Embedded Files
Auscultory Exam MA Notes
Auscultory Exam MA Notes
S1
-Single, low freq, best at LLSB
-after infancy, it might split w respiration
S2
-A2 precedes P2 because LV contraction ends first, slightly
-P2 is softer than A2, unless PAP is elevated
-best heard at mid/upper LSB
-often single postnatally (DOL1-2)m then should vary w respiration
-Increase S2 split - occurs w increase in RV ejection time
-ASD
-TAPVR
-PS
-RBBB
-Decrease S2 split - occurs w early closure of Pulm Vlv, or bc of delay in Ao valve closure
-Phtn
-AS (severe AS)
-Paradoxical Splitting (A2 after P2) - if very severe AS
-Single S2 also occurs if there is cardiac dz that shifts the pulmonary valve away from the front of the chest (TGA) - bc P2 is soft, you cannot hear it well if it is not right up against the chest wall
S3
-occurs w rapid early diastolic filling
-low freq, @LLSB/apex; best heard w the bell (low freq)
-due to rapid ventric filling --> vibrations
-Nl in older kids or athletes--> dull, low freq, mid diastolic, best at apex
S4
-low freq, end diastole, just before S1
-2y to ventricular resistance to distension (poor compliance, e.g. w cardiomyopathy)
-ALWAYS pathological; c/s CHF...
Click
-Ejection Click- soon after S1 - due to Ao or PA vlv stenosis or dilated GA's
-Ao- best @ apex/RUSB - note no change w respiration (L sided)
-PA- best @ LSB, louder with expiration (R sided)
-if assoc w dilated GA--> best at LUSB for Ao and RUSB for PA
Rub
-sandpaper sound, in sync w HR
-best at apex
-can decrease with a worsened effusion, bc pericardium no longer touches myocardium
MURMURS
-2y to turbulent blood flow
-Intensity
-1 - barely audible (< S1,S2 volume)
-2 - soft (about the same as S1,S2 volume)
-3 - louder than S1,S2, but no thrill
-4 - +thrill (vibration on palpation, in sync with the murmur)
-5- +thrill and heard with stethoscope barely on the chest
-6- +thrill and heard with stethoscope off the chest
-Intensity can reflect the P difference bn the two chambers
-thus increases with PS & AS degree, decreases with VSD size
-Timing
-Systolic
-Ejection
- = onset shortly after S1, separated bc of the pd of isovolumetric contraction
-long or short; crescendo-descresendo quality
-should end prior to S2
-bc of obstructed Q thru a stenotic semilunar vlv
-heard w semilunr vlv stenosis, subvlvr & supravlv stenosis, branch PA stenosis, or HOCM
-bc of excess volume thru a Nl semilunar vlv
-heard @PA w ASD, PR, Anom Pulm Vn Return & pregnancy
-heard @Ao w AR, PDA, systemic AV malformations, decreased viscosity (anemia)
-best @ the site of altered flow (Ao @ RUSB, PA @LUSB)
-radiate in the direction of the Q (Ao to neck, PAs to axillae/back)
-S1 Coincident- onset at S1, so you usually don't hear S1 with the murmur
-aka Pansystolic or Holosystolic bc usually last thru much of systole
-bc Q fr high pressure to low pressure chamber during what should be isovolumetric contraction in early systole
-fr VSD, MR, TR
-if fr regurg, then TR @LLSB & MR @apex; if VSD @LLSB w rad to right side sometimes
-Frequency (Pitch) of VSD murmur relates to the P drop thru the defect- higher freq = smaller VSD and thus higher P gradient
-MR & TR is usually higher frequency & "blowing" quality
-Late Systolic Murmurs
-fr MR due to MV Prolapse- often after a midsystolic click
-best at apex
-blowing quality
-Diastolic
-Early
-just after S2
-Decrescendo in intensity- bc the P diff bn the artery and the ventricle decreases during diastole as the ventricular P increases with filling and the arterial P drops
-bc of regurg fr a GA into the ventricle
-AR- fr higher diastolic P in Ao - so high pitch
-best heard w diaphragm of steth, at LMSB, w rad twd the apex
-as the diastolic P gradient decreases, the intensity decreases.
-listen as pt leands fwd & exhales --> accentuates the AR murmur
-PR- medium-low pitched murmurs, unless there is Phtn
-@ LUSB to midstenal border, w radiation down the LSB
-Mid
-during rapid filling of ventricle, fr Q across the AV vlv
-low pitch (not much P diff bn the atrium and ventricle in diastole)
-often rumbling, best w bell of stethoscope
-fr MS & TS, or excessive flow thru a Nl sized AV vlv
-Austin-Flint murmur: sometimes an AR jet can hold the MV partly closed during diastole--> middiast murmur
-@apex- hear MS murmur, VSD murmur, PDA murmur, and MR during middiastole
-@LLSB- hear TS, ASD, Anom PVn return during middiastole
-Late (aka presystolic)
-fr Q thru a narrow AV vlv
-occur late in diastole bc of atrial contraction pushing Q thru the narrow vlv
-accentuated w atrial contraction (so absent if pt has a-fib)
-low frequency
-rare in kids bc rare to have TS & MS in kids
-Continuous
-start in systole & continue into/thru diastole
-nearly always vascular in origin
-Aortopulmonary- PDA, AP shunt (BTS), or Arteriovenous- AV fistula/coronary fistula, or Turbulence in the Arteries- Coarc, sev branch PA stenosis, or Turbulence in the Veins- venous hum
-PDA - #1 pathologic cont murmur
-loudest in systole, softest w diastole --> "machinery" like
-it is continuous bc there's always a P gradient bn Ao & PA, which increases w systole...
-best @L infraclavicular area if levocardia
-AP Shunt- sounds similar to PDA...
-AV Malformations- cor art fistula, pulm AV fistula, bronchial collaterals, pulm vssls arising fr truncus arteriosus- may be louder in diastole
-location varies by xx, but usually located on the low pressure side of the connection
-Venous Hum- can be benign,
-heard at L or R upper chest, disappear w changes in head position/compression of jugular vn
-low frequency & vary w respiration (R sided) and best heard w pt upright
-Obstructed TAPVR
-soft, high-pitched continuous murmur at the obst site
-site d/o location of the drainage... check the liver...
a- SEM
b- S1 coincident
c- late systolic
d- cont murmur of vascular origin
e- cont venous hum
f- early diastolic
g- late diastolic
Dynamic Auscultation
-assess in several positions, at least both w sitting & supine
-def check pts for a sports screen, and pts w collagen vasc d/o w supine, upright, and squat to stand to check for a click & murmur of MVP or ejection murmur of HOCM
-going fr squat to stand: first places incr AL on the heart--> enlarge the LV; then as pt stands the ventricle is relatively unloaded --> allow MV prolapse, or allow for dynamic outflow obstruction to be more manifest (in case of HOCM) (HOCM murmur will sound worse, as would MVP w MR)
-if pt had a Still's murmur it would soften w standing, increase w supine
-if pt has venous hum, it should disappear w change fr sitting to supine
INNOCENT MURMURS
-bc of noisy Q thru Nl heart
-heard in >50% of kids at some pt, espec at 3-4yrs old
-incr with incr CO- excited, anemic, febrile
-usually low intensity, low in frequency
-usually not harsh in quality
-all are systolic ejection, except for venous hum
-palpation is normal- PMI not displaced, precordium normal activity, pulses normal
-if +click, it is not innocent
Still Murmur
-#1 innocent murmur of childhood
-described as innocent, vibratory, functional, normal and physiologic; also as vibratory, musical, tanging string
-a systolic ejection murmur, loudest bn LLSB and apex
-I-III/VI intensity
-low frequ murmur
-best w pt supine, less w sit/standing
-varies with respiration- softer & less vibratory w inspiration
-Nl ECG & CXR
-?exact cause, likely relatively smaller Ao size --> incr q velocity thru Ao w ejection, or fr LV false tendons, w exaggerated vibrations of ventric contraction, or incr CO
-no need for imaging etc.
Pulmonary Flow Murmur of Childhood
-often heard in thin-chested pts 8-14yo
-loudest at LUSB
-sounds like a PS ejection murmur but not harsh, and no click or thrill
-1-3/6 intensity
-S2 has Nl physiologic split, w Nl P2 sound
-heard w incr CO- fever, anemia, pregnancy
-if present in a pt w/o incr in CO, then c/s ASD or other cause of increased Qp
Pulmonary Flow Murmur of Infancy
-aka Peripheral Pulmonary Flow aka Peripheral Pulmonary Stenosis
-common in newborn and early infancy, espec premies
-ejection murmur, radiate fr LUSB to lung fields- axillae and back
-?fr relatively small branch PA size just after birth, and the angle of takeoff fr the MPA as a newborn
-usually gone by 6 months
-if persists at >6mo, then c/s structural PA tree abNly, or xx w incr Qp (ASD)
Venous Hum
-only nonsystolic innocent murmur
-low frequency - "sounds like a motor running in the background"
-truly constant, when pt is upright
-some variation in pitch & intensity w respiration & cardiac cycle
-stops w maneuvers that occlude neck veins- direct compression w thumb, or turning head to look at the contralateral shoulder (or flexion)
-it is gravity driven, so should disappear when pt is flat w supine
Abdominal Exam
-important
-palpate last
-bending knees helps relax belly/reduce tension/ticklishness
-check liver & spleen size
-palpate pelvic brim & work slowly upward until the liver/spleen edge is felt
-percuss the liver to determine the margins/liver span - needed espec if lungs are hyperinflated which will push down the liver
Back Exam
-check scoliosis bc high risk if connective tissue d/o
Page updated
Google Sites
Report abuse