Sec4 “ auscultation “ seminar

Cardiac cycle and heart sound

1-atrioventricular valve : ( mitral , tricuspid)
Function : prevent move blood from ventricular to atrium ( when pressure in ventricular higher )
Produce : sound 1 ( lub ) in the beginning of systole ( contraction atrium )
‫ٮﺮﰷل‬,‫ٮ‬+‫ڡ‬+‫ﻮدي اﻟﺪم ﻟﻠ‬B ‫ريﻢ ﻋﻠﺸﺎن ٮ‬,‫ى (ٮيﺤﺼﻞ ﻣﻦ اﻻٮ‬7‫ٮﺮﻛﺸﻦ ال‬,‫ٮ‬+‫ٮﺞ ﻋﲆ اﻟﻜﻮ‬,‫ٮ‬+‫اﻟﺼﻮت دا (ٮي‬
2-semilunar valve;(pulmonary, aorta )
Function: ventricular filling blood more pressure ( when ventricular contraction and out blood
toward aorta ) will close valve to prevent move blood from aorta or pulmonry ( when high
pressure) to ventricular
Produce: sound 2 ( Dub ) in the beginning of diastolic ( sound ventricular contraction)

Auscultatory area
Aortic , pulmonary, tricuspid, mitral ( apex of heart
A-aortic: right second intercostal space parasternal line
B-pulmonary : left second intercostal space parasternal line
C-tricuspid: fourth left intercostal space parasternal line ( or left border of sternal )
D-mitral (in apex ) : fifth left intercostal space mid clavicular line

How to exam ( note )

1-use diaphragm to listen ( high pitch sound ) S1,S2 + use bell to listen ( low pitch sound ) S3,S4
2-put Stethoscope anterior to be parallel external auditory canal
3-must patient bare skin in quiet area
4-warming Stethoscope
5-count intercostal
6-to sound high pitched by diaphragm then roll Stethoscope to sound by bell
‫ٮﻌﻤﻠﻬﻢ كﻠﻬﻢ‬+‫ڡﻠﺐ اﻟﺴﻤﺎﻋﻪ و‬,‫ٮ‬+‫ٮﻌﻤﻠﻬﻢ كﻠﻬﻢ و‬+‫ﺖ او (ٮ‬B ‫ڡﻠﺐ اﻟﺴﻤﺎﻋﻪ ﻣﻊ كﻞ ﺳﺎٮ‬,‫ٮ‬+‫(ٮ‬

Normal sound ( S1,S2) :

S1:
Character :high pitched loud sound
Cause: atrioventricular valve close
Timing: beginning of systolic
Best heard : tricuspid, mitral by diaphragm
S2
Character :high pitched loud sound
Cause: semilunar valve close
Timing: beginning of diastolic
Best heard : base of heart ( aorta, pulmonary ) by diaphragm

Normal splitting of Sound 2 ( S2) ( physiological)

Occur during deep inspiration
Mechanism:
1-deep inspiration lead to increase volume of chest
2-when increase volume of chest lead to decrease intra thorax pressure
‫ڡﻞ‬,‫ٮ‬B‫ﻌﻂ ﻫ‬U‫ﻜ(ٮﺮ اﻟﻤﲀن اﻟﺼ‬B ‫ﻟﻤﺎ ٮ‬
3-when decrease pressure lead to faster venus return
4-venus return inter right side of heart in right atrium lead to fill right ventricular
‫ٮﻜون ﻋﲆ ﻣراﺣﻞ‬,‫ﺤﻄﻮه دي (ٮ‬+‫(ٮﺲ اﻟ‬
5-right ventricular need more time to complete filling lead to one contraction
‫ٮراﻛﺸﻦ ﻣرا وﺣﺪه‬,‫ٮ‬+‫ﻌﻤﻞ ﻛﻮ‬,‫ﺤﻠﺺ ﻋﻠﺸﺎن ٮ‬+,‫ريﺎم ٮ‬,‫ى اﻻٮ‬7‫ڡ‬+ ‫ى‬7‫ٮﲏ كﻞ اﻟﺪم ال‬,‫(ٮيﻜون ﻣﺴ‬
6-lead to slow contraction in right ventricular but the past circulation left ventricular finishing
‫ٮﻪ‬+‫ٮﺞ ﻋ‬,‫ٮ‬+‫ٮﻦ ورا (ٮﻌﺾ (ٮي‬B,‫ٮﻌﻤﻞ ﺻﻮٮ‬B‫ڡ(ٮ‬+ ‫ٮﻦ‬B‫ٮﻤ‬B‫ٮﺴﻤﻊ ﺻﻮت اﻟﺸﻤﺎل (ٮﻌﺪﻫﺎ ﺻﻮت اﻟ‬+‫ٮﺎ (ٮ‬+‫ڡﺎﺣ‬+
7-Lub dup dup

Abnormal heart sounds

S3( lub dup dup )
Character :low pitched sound by bell
Cause:
-phy: children and young adult and athlete
-pathological: tricuspid regurgitation , mitral regurgitation, atrial septal defect , ventricular septal
defect
Timing: after s2 ( early diastolic)
Best heard : apex of heart
Problem in Cardiomyopathy: dilation

Cardiomyopathy: problem in muscle of heart, may dilation ( heart itself large ) or hyper
atrophy( muscle wall thickness )
S4( LA LA dup )
Character :low pitched sound by bell
Cause:
“ kitting of blood against wall of ventricular “
-phy: old age (>60 year ) by stiffness ventricular
-pathological:
Hypertension
Ischemic heart disease ( MI , angina)
Timing: end of diastolic before S1
Can determine by hear low pitched ( s4) before high pitched (s1)
Best heard : apex of heart
Problem in Cardiomyopathy: hyper atrophy

Others abnormal sounds

1-gallop sound : abnormal conditions hear 4 sounds plus tachycardia ( high rate of heart )
‫ٮﺴﻤﻊ ﺻﻮت ر(ﺣﻞ اﻟﺤﺼﺎن‬+‫(ٮ‬
2-murmur sound : turbulent blood flows
ّ ‫ﺻﻮت َو‬
( ‫ٮور(ٮيﻦ ) اﻟﻌ(ﺤﻼت‬,‫ش او اﻟ‬
Causes :
A-passage of blood through stenosis
B-passage of blood through dilation structure ( pulmonary hypertension)
C-shunt : atrial septal defect , ventricular septal defect

Thrill : palpation murmur

‫ڡﻄﻪ‬,‫ﺣﺮه زي ﺿﻬﺮ اﻟ‬+‫ﺣﺮ‬+ ‫ٮﺴﺖ ﻫﺤﺲ (ٮﺼﻮت‬B‫ﺪي ﻋﲆ اﻟﺸ‬B ‫ﻫﺤﻂ اٮ‬
-how differentiation murmurs sound
Best heard in apex of heart by diaphragm
Palpation carotid artery
-if hear sound of murmur when pulse mean “ systolic murmur “
-if hear sound of murmur when no pulse ‫ٮﻬﻢ‬+‫ى (ٮي‬7‫ڡﺖ ال‬,‫ اﻟﻮ‬mean “ diastolic murmur “
Grades of murmur:
1-grade 1: poorly audible ( need experienced)
2-grade 2 : soft murmur
3-grade 3: audible without thrill
4-grade 4: easy audible with thrill
5-grade 5: easy audible with thrill ( very loud , audible with light touch of chest )
6-grade 6 : loudest audible with thrill ( very loud , audible with no touch of chest )