Auscultation Auscultation of of

The HeartThe Heart

Dr. R. TandonDr. R. TandonSitaram Bhartia Institute, New DelhiSitaram Bhartia Institute, New Delhi

First Sound (S1)

Due to closure of MV/TV Accentuated, diminished or variable intensity Wide split – Rt. BBB.

First Sound (S1)Accentuated : Loud M1 Tachycardia Short PR interval Mitral stenosis VSD, PDA. LVH

Loud T1 : ASD, TAPVC Tricuspid Stenosis

First Sound (S1)

Diminished :- S2 > S1 at apex. LV contractility 1° AVB AR

First Sound (S1)

Variable Intensity Comp. AVB Atrial fibrillation.

Second Sound

Normal :- Two components A2 & P2 A2 louder than P2 Insp.; split S2; A2-P2 Exp. : Single S2 A2 all over the precordium P2 - 2-3 ULSB

Second Sound

Abnormalities : A2 or P2

Intensity : Increased or decreased

Timing : Early or late

Second Sound

Splitting :- Normal. W&V - PS, PAPVC - IAS, MR, VSD W&F - ASD, TAPVC, Rt. BB, WPW(A) Single -A2 or P2 or A2 + P2 Paradox -AS, PDA, LVF, Lt. BB, WPW (B)

Third Sound (S3) End of early diast. filling. Dull, 50 to 100 msec after S2. Normal in children and young adults Abnormal above 40 yrs. Left or right sided.

Fourth Sound Abnormal if audible. Rt. / Lt. sided Rt. / Lt. atrial hypertension (high

RV/LV edp). Audible intermittently in comp. AVB. Acute MR - S4+.

Systolic Clicks (x) Loud sharp sounds Ejet. or Non-eject. Eject – Aortic, pulmonary – single. Non-eject - MV / TV prolapse - single

or multiple.

Systolic Clicks Aortic : Constant, early Heard all over the precard Bicuspid AoV. Dilated Asc, Ao

Syst. hypertension, aneurysms

Fallot’s physiology, PTA. Disapear - fibrosis, calcification.

Systolic Clicks

Pulmonary :- PS or PAH at ULSB. PS - Valvar PS

- Audible in expirat. only

- severity - closer to SI PAH - PVOD - Constant

Systolic Clicks

Non-Ejection : MVPS Single or multiple. Mid systolic but can be early - radiates

to base and neck Late murmur ±

S1 X A2 P2

Syst. m.

Opening Snap Mitral, diast. sound 40-120 msec after A2 A2-OS interval - severity Disappears in immobile valves Tricuspid OS drowned in MSm.

MurmurSystolic - Pansystolic.

Ejection systolic

Diastolic * Semilunar valves- Regurgitant m.

Early diastolic m.

* Atriovent. Valves- Functional m.- Obstructive m.

Delayed diast. (Middiast.)Late diast. (Presyst.)

Continuous

S1 X

ES. m.

A2

AR. m.

A2 P2

ES. m.

S1 X

PR m.

S1 X

ES. m.

A2 P2

PR. m.

S1x S2 S1 x

Cont. m.

S1x S2 S1

Cont. m.

AuscultationAuscultation

Clinical UtilityClinical Utility :- :- Murmurs present.Murmurs present. Murmurs absent.Murmurs absent.

AuscultationAuscultation

Clinical UtilityClinical Utility :- Murmurs absent :- Murmurs absent Myocardial diseaseMyocardial disease

- Primary – DCM, RCM, HCM- Primary – DCM, RCM, HCM

- Secondary to CAD- Secondary to CAD Pericardial diseasePericardial disease

Utility of S3, S4, S2, S1 Utility of S3, S4, S2, S1

AuscultationAuscultation

Clinical UtilityClinical Utility :- Murmurs present :- Murmurs present Cong. Ht. Dis.Cong. Ht. Dis. Rh. Ht. Dis.Rh. Ht. Dis. PMD -PMD - DCM – MR/TRDCM – MR/TR

HOCM HOCM - Outflow m.- Outflow m.-- MR. m.MR. m.

Post M.I. - MR / VSD.Post M.I. - MR / VSD.