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HEART SOUNDS ______THAT MATTER Willard Baker, Jr. MMS PA-C ______DFAAPA
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Slide 3 ______Objectives
• After attending this workshop the attendees will be able to distinguish between normal and abnormal heart sounds ______• Attendees will utilize case study histories, and physical findings to determine the etiology of the heart sounds. • Attendees will utilizes the Student Auscultation Manikin II (SAM II) system. This will allow the attendees to audibly distinguish between ______various cardiac sounds using an infrared stethoscope. • Utilize the mnemonic TPLRP to help identify specific murmurs. ______
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______Slide 4 ______First Things First! History ______
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Slide 5 ______Exam of the Patient • Position of the Patient ______• Procedure of the exam • Possible sounds or things palpated ______
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Slide 6 ______Position of the Patient • Upright ______• Upright and leaning forward • Recumbent at 30degrees • Left lateral decubitus ______
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______Slide 7 ______Procedure of the Exam
• Observation (inspection) – does the patient look sick, neck, chest, extremities ______• Palpation of the four cardiac points – Aortic, Pulmonic, Tricuspid, Mitral, neck, femoral and radial pulses • Auscultation - (APTM), neck, back and blood pressure ______
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Slide 8 Palpable Sensations ______Possible Heart Sounds • S1, S2, ______• S3, S4 • Rate & Rhythm • Thrill • Lifts ______• Murmurs
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Slide 9 ______S1,S2,S3&S4
• S1 High Pitch Sound Diaphragm ______• S2
• S3 Low Pitch Sound Left Lateral Decubitus May be • Bell Normal or Pathological S4 S3 early diastole S4 late diastole ______
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______Slide 10 ______Normal S3
Third Trimester of ______Pregnancy Small Children Young Adults ______
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Slide 11 ______Pathological S3 • Ventricular Dysfunction: ______• Myocardial ischemia • Cardiomyopathies • Myocarditis ______
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Slide 12 ______Normal S4 • Trained Athletes ______• Healthy Older People
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______Slide 13 ______Pathological S4 • Associated with hypertension ______• Hypertrophic Heart Disease • Aortic Stenosis • Cardiac Heart Disease ______
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Slide 14 ______A Split S2 • Physiological – normal & associate with deep inspiration ______• Paradoxical – abnormal & associated Left Bundle Branch Block (LBB)
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Slide 15 ______Rate & Rhythm • Rate – Bradycardic, Normal, Tachycardic ______• Rhythm – Normal, Regularly Irregular, Irregularly Irregular, & pauses
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______Slide 16 ______Rhythm
• Regularly Irregular – Premature Ventricular Contractions (PVC’s), Blocks (Mobitz I or II) ______• Irregularly Irregular – Atrial Fibrillation & Complete Heart Block • Pause – Sick Sinus Syndrome ______
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Slide 17 ______Cardiac Rub • Pericarditis – inflammation of the pericardium ______
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Slide 18 Pericardial Effusion or ______Tamponade • Distant or muffled heart sounds ______• Associated JVD • Pulsus paradoxus ______
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______Slide 19 ______Murmurs • Innocent ______• Pathological • Caused by turbulence: • strictured valve • incompetent valve ______• septal defect • hypertrophic obstructive cardiomyopathy (HOCM) ______
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Slide 20 ______Murmur Timing • Systolic – S1 “Lub” • Aortic Stenosis ______• Pulmonary Stenosis • Mitral Insufficiency • Tricuspid Insufficiency • Diastolic –S2 “Dub” • Mitral Stenosis ______• Tricuspid Stenosis ALL Diastolic Murmurs • Aortic Insufficiency Are Pathological • Pulmonary Insufficiency ______
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Slide 21 ______Pathology Potentials • Aortic – Stenosis & Insufficient (Regurgitation) ______• Mitral – Stenosis & Insufficient • Tricuspid – Stenosis & Insufficient • Pulmonic – Stenosis & Insufficient • HOCM – Stenosis ______• Artrioseptal Defect • Ventioculoseptal Defect ______
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______Slide 22 ______Murmur Evaluation - Typical • TIMING (DIASTOLIC/SYSTOLIC) (early, mid, late) ______• AFFECTED BY BREATHING (YES Rt./NO Lt.) • LOCATION – heard best(2ND ICS LT., 4TH ICS LT, etc.) • [Aortic, Pulmonic, Mitral, Tricuspid] • INTENSITY (1/6,2/6,3/6,4/6-thrill,5/6, 6/6) ______
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Slide 23 ______Murmur Evaluation - Typical • RADIATES (LT. AXILLA, NECK, BACK, LEAN) ______• QUALITY (HARSH,BLOWING,MUSICAL) • PATTERN (CRESENDO,DECRESENDO, HOLOSYSTOLIC) • PITCH (HIGH-DIAPH./LOW-BELL or Both) ______
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Slide 24 ______Murmur Evaluation – Modified • Timing ______• Affected by inspiration (Pulmonary) • Location • Radiate • Pitch ______
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The Proud Lion Roared Perfectly ______
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Slide 26 ______Aortic Stenosis • Occurs during? (timing – systolic/diastolic) ______• Affected by respiratory inspiration? (yes/no) • Heard best where? (location) • Heard best with the? (diaphragm/bell) • Does it radiate? ______• Valsalva maneuver? (increases/decreases)
Squatting increases intensity of the murmur *** ______
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Slide 27 ______Hypertrophic Cardiomyopathy • Occurs during? (timing – systolic/diastolic) ______• Affected by respiratory inspiration? (yes/no) • Heard best where? (location) • Heard best with the? (diaphragm/bell) • Does it radiate? ______• Valsalva? (increases/decreases) Squatting? ______
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______HOCM Hyp’s the Volume But Not worth a Squat ______
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Slide 29 ______Ventricular Septal Defect VSD • Occurs during? (timing – systolic/diastolic) ______• Affected by respiratory inspiration? (yes/no) • Heard best where? (location) • Heard best with the? (diaphragm/bell) • Does it radiate? ______• Valsalva maneuver? (increases/decreases) ______
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Slide 30 ______Aortic Insufficiency • Occurs during? (timing – systolic/diastolic) ______• Affected by respiratory inspiration? (yes/no) • Heard best where? (location) • Radiates? • Heard best with the? (diaphragm/bell) ______• Character? • Intensity? *** ______
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______Slide 31 ______Mitral Stenosis • Occurs during? (timing – systolic/diastolic) ______• Affected by respiratory inspiration? (yes/no) • Heard best where? (location) • Radiates? • Heard best with the? (diaphragm/bell) ______• Character? • Intensity? *** ______
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Slide 32 ______Tricuspid Stenosis • Occurs during? (timing – systolic/diastolic) ______• Affected by respiratory inspiration? (yes/no) • Heard best where? (location) • Radiates? • Heard best with the? (diaphragm/bell) ______• Character? • Intensity? • Plus? ______
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Slide 33 ______Mitral Insufficiency • Occurs during? (timing – systolic/diastolic) ______• Affected by respiratory inspiration? (yes/no) • Heard best where? (location) • Heard best with the? (diaphragm/bell) • Character? ______• Intensity?
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______Slide 34 ______Mitral Valve Prolapse • Occurs during? (timing – systolic/diastolic) ______• Affected by respiratory inspiration? (yes/no) • Heard best where? (location) • Radiates? • Heard best with the? (diaphragm/bell) ______• Character? • Intensity?
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Slide 35 ______Tricuspid Insufficiency • Occurs during? (timing – systolic/diastolic) ______• Affected by respiratory inspiration? (yes/no) • Heard best where? (location) • Heard best with the? (diaphragm/bell) • Character? ______• Intensity? • Plus? ______
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Slide 36 ______PDA • Occurs during? (timing – systolic/diastolic) ______• Affected by respiratory inspiration? (yes/no) • Heard best where? (location) • Heard best with the? (diaphragm/bell) • Character? ______• Intensity?
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Case studies ______
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You are seeing a Guyanese male who is approximately 59 years-old and accompanied by his son. ______The son tells you that his father “has been falling a lot”. His hx. Is significant for recurrent bouts of malaria, no injuries from his falls and no hx. of surgeries. ______He is not on any medication and has no known allergies. ______
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The Guyanese man walks into the exam area without help and did not appear to be in distress. ______His chest was of normal size and configuration. There were no observed abnormalities but there was a palpable lift, associated thrill & his PMI was lateral to the MCL His rate & rhythm was normal but you hear the ______following on auscultation.
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Slide 41 ______Findings: • Carotid pulses are diminished ______• Associated with an upstroke of the carotid pulse T • On inspiration the murmur does not get louder P • It is heard best over the 2ICS LSB L • It does radiate into the patient’s neck R ______• Heard with the diaphragm and bell of the stethoscope P ______
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Slide 42 ______A 24yr. old female who presents with a hx. of intermittent episodes of chest pain, palpitations and a sensation she is about to die over the past two years. ______She has no major significant hx. other than the presenting complaint. No use of alcohol, tobacco or street drugs. She is not ______on OCM’s.
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______Slide 43 ______On exam of the heart there is no observed or palp. lifts or thrills. On auscultation she has the following sounds over the apex area while the patient is in the reclined and ______sitting position. Also noted that her sternum is slightly depressed consistent with pectus excavatum. ______
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Slide 44 ______Findings • Heard shortly after the upstroke of the carotid T ______• Inspiration does not affect it P • Heard best at the 5ICS MCL L • Does not radiate R • Heard with the diaphragm P ______
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Slide 45 ______A 24-year-old male presents to your clinic with an awareness over 50+hours of an irregular heart rate. He is generally well but has a history of hypertension ______(too many super-jumbo burgers … with bacon … he's been “supersized”), which he has been trying to control with exercise and diet (he switched to ______tofu burgers yesterday). ______
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______Slide 46 ______There is no prior history of cardiac disease or palpitations. No family hx. of heart disease. He smokes “socially”. He did “have a bit to drink.” “Celebrating ______… well, whatever, just celebrating … who needs a reason!” He was embarrassed about his drinking and thus waited 2 days to seek care. ______
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Slide 47 ______Vital signs reveal an irregular radial pulse of ~130 bpm and a blood pressure of 146/92 mm Hg. The patient seems somewhat anxious, but is ______afebrile and has normal respirations. He has no heart murmur. But on auscultation you hear this. ______
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Slide 48 ______A 40yr. old homeless male is seen in your urgent care facility. He states that he has not been feeling well for almost a week. He says that he has felt like he had a fever ______and has had chills. Further hx. reveals that on several occasions he has used IV drugs. . ______
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______Slide 49 ______He appears chronically ill. His vital signs indicate his temp. being 102degrees F. His pulse is 110bpm His skin is pale and there are old ______injection sites of his arms without noted erythema or pus. He has bilateral bibasilar rales, and he has JVD. This is what you ______hear on auscultation
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Slide 50 ______Findings • No palpable upstroke of the carotid T ______• Murmur gets louder on inspiration P • Heard best in the 4ICS LSB L • Does not radiate R • Heard best with the bell P ______• There is JVD ______
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Slide 51 ______A 18-year-old female presents to your office with her parents. She runs track for her high school but seems to get “winded quickly” and “lightheadedness”. ______There is a hx. of palpitations, but no chest discomfort. She is taking no medications, and there is no family history of heart disease. ______
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______Slide 52 ______On exam she appears to not be in any distress at this time. On auscultation of her chest there is note a murmur. ______
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Slide 53 ______Findings • A double upstroke at the carotid pulse ______• Not affected by inspiration • Noted at the 2ICS RSB • Question of a bruit ¼ or the murmur radiating into the neck • Heard with diaphragm ______• Valsalva increased the intensity • Squatting decreased the intensity ______
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Slide 54 ______A 28-year-old male presents to your clinic with a gradual onset of dyspnea as well as orthopnea. His hx. essentially has been benign except for recurrent sore throats that ______eventually lead to a T&A at age 12yrs. He is moderately active but has noted that his endurance is significantly decrease over the last ______several months. He does smoke but not use of alcohol or drugs. ______
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______Slide 55 ______His vital signs at the time of exam T- 99 degrees F, P- 98, R- 12 On exam he is WD, WN and does not appear acutely ill. ______His chest appears normal but on palpation there is a suggestion of a lift. He has normal R/R but there is a ______murmur noted at the PMI & other areas of the chest.
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Slide 56 ______Findings • Heard throughout the heart cycle ______• Does not increase in intensity on inspiration • Noted at the apex & left sternal border • Systolic portion noted more in the LLD position with the bell • Diastolic portion noted more when leans forward ______• It is noted in the left axilla ______
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Slide 57 An 18-year-old high school ______student has just returned from a basketball game where he began experiencing chest pain that has been getting ______progressively worse over the last several hours. His father brings him into your night clinic and gives you a hx. that overall the patient has been health but ______has just gotten over “a nasty cold”. The pain is worse if he lays down and better if he sits up. ______
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______Slide 58 ______On exam he appears ill. His temp. is 101degrees F. He does have some cervical adenopathy that is nontender. ______Auscultation reveals the following sounds. ______
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Slide 59 ______A 6th month-old baby is brought in for its well baby check where you are practicing. The mother states that her pregnancy, L&D, and ______postpartum periods were without complication. The mother gave birth at home while on mission work in ______Central America
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Slide 60 ______On examination the child appears fearful but cooperative. Vital signs are normal. Exam is normal except for a systolic murmur that is ______heard. Findings: Heard best in the 2ICS RSB ______
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______Slide 61 Questions? ______?Preguntas? ______
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THANK YOU FOR YOU ATTENTION! ______
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