Cardiac auscultation

1. BPT 4TH 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 3rd to 5th
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 4th or 5th 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
2nd interspace at the sternal border (aortic area), then left
3rd, 4th and 5th 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;
i. Aortic region (between the 2nd and 3rd intercostal spaces at the right sternal
border) (RUSB – right upper sternal border).
ii. Pulmonic region (between the 2nd and 3rd intercostal spaces at the left sternal
border) (LUSB – left upper sternal border).
iii. Tricuspid region (between the 3rd, 4th, 5th, and 6th intercostal spaces at the left
sternal border) (LLSB – left lower sternal border).
iv. 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.

15. 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).

16. 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.

17. 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