Cardiac auscultation

Cardiac auscultation

1. BPT 4 TH YEAR 402 PHYSIOTHERAPY IN CARDIOPULMONARY CONDITIONS Submitted By:- Stuti Sah Submitted To :- Dr. Jamal Ali Moiz Centre Of Physiotherapy And Rehabilitation Sciences, Jamia Millia Islamia , New Delhi CARDIAC AUSCULTATION

2. AUSCULTATION Auscultation is the medical term for using a stethoscope to listen to the sounds inside of our body. This simple test poses no risks or side effects. It is an integral part of physical examination of a patient and is routinely used to provide strong evidence in including or excluding different pathological conditions that are manifested clinically in the patient.   Auscultation is used to investigate the abnormal sounds which may indicate problem in these areas- Lungs Abdomen Heart Major blood vessels Potential issues can include: Irregular heart rate Crohn’s disease Phlegm

3. Skill in auscultation is dependent on the following four factors: A functional stethoscope Proper technique Knowledge of the different categories of lung sounds Knowledge of the different categories of heart sounds and murmurs Stethoscope- The stethoscope is an acoustic medical device for auscultation, or listening to internal sounds of an animal or human body. The stethoscope comprises a bell and a diaphragm. The bell is most effective at transmitting lower frequency sounds, while the diaphragm is most effective at transmitting higher frequency sound. In other words, the bell is designed to hear low pitched sounds and the diaphragm is designed to hear high pitched sounds. They are connected via rubber tubing to the ear pieces. These should be worn facing forward as the ear canals run anteriorly .

4. 1) Prerequisites of Auscultation –  Environment for auscultation- To optimize the effectiveness of auscultation the surroundings should be- Quiet - the ambient noise might interfere the heart and lung sounds. Warm - so that the patient feels comfortable while, the upper part of the body is being exposed. Also, it is to avoid shivering that may add the noise. Appropriate lighting - to allow good coordination between visual and auscultatory findings . Fig.- A Stethoscope

5. 2 ) Self preparation- We should ensure that we incorporate appropriate greeting processes, such as getting up from our seat and interacting personally and warmly with the person coming to see, and their supporters who may be present as their spokesperson. A person may not immediately reveal their name or their situation, without the preliminary formalities having been appropriately completed. Time needs to be allowed for issues to be set out and explained, talked through sufficiently for a clear decision pathway to emerge. Be aware that silence does not equal assent and may be more likely to indicate that further debate is required. Think through the whole procedure and consider the potential problems you might encounter Wash hands carefully in warm water.  

6. 3) Patient preparation- Introduce yourself and confirm about the client‘s identity. Explain and discuss the whole procedure, in order to reduce patient’s anxiety and embarrassment, and to ensure a better understanding, so that consent which is given, is well informed. Ask if the client wishes for a support person to be present. All upper clothing should be lifted clear of the area to be examined. When patients are embarrassed, shy, feeling powerless, frustrated, under scrutiny or at a disadvantage, they may express unhappiness, and this will require time and sensitivity to discover what is creating the unhappiness. Note the potential influence of cultural inhibitions on modesty and what is or isn‘t proper exposure is ingrained into most girls at an early age.

7. S.No . Action 1. Observe for general signs of heart and respiratory disease 2. Ask the patient to lower the gown. Indicating patient in control of exposure. 3. Inspect the chest for asymmetry, deformity, injury, scars, skin color, lifts/ heaves or pulsations, and increased or decreased antero -posterior chest diameter, or use of accessory muscles. 4. Palpate the ribs and sternum noting any tenderness, muscle spasm, surgical emphysema. Helps to distinguish traumatic chest pain from lung or cardiac pain. 5. Asses jugular venous pressure Position patient at 45 degree angle with head supported by pillows to allow for a natural zero point from which to measure the vertical height. To distinguish from arterial pulsation observe that JVP: Is visible but not palpable and as a more pronounced inward movement It is usually seen to flutter twice with every cardiac cycle(in normal sinus rhythm) When applying light pressure to the base of the neck it will disappear and return from the top Auscultation Proceed-

8. 6. On anterior chest, INSPECT , PALPATE and assess expansion and fremitus as shown

9. 7. PERCUSS the anterior and lateral chest in pattern as shown, noting any important notes Expect dullness over heart at 3 rd to 5 th interspace on left. 8. AUSCULTATE , noting intensity of sounds and vibration from normal. 9. If indicated, listen for transmitted voice sounds as before. 10. Position patient supine with head slightly elevated and examining from right- INSPECT and PALPATE for apical impulse. Normally located in 4 th or 5 th intercostal space, medial to midclavicular line. If location is difficult ask patient to exhale and hold breath. Note location, diameter, amplitude and duration. Positioning patient on left side increases the intensity of the apical beat.

10. 11. AUSCULTTE with the diaphragm of stethoscope at right 2 nd interspace at the sternal border (aortic area), then left 3 rd , 4 th and 5 th interspace at midclavicular line (mitral area) Intensity, rhythm and splitting of sound on each event of the cardiac cycle should be noted 12. Positioning patient over onto lest side, AUSCULTATE with the bell of stethoscope at apex (mitral area). Low pitched sounds of S3 and S4 and murmur of mitral stenosis are heard more easily.

11. 13. Asking patient to sit up, lean forward and hold breath in exhalation, listen with diaphragm of stethoscope along left sternal border and at apex, pausing periodically for patient to breathe. Accentuates aortic murmurs. Pericardial friction rub may be heard. 14. Ask the patient to hold their breath, AUSCULATE for bruits using the bell of the stethoscope over the carotid arteries in turn. Indicates arterial narrowing.

12. Cardiac examination- It should be noted that auscultation comes after palpation, the patient is normally lying comfortably at a 45 degree angle with their chest region fully exposed. There are four main regions of interest for auscultation, and a brief knowledge in human anatomy is crucial to pinpoint them. The four pericardial areas relate to the heart sounds and can detect various abnormalities in the heart such as the valve stenosis or incompetence which are diagnostic for many diseases in the cardiovascular system. Heart sounds- Superficial topographical landmarks assist the therapist in auscultation of heart sounds and murmurs. There are four reference areas for cardiac auscultation; Aortic region (between the 2nd and 3rd intercostal spaces at the right sternal border) (RUSB – right upper sternal border). Pulmonic region (between the 2nd and 3rd intercostal spaces at the left sternal border) (LUSB – left upper sternal border). Tricuspid region (between the 3rd, 4th, 5th, and 6th intercostal spaces at the left sternal border) (LLSB – left lower sternal border). Mitral region (near the apex of the heart between the 5th and 6th intercostal spaces in the mid- clavicular line) (apex of the heart).

13. The first heart sound ( Sl ) signifies the closing of the atrioventricular valves. Its duration is O. 10 seconds; it is heard the loudest at the cardiac apex. The two components of Sl are tricuspid and mitral. Both the diaphragm and the bell of the stethoscope can be used to hear Sl. Its loudness is enhanced by any condition in which the heart is closer to the chest wall (i.e., thin chest wall) or in which there is an increased force to the ventricular contraction (e.g., tachycardia resulting from exercise). The second heart sound (S2) represents the closing of the semilunar valves and the end of ventricular systole. Its components are aortic and pulmonic . Diaphragm of the stethoscope should be used to hear the split. The pulmonic component is the softer sound and is best heard at the LSB, in the second to fourth ICS. The two components may be heard best in the aortic and pulmonic areas, respectively.

14. Gallops - The third heart sound (S3) is a faint, low frequency sound and reflects the early (diastolic) ventricular filling that occurs after the atrioventricular valves open. An extra effort must be made to auscultate S3; the bell of stethoscope should be used. The ideal position to hear S3 would be left side lying; the bell would be placed over the cardiac apex. Causes of a pathological S3 may include ventricular failure, tachycardia, or mitral regurgitation. " Ken-TUCK'-y" is one sound that has been used to approximate the sound sequencing of S3 in the cardiac cycle (S1, S2,S3). The fourth heart sound (S4) signifies the rapid ventricular filling that occurs after atrial contraction. When present, it is heard before Sl. S4 may be heard in the "normal" trained individual with left ventricular hypertrophy. Location of S4 is similar to S3. It can be described as dull because of the sudden motion of stiff ventricles in response to increased atrial contraction. Pathologies eliciting an S4 may include systemic hypertension, cardiomyopathies , or coarction of the aorta. “ TENN'-ess-ee ” is a sound that approximates the sound sequencing when S4 is present (S4, S1, S2).

15. Murmur - Cardiac murmurs are the vibrations resulting from turbulent blood flow. These may be described based on position in cardiac cycle (systole, diastole), duration, and loudness. Systolic murmurs occur between S1 & S2; diastolic murmurs occur between S2 and S1. A continuous murmur starts in S1 and lasts through S2 for a portion or all of diastole. The loudness of a murmur is a factor of the velocity of blood flow and the turbulence created through a specific opening such as a valve. Murmurs are graded from grade I to VI. Murmurs that are Grade III or greater are usually associated with cardiovascular pathology.

16. Grades I to VI are described as follows:- GRADE DESCRIPTION I faint-requires concentrated effort to hear II faint-audible immediately III louder than II-intermediate intensity IV loud-intermediate intensity; associated with palpable vibration (thrill) V very loud-thrill present VI audible without stethoscope