Auscultation of The Heart Dr. R. Tandon Sitaram Bhartia Institute, New Delhi

1. Auscultation of The HeartDr. R. TandonSitaramBhartia Institute, New Delhi

2. First Sound (S1) • Due to closure of MV/TV • Accentuated, diminished or variable intensity • Wide split – Rt. BBB.

3. First Sound (S1) Accentuated : Loud M1 • Tachycardia • Short PR interval • Mitral stenosis • VSD, PDA. • LVH Loud T1 : ASD, TAPVC Tricuspid Stenosis

4. First Sound (S1) Diminished :- • S2 > S1 at apex. •  LV contractility • 1° AVB • AR

5. First Sound (S1) Variable Intensity • Comp. AVB • Atrial fibrillation.

6. Second Sound Normal :- • Two components A2 & P2 • A2 louder than P2 • Insp.; split S2; A2-P2 • Exp. : Single S2 • A2 all over the precordium • P2 - 2-3 ULSB

8. Second Sound Abnormalities : A2 or P2 Intensity : Increased or decreased Timing : Early or late

11. Second Sound Splitting :- • Normal. • W&V - PS, PAPVC - IAS, MR, VSD • W&F - ASD, TAPVC, Rt. BB, WPW(A) • Single - A2 or P2 or A2 + P2 • Paradox - AS, PDA, LVF, Lt. BB, WPW (B)

12. Third Sound (S3) • End of early diast. filling. • Dull, 50 to 100 msec after S2. • Normal in children and young adults • Abnormal above 40 yrs. • Left or right sided.

13. Fourth Sound • Abnormal if audible. • Rt. / Lt. sided • Rt. / Lt. atrial hypertension (high RV/LV edp). • Audible intermittently in comp. AVB. • Acute MR - S4+.

14. Systolic Clicks (x) • Loud sharp sounds • Ejet. or Non-eject. • Eject – Aortic, pulmonary – single. • Non-eject - MV / TV prolapse - single or multiple.

15. Systolic Clicks • Aortic : Constant, early • Heard all over the precard • Bicuspid AoV. • Dilated Asc, Ao Syst. hypertension, aneurysms Fallot’s physiology, PTA. • Disapear - fibrosis, calcification.

16. Systolic Clicks Pulmonary :- • PS or PAH at ULSB. • PS - Valvar PS - Audible in expirat. only -  severity - closer to SI • PAH - PVOD - Constant

17. Systolic Clicks Non-Ejection : MVPS • Single or multiple. • Mid systolic but can be early - radiates to base and neck • Late murmur ±

18. A2 P2 S1 X Syst. m.

19. Opening Snap • Mitral, diast. sound • 40-120 msec after A2 • A2-OS interval - severity • Disappears in immobile valves • Tricuspid OS drowned in MSm.

21. Murmur Systolic - Pansystolic. Ejection systolic Diastolic * Semilunar valves - Regurgitant m. Early diastolic m. * Atriovent. Valves - Functional m. - Obstructive m. Delayed diast. (Middiast.) Late diast. (Presyst.) Continuous

25. S1 X A2 ES. m. AR. m.

26. S1 X A2 P2 ES. m. PR m.

27. S1 X A2 P2 ES. m. PR. m.

28. S1x S2 S1 x Cont. m.

29. S1x S2 S1 Cont. m.

32. Auscultation Clinical Utility :- • Murmurs present. • Murmurs absent.

33. Auscultation Clinical Utility :- Murmurs absent • Myocardial disease - Primary – DCM, RCM, HCM - Secondary to CAD • Pericardial disease Utility of S3, S4, S2, S1

34. Auscultation Clinical Utility :- Murmurs present • Cong. Ht. Dis. • Rh. Ht. Dis. • PMD - DCM – MR/TR HOCM - Outflow m. - MR. m. • Post M.I. - MR / VSD.

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