knock_de.mp3?la=de&thn=0&mw=350’, Mime Type: ‘audio / wav’}, playerPanel.get (0)); Diastolic knock recording provided by Jules Constant, M.D. Noise of S1-A2-OS with a relatively long A2-OS interval. From the opening signal, which usually occurs in mitral that it is caused by a sudden bulging (cracking) of the anterior leaflet down is assumed when the left ventricular pressure falls below the left atrial pressure during diastole falls. A2-OS can be from an S2 splitting by dynamic maneuvers (OS intensity increases with inspiration, A2-OS interval widens in a standing position), a triple S2 (ie A2-P2-OS) and a higher volume in the tip be distinguished. var player panel = $ (MManual.utils.getCurrentScript ()) Closest ( ‘player..’); ko.applyBindings ({MediaUrl ‘/-/media/manual/professional/sounds/mitral_valve_opening_snap_de.mp3?la=de&thn=0&mw=350’, Mime Type: ‘audio / wav’}, playerPanel.get (0)); Opening signal of the mitral valve intake provided by Jules Constant, M.D. S3 occurs in early diastole, when the ventricles dilated and “noncompliant.” It is produced during the passive diastolic ventricular filling and usually shows a severe ventricular dysfunction in adults at. In children, however, and sometimes up to the age of 40 persistent it can be normal. S3 may be normal during pregnancy. The right ventricular S3 is best (but only sometimes) during inspiration (as the negative intrathoracic pressure increases right ventricular filling volume), is in a supine patient. The left ventricular S3 is the best and the patient heard during expiration (as the heart then closer to the chest wall) in the left lateral position. S4 is produced at elevated ventricular filling and is caused by the atrial contraction just before the end of diastole. It is similar to S3 and is heard best or only with the hopper of the stethoscope. During inspiration, the right ventricular S4 gets louder and the left ventricular S4 quieter. S4 is heard much less frequently than S3 and shows a less severe degree of diastolic ventricular dysfunction usually on. S4 is absent in atrial fibrillation (because the court will not contracted), but is almost always in acute myocardial ischemia or early after myocardial infarction present. S3 with or without S4 is usually present in severe systolic dysfunction; S4 without S3 is usually present at diastolic left ventricular dysfunction. A summation Gallop arises when S3 and S4 are present in a patient with a tachycardia, which shortens the diastole such that the heart sounds 2 merge. Loud S3 and S4 can be palpated at the apex, when the patient is in the left lateral position is. A diastolic knocking occurs at the same time as S3 early in diastole. It is not accompanied by S4, and a louder, beat sound, the abrupt end of the ventricular filling “noncompliant” at a constrictive indicating pericardium. An opening signal can occur in early diastole at a mitral stenosis, or rarely at a Trikuspidalklappenstenose. The mitral very high frequency, short and is best heard with the diaphragm of the stethoscope. is, depending on the mitral higher grade (i. e. the higher the left atrial pressure), the closer the mitral at the Pulmonalklappenkomponente of S2. The intensity depends on the compliance of the leaflets from: The opening signal is loud when the valve leaflets remain elastic, but is gradually quieter and finally disappears entirely when developing sclerosis, fibrosis and calcification of the valve. Although the mitral is sometimes heard at the apex, it is common to hear the best, if not exclusively at the lower left sternal border. Procedure for heart sounds, the temporal occurrence of murmur in the heart cycle correlated with the cause (see Table: etiology of heart sounds based on their occurrence in time). The auscultatory findings correlate with specific heart valve diseases. Various maneuvers (. Eg for inspiration, Valsalva, hand grip, squatting position, amyl nitrate inhalation) cardiac physiology can easily modify so that it is possible to differentiate the cause of the murmur (see table: maneuvers that help in the diagnosis of heart murmurs ). Etiology of heart sounds based on their occurrence in time temporal occurrence Associated diseases during systole (ejection) obstruction of the aorta (supravalvular stenosis, coarctation of the aorta, aortic stenosis, aortic sclerosis, hypertrophic cardiomyopathy, subvalvular stenosis) Increased blood flow through the aortic valve (hyperkinetic states, aortic regurgitation) dilatation of the ascending aorta (atheroma, aortitis, aortic aneurysm) Pulmonary obstruction (supravalvular pulmonary artery stenosis, pulmonary stenosis, infundibular stenosis) Increased blood flow through the pulmonary valve (hyperkinetic states, left-to-right shunt due to atrial septal defect, ventricular septal defect) Dilatation of the Pulmonary Artery middle to late systole mitral valve prolapse Papillarmuskelsdysfunktion Holosystole Mitralklappeninsuffizienz tricuspid regurgitation Early ventricular diastole (regurgitant) Aortenklappeninsuffizienz: acquired or congenital anomaly flaps (eg. B. myxomatous degeneration or calcifying, rheumatic fever, endocarditis) dilation of the valve annulus (aortic dissection, annuloaortische ectasia, cystic medial necrosis or hypertension), enlargement of the commissures (for example syphilitic). congenital bicuspid valve with or without ventricular septal defect Congenital bicuspid valve with or without ventricular septal defect Pulmonalklappeninsuffizienz acquired or congenital Klappenanomalität dilation of the valve ring (z. B. pulmonary hypertension, Marfan syndrome), tetralogy of Fallot ventricular During diastole mitral stenosis (z. B. rheumatic fever, congenital stenosis Cor triatriatum) Increased blood flow through nonstenotische mitral valve (z. B. mitral regurgitation, ventricular septal defect, patent ductus arteriosus, high-output states, atrioventricular block) Trikuspidalklappenstenose Increased blood flow (by nonstenotische tricuspid z. B. tricuspid regurgitation, atrial septal defect, anomalous pulmonary venous return) links – or right atrial tumors Atrial ball valve thrombi Continuously patent ductus arteriosus stenosis of the pulmonary artery Coronary or intercostal arteriovenous fistula ruptured aortic aneurysm of the sinus of Valsalva aortic septal defects Cervical venous hum Abnormal left main coronary artery proximal coronary artery stenoses “Mammary souffle” (venous hum jammed breast vessels during pregnancy) pulmonary artery branch stenosis (pulmonary artery branch stenosis) Bronchial collateral circulation Small (restrictive) atrial septal defect with mitral stenosis Coronary-cameral fistula, aortic right ventricular or atrial fistula maneuvers in the diagnosis of He rzgeräuschen help maneuver effect on blood flow effect on heart sounds inspiration same time, increased venous return to the right ventricle (RV), decreased venous return strengthened in the left heart right heart sounds (eg. B. Noise of tricuspid stenosis and insufficiency, those of pulmonary stenosis * [immediately] and insufficiency [usually]). Reduced left heart sounds Valsalva maneuver decreases size of the left ventricle (LV); reduced venous return to the right heart and then into the left atrial amplified sounds of hypertrophic obstructive cardiomyopathy and mitral valve prolapse reduces noise of the aortic, mitral and tricuspid stenosis completion of Valsavamanöver Increases volume of the RV and LV amplified noises of the stenosis, the aortic regurgitation (after 4 or 5 beats) and pulmonary insufficiency or pulmonary stenosis * (immediately) reduces noise of the tricuspid stenosis Isometric hand grip Increases afterload and peripheral arterial resistance reduces noises of the stenosis, hypertrophic obstructive cardiomyopathy and mitral valve prolapse or papillary muscle dysfunction amplified sounds of the mitral insufficiency and aortic insufficiency and diastolic murmurs of mitral stenosis squatting simultaneous increase in venous return to the right heart and increase of afterload and peripheral resistance Increases noise of aortic regurgitation, aortic stenosis, mitral regurgitation and diastolic murmur of mitral reduces noise of hypertrophic obstructive cardiomyopathy and mitral valve prolapse amyl nitrite Causes intensive Venodilation that reduces venous return to the right heart reinforced G eräusche of hypertrophic obstructive cardiomyopathy, aortic stenosis and mitral valve prolapse; reduces noise of aortic stenosis Reduces noise of mitral regurgitation. * Patient may need to be, so that the effect can be heard on pulmonary stenosis. All patients with heart murmurs are further examined with chest X-ray and ECG. Most require an echocardiogram to confirm the diagnosis, to determine the severity and track the severity over time. Usually a cardiological case conference / cardiological idea is performed when a significant disease is suspected. Systolic murmurs systolic murmurs may be physiological or pathological. You can Early, Middle or spätsystolisch but also holosystolic (pansystolisch). Systolic murmurs can be divided into the stripper, Insuffizienz- and shunt noise. Austreibungsgeräusche caused by turbulent blood flow due to the forward constricted or irregular flaps or outflow tracts (z. B. due to an aortic or pulmonary valve). They are typically mittelsystolisch and have a crescendo decrescendo character and are usually louder and longer when the blood flow is more concentrated. Depending higher grade stenosis and turbulence, the longer the crescendo stage and the shorter the decrescendo phase lasts. Systolic Austreibungsgeräusche can arise even without hemodynamically significant outflow tract obstruction and are therefore not always necessarily pathological. In healthy infants and children, the blood flow is often slightly turbulent, so quietly systolic noise. Older people often have Austreibungsgeräusche due to valvular and vascular sclerosis. During pregnancy, many women have quietly Austreibungsgeräusche in the second intercostal space on the left or right of the sternum. The noises as a physiological increase in blood volume and cardiac output, the

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