Auscultation of the HeartI. Auscultatory Valve Area 1. MV: apex, fifth left intercostal space, medial to the midclavicular line 2. PV: second left intercostal space 3. AV: second right intercostal space 4. AV2: left third intercostal space 5. TV: lower part of sternal 6. Other partII. Auscultatory order ApexPV AV AV2 TVIII. Content of auscultation 1. Heart rate 2. Heart rhythm 3. Heart sound 4. Heart murmurs 1. HR Varies with age, sex. Physical activity and emotional status Normal adult: 60-80/min Sinus tachycardia: 100/min Sinus bradycardia: 60/min2. Heart rhythm 1) Sinus arrhythmia 2) Premature beat: A sudden extrasystole of the heartin the basic of normal heart rhythm S1; S2 Pulse absentEctopic point at atrial, AV node, ventricle 3) Atrial fibrillation:Mechanism: a very high frequency impulse coming from the atrial ectopic point, in multi-reentryThree inconsistence: ventricular rhythmS1 intensityHeart rate; pulse3. Heart sound: S1, S2, S3, S4 S1: S1 indicates the beginning of the ventricular constraction1) Vibration of the closure of A-V valve2) Opening of the semilunar valve3) Acceleration of the blood in arteries S1: Character of auscultation1) Area: apex2) Pitch3) Lasting time:4) Together with apex impulse S2: Vibration of the closure of AV, PV, during the beginning of ventricular diastole, Indicates the beginning of ventricular diastole S2: Character of auscultation1) Area: loudest at the basic2) Pitch 3) Lasting time The differentiate between S1S2 1) S1 apex pitch , lasting time S2 basic, pitch lasting time 2) Duration: S1_S2 S2_S13) Apical pulse S3: Mechanism:In early diastole filling blood moves from atrium to ventricle, Produces the vibration of ventricle wall Character: at apex or superinternal of apex0.120.18 after S2frequency intensity S4: Occur late in diastole, with effective atrial contraction 0.11 prior to S14. Abnormal of heart sound Change in loudness Both S1 and S2: Thinner chest wallActivity of the heart increased : Fat, edema,Pericardial effusion, heart failure Change in S1: S1 depends on: myocardial contraction filling degree of ventricle elastic and position of the valveS1: 1) MS 2) Tachycardia: in high fever, the diastolic period was shortenedS1: 1) Infarction2) MI Change of S2:S2 depends on (1) the pressure within the great vessel (2) the situation of semiluner valvesA2: hypertension P2 : pulmonary hypertension in MS, MIA2: AS ,AIP2 : PS, PI Change in quality of heart sound When the myocardial muscle is damaged severely, S1 is similar to S2. The heart sound like a pendularpendular rhythm.Usuallyaccompany with tachycardiaembryocardia. Splitting of heart sounds Splitting of S1: it is due to closure of MV and TV asynchronously loudest over the apex in RBBB Splitting of S2:1) In normal person, physiologic splitting due to the closure of AV and PV asynchronously in inspiration 2) In pathological situation delay of emptying time of one side of the heart such as ASD,MS.3) The influence of respiration in inspiration: the pressure within the thorax, venous return to RV, so empty time to be delayed, PV closure more later.4) Paradoxical splitting of S2 the abnormal is within the left heart,(AS), the emptying time of LV is delayed, the order of valve closure is reversed. In inspiration, the two components then more closer together or may be single.5)Fixed splitting of S2: in ASD, S2 is widely split over the PV area with little or no change in the degree of splitting in either phase of respiration.5. Extra sounds In diastolic period 1) Gallop: Three or four sounds are spaced to audibly resemble the center of a horse, the extra sounds occurs after S2. Protodiastolic gallop rhythm S3 gallop, ventricular gallop rhythm. S1 + S2 + pathologic S3 In early diastole, the blood through into ventricle from atrium in failing myocardium, the ventricular wall tension is poor, produce vibration. Reflex that the ventricular function Auscultation character of S3 gallop: lower in pitch After S2 Best hear at apex Loudest at the end of expiration. S3 gallop: differ from normal S3 Occur in severe organic heart disease HR100 bpm The interval time between S1 and S2 are almost equal, mimicking quality, normal S3 is nearer from S2 Normal S3 will disappear in standing or sitting position Late diastolic gallop S4 gallop, atrium gallop At late diastole, related to atrial contraction. In LVEDP compliance Artial contractionoccur precede S1, far from S2low-pitch; best heard at apex Tensity: end of expiration(from LA)end of inspiration (from RA) Occur in pressure overload,LVH, in myocardial damaged , LV compliance , such as BP, IHSS, CHD. Summation gallop Overlapping of S3G and S4G while HR 2) Opening snap In MS In early diastole of LV, the blood from LALV, the opening MV suddenly stopped make itself vibration