Slide 1 ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 2 ___________________________________ HEART SOUNDS ___________________________________ THAT MATTER Willard Baker, Jr. MMS PA-C ___________________________________ DFAAPA ___________________________________ ___________________________________ ___________________________________ ___________________________________ 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. ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 4 ___________________________________ First Things First! History ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 5 ___________________________________ Exam of the Patient • Position of the Patient ___________________________________ • Procedure of the exam • Possible sounds or things palpated ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 6 ___________________________________ Position of the Patient • Upright ___________________________________ • Upright and leaning forward • Recumbent at 30degrees • Left lateral decubitus ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 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 ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 8 Palpable Sensations ___________________________________ Possible Heart Sounds • S1, S2, ___________________________________ • S3, S4 • Rate & Rhythm • Thrill • Lifts ___________________________________ • Murmurs *** ___________________________________ ___________________________________ ___________________________________ ___________________________________ 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 ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 10 ___________________________________ Normal S3 Third Trimester of ___________________________________ Pregnancy Small Children Young Adults ___________________________________ *** ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 11 ___________________________________ Pathological S3 • Ventricular Dysfunction: ___________________________________ • Myocardial ischemia • Cardiomyopathies • Myocarditis ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 12 ___________________________________ Normal S4 • Trained Athletes ___________________________________ • Healthy Older People ___________________________________ ___________________________________ *** ___________________________________ ___________________________________ ___________________________________ Slide 13 ___________________________________ Pathological S4 • Associated with hypertension ___________________________________ • Hypertrophic Heart Disease • Aortic Stenosis • Cardiac Heart Disease ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 14 ___________________________________ A Split S2 • Physiological – normal & associate with deep inspiration ___________________________________ • Paradoxical – abnormal & associated Left Bundle Branch Block (LBB) ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 15 ___________________________________ Rate & Rhythm • Rate – Bradycardic, Normal, Tachycardic ___________________________________ • Rhythm – Normal, Regularly Irregular, Irregularly Irregular, & pauses ___________________________________ *** ___________________________________ ___________________________________ ___________________________________ ___________________________________ 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 ___________________________________ *** ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 17 ___________________________________ Cardiac Rub • Pericarditis – inflammation of the pericardium ___________________________________ ___________________________________ *** ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 18 Pericardial Effusion or ___________________________________ Tamponade • Distant or muffled heart sounds ___________________________________ • Associated JVD • Pulsus paradoxus ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 19 ___________________________________ Murmurs • Innocent ___________________________________ • Pathological • Caused by turbulence: • strictured valve • incompetent valve ___________________________________ • septal defect • hypertrophic obstructive cardiomyopathy (HOCM) ___________________________________ ___________________________________ ___________________________________ ___________________________________ 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 ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 21 ___________________________________ Pathology Potentials • Aortic – Stenosis & Insufficient (Regurgitation) ___________________________________ • Mitral – Stenosis & Insufficient • Tricuspid – Stenosis & Insufficient • Pulmonic – Stenosis & Insufficient • HOCM – Stenosis ___________________________________ • Artrioseptal Defect • Ventioculoseptal Defect ___________________________________ ___________________________________ ___________________________________ ___________________________________ 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) ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 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) ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 24 ___________________________________ Murmur Evaluation – Modified • Timing ___________________________________ • Affected by inspiration