HeartS oundsW orkshop
CAP A Conference 2014
N orm alHeartsounds S 1/S 2
“ Bad Heart” • AorticValvularDisease-(Aortic S tenosis/R egurgitation)
R ichardH.O nysko,P A-C,M P AS
1
HeartS oundsW orkshop
CAP A Conference 2014
1816 S tethoscope P aris,France. R eneL aennec.
T raube-Ivory
R ichardH.O nysko,P A-C,M P AS
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HeartS oundsW orkshop
CAP A Conference 2014
Early term s • L aennec-w asthe FIR S T toclassify & discuss: rales,rhonchi, crepitance, & egophony. • 1818-Academ ie deM edecin. • M ediate auscultation (indirect listening)apposed to( direct listening)-eartochest. • S tethos=Chest/ S kopos=exam ination.
M odernBinaural • T w o earpieces-1851-by A rthurL eared,& perfected by GeorgeCam m an-1852. • W asanIrish P hysician. • T he m edicalhistorian,Jacalyn Duffin argued thatthe invention ofthe stethoscope-m arked am ajorstepinthe re-definition ofdiseases from being abundle ofs ym ptom s-tothe currentsense ofdisease.
R ichardH.O nysko,P A-C,M P AS
3
HeartS oundsW orkshop
CAP A Conference 2014
M odernS tethoscope • R appaportand S praguedesigned the new stethoscope inthe 1940’s-(new standard). • Even betterversion-Hew lett-P ackard. • 1960’sDavidL ittm ann (Harvard)-refined the diaphragm /bell. • 1999-P uretone-noise reduction- insulated tubing,& even now electronic augmentation.
S tethoscope • Considered the s ym bolofhealthcare professionals. • P robably should be keptinthe frontseatof yourcar(m ightgetyou outofaspeeding ticket)!
R ichardH.O nysko,P A-C,M P AS
4
HeartS oundsW orkshop
CAP A Conference 2014
M urm ur • Caused by turbulentflow,& valvular vibrations,even abnorm alcom m unications“ hole inthe heart”. • M ostarebenign,butrequires:skill, experience,and confidence-tosortouttrue pathology. • “A lostart” -justgetan Echocardiogram .
Don’tP anic
R ichardH.O nysko,P A-C,M P AS
5
HeartS oundsW orkshop
CAP A Conference 2014
Don’tS KIP S teps
You w illbesurprisedw hatyou can find.
R ichardH.O nysko,P A-C,M P AS
6
HeartS oundsW orkshop
CAP A Conference 2014
P ay attentiontodetail.
AuscultationS ites
R ichardH.O nysko,P A-C,M P AS
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HeartS oundsW orkshop
CAP A Conference 2014
InspectionandP alpation • • • •
Inspect forobviouspulsations. P alpatew iththe ballofyourrighthand. Approach the patientfrom theirrightside. Bevery aw areofthe “ intimacy” ofthisexam .
Heaves-Lifts, & T hrills. • Cardiacout-put cancreateaR ightVentricular heave or lift. • A VentricularS eptalDefectcancauseathrill. • Feelslikeacatpurring.
R ichardH.O nysko,P A-C,M P AS
8
HeartS oundsW orkshop
CAP A Conference 2014
PU RR!
Auscultation • S hould goincorrectorder:Aortic-P ulm onic3rd L t.interspace-Tricuspid,& M itral. • S upine,& sitting,& specialpositions(L t.lateral decubitus,& exhale-lean forw ard)-Aortic. • U singboth the diaphragm (high-pitch),& the bell(low -pitch)-gallops.
R ichardH.O nysko,P A-C,M P AS
9
HeartS oundsW orkshop
CAP A Conference 2014
N orm al:S 1/S 2
S1– S2 • T he sound ofthe M itral& T ricuspid closing. • T he Aortic& P ulm onicareopen. • Carefully listenand determ ine w hichsound is S 1,& w hichisS 2. • T here isalw aysapause afterS 2. • Diastoleisthelongpause(resting). • S ystoleisthe short-phase(ventricularejection)
R ichardH.O nysko,P A-C,M P AS
10
HeartS oundsW orkshop
CAP A Conference 2014
N orm al-S 1/S 2. • L istenforany noise before the S 1-(s4),& any noise afterthe S 2 (S 3)-Gallop.
Gallops-S-4/S -3 • AnS 4 gallop(“ atrialgallop” )-suggestsastiff Ventricle-heard inHT N ,& Ischem ia. • A low pitch heard atthe apex w iththe bell. • Very difficulttohear(low -pitch). • S oundslike“ T ennessee”. • T he Firstsound-islike2-sounds,& the rhythm isdifferent(agallop).
R ichardH.O nysko,P A-C,M P AS
11
HeartS oundsW orkshop
CAP A Conference 2014
S -4 Gallop. • L istentothe S -1-,ithasa“ hitch” justbefore it.T hatistheS -4. • P icturethe atrium contractinginlatediastoleasitm akesalow pitched grunt. • Expecttohearitinapatientw ithlong standingHT N /L VH.
S -3 Gallop • • • •
O ccursinapatientw ithvolum e overload-CHF. Islow pitch-heard attheapex.U se the bell. Isheard inearly diastole(justafterthe S -2). S oundslike“ Kentucky”
R ichardH.O nysko,P A-C,M P AS
12
HeartS oundsW orkshop
CAP A Conference 2014
S -4 Gallop • Da-Da Bum p, Da-Da Bum p. • S 4-S1 S 2, S 4-S1 S 2. • “ T ennessee”
S -3 Gallop • Da- Da-Bum p. • S 1- S 2-S 3. • “ Kentucky”
R ichardH.O nysko,P A-C,M P AS
13
HeartS oundsW orkshop
CAP A Conference 2014
T achycardia-S 3 • P retty m uch how itreally sounds. • T he S -3 w illgoaw ay w hen you getthe volum e off(lasix).
S um m ationGallop • All4 heartsounds:S 4-S1-S2-S3.
R ichardH.O nysko,P A-C,M P AS
14
HeartS oundsW orkshop
CAP A Conference 2014
N orm alS 1/S 2 • N O extrasounds!
M itralValveP rolapse • A “ click” heard inM id-s ystole. • T ypically abenign condition. • P atientshave + s ym ptom sof:palpitations,& sharpchestpain. • T hey need re-assurance. • R X :Beta-Blockers. • A bitm orecom m on inFem ales,“ T ype-A”.
R ichardH.O nysko,P A-C,M P AS
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HeartS oundsW orkshop
CAP A Conference 2014
M itralValveP rolapse • S 1 “ click” S 2.
M V P – L ateM urm ur • T he m urm ur(regurgitation)happensafterthe click,lateins ystole.
R ichardH.O nysko,P A-C,M P AS
16
HeartS oundsW orkshop
CAP A Conference 2014
M urm urs
M urm urs • T im ing: S ystolicvs.Diastolic.Early-m id-late. • Holo-s ystolicorpan s ystolic. • T he m urm ur(noise)goesallthe from S 1 – to– S 2. • Doesitsound thesam e,ordoesthefrequency have abuilding-up(crescendo)-(decrescendo) pattern.“ Diam ond” shape. AorticS tenosis.
R ichardH.O nysko,P A-C,M P AS
17
HeartS oundsW orkshop
CAP A Conference 2014
L ocation • W here do you here itbest? • Aorticarea/M itralarea.
R adiation • W here doesitseem totravelto? • T he neck(carotids)-AorticS tenosis. • T he axilla-M itralR egurgitation.
R ichardH.O nysko,P A-C,M P AS
18
HeartS oundsW orkshop
CAP A Conference 2014
P itch • High. • M edium . • L ow .
Q uality • • • •
Blow ing.(AorticR egurgitation). R um bling.(M itralS tenosis). Harsh.(AorticS tenosis). M usical.(M itralR egurgitation).
R ichardH.O nysko,P A-C,M P AS
19
HeartS oundsW orkshop
CAP A Conference 2014
HarshQ uality • • • •
AorticS tenosis. S ystolic. Crescendo – Decrescendo. Istruepathology-N O T benign.
Blow ingQ uality • AorticR egurgitation-AorticInsufficiency. • Diastolic.
R ichardH.O nysko,P A-C,M P AS
20
HeartS oundsW orkshop
CAP A Conference 2014
Intensity Grade I= Very faint. Grade II= Q uiet,butisheard im m ediately. Grade III= M oderately loud. Grade IV = L O U D. Grade V = Very L O U D,heard w iththe stethoscope partially offthe chest.T hrill • Grade VI= Heardw ithO U T the stethoscope. T hrill. • • • • •
S pecialM anuevers • Valsalva:W illincreaseHO CM . • Valsalva:W illdecrease-AorticS tenosis,M itral regurgitation,& M VP . • S tanding:W illincrease:HO CM ,& Aortic S tenosis,& M VP & decreaseM itral regurgitation.
R ichardH.O nysko,P A-C,M P AS
21
HeartS oundsW orkshop
CAP A Conference 2014
S pecialM anuevers • Handgrip/S quatting:IncreaseM itral regurgitation,& decrease:HO CM ,Aortic S tenosis,& M VP . • Exercise:Increase-HO CM ,AorticS tenosis,& M VP ,& decreaseM itralregurgitation.
AorticS tenosis • • • • • • •
S ystolic. Congenital(bicuspid). Degenerative-calcific,50% alsohave C.A.D. S ym ptom s:Chestpain,dyspnea,& s yncope. T reatm ent:S urgery. Do N O T letthem goonatreadm ill! GetanEchocardiogram :AVA< 1.0cm 2/or gradientover40-50 m m Hg.BAD.R efer!
R ichardH.O nysko,P A-C,M P AS
22
HeartS oundsW orkshop
CAP A Conference 2014
AorticS tenosis
AorticR egurgitation • • • • • • •
Diastolic. Blow ing. W ide pulse pressure. Canpresentw ithCHF. Afterload reduction canhelp. S urgery if:sx,L V-dilates> 5.0 cm . N eed Echocardiogram /Angio.
R ichardH.O nysko,P A-C,M P AS
23
HeartS oundsW orkshop
CAP A Conference 2014
AorticR egurgitation
AorticS tenosis/R egurgitation
R ichardH.O nysko,P A-C,M P AS
24
HeartS oundsW orkshop
CAP A Conference 2014
M itralR egurgitation S ystolic. Com m on. Blow ing/m usical. HeartFailure. S urgery only ifthe L V function isok. R eplacem ent:Bio ifover60yrs.old,& m echanical ifyoung. • R epairifpossible.Judgm entofagood surgeon. • • • • • •
M itralR egurgitation
R ichardH.O nysko,P A-C,M P AS
25
HeartS oundsW orkshop
CAP A Conference 2014
M itralR egurgitation/S 3 • Isin+ CHF!
M itralS tenosis • L oud S 1 – S 2 – O S – Diastolicrum ble. • Hardtohearthe O pening snap(justafterS 2). • T he diastolicrum ble islow pitch & notloud, m ighthave tohave patientlieinL t.lateral decubitusposition.
R ichardH.O nysko,P A-C,M P AS
26
HeartS oundsW orkshop
CAP A Conference 2014
M itralS tenosis • R heum aticinorigin. • Com m on s ym ptom sare:AtrialFibrillation, exertionaldyspnea,& pulm onary hypertension. • N eed anEchocardiogram -avalveareaofless than1.5 cm 2 – w illstarttorenders ym ptom s. • M ay eventually need M itralValve surgery(repairvs.replacem ent).
M itralS tenosis
R ichardH.O nysko,P A-C,M P AS
27
HeartS oundsW orkshop
CAP A Conference 2014
Charting • S om e w rite:S 1-S2 N L .N oM /C/G. • S om e w rite:R S R . • Alw aysnote the m urm ur:either s ystolic/diastolic. • W here you heard itbest,itspitch,& Grade. • Any transm ission? • S ystolicm urm ur-atthe L tsternalborder, harsh,m edium pitch,Gr.III,radiatingtoneck.
P ost-Test# 1
R ichardH.O nysko,P A-C,M P AS
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HeartS oundsW orkshop
CAP A Conference 2014
N orm al– S 1/S 2
P ost-Test#2
R ichardH.O nysko,P A-C,M P AS
29
HeartS oundsW orkshop
CAP A Conference 2014
P ost-Test#2 • S 4 Gallop(Atrial– gallop).
P ost– T est# 3
R ichardH.O nysko,P A-C,M P AS
30
HeartS oundsW orkshop
CAP A Conference 2014
P ost– T est#3 • S 3 Gallop:
P ost– T est#4
R ichardH.O nysko,P A-C,M P AS
31
HeartS oundsW orkshop
CAP A Conference 2014
P ost– T est#4 • T achycardiaw ithanS -3 gallop.
P ost– T est#5
R ichardH.O nysko,P A-C,M P AS
32
HeartS oundsW orkshop
CAP A Conference 2014
P ost– T est#5 • S um m ation Gallop.(S 4-S1-S2-S3).
P ost– T est#6
R ichardH.O nysko,P A-C,M P AS
33
HeartS oundsW orkshop
CAP A Conference 2014
P ost– T est#6 • M itralValveP rolapse. • M id-s ystolicm urm ur.
P ost– T est#7
R ichardH.O nysko,P A-C,M P AS
34
HeartS oundsW orkshop
CAP A Conference 2014
P ost– T est#7 • AorticS tenosis. • S ystolic,Harsh.
P ost– T est#8
R ichardH.O nysko,P A-C,M P AS
35
HeartS oundsW orkshop
CAP A Conference 2014
P ost– T est# 8 • AorticR egurgitation. • DiastolicBlow . • M ightneed specialm aneuver(exhale& lean forw ard).
P ost– T est#9
R ichardH.O nysko,P A-C,M P AS
36
HeartS oundsW orkshop
CAP A Conference 2014
P ost– T est#9 • AorticS tenosis& AorticR egurgitation. • BO T H:systolic & diastolic murmur.
P ost– T est#10
R ichardH.O nysko,P A-C,M P AS
37
HeartS oundsW orkshop
CAP A Conference 2014
P ost– T est#10 • M itralR egurgitationw ithan S -3 gallop.
P ost– T est#11
R ichardH.O nysko,P A-C,M P AS
38
HeartS oundsW orkshop
CAP A Conference 2014
P ost– T est#11 • M itralR egurgitation. N O S -3. • S ystolic,Blow ing,radiatestothe axilla.
P ost-T est#12
R ichardH.O nysko,P A-C,M P AS
39
HeartS oundsW orkshop
CAP A Conference 2014
P ost– T est#12 • N orm al:S 1/S 2. • N o m urm ur,click,orgallop.
HappinessisN -S -R .
R ichardH.O nysko,P A-C,M P AS
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