Auscultation of the heart. Functional and organic cardiac ..., Summaries of Cardiology

Download Auscultation of the heart. Functional and organic cardiac ... and more Summaries Cardiology in PDF only on Docsity! Auscultation of the heart. Functional and organic cardiac murmurs Heart murmurs • Heart murmurs are rather long sounds arising at turbulent movement of a blood. Turbulence appears at the disorder of a normal correlation of three hemodynamic parameters: 1) A diameter of a valve aperture or a lumen of a vessel; 2) The rate of a bloodstream (linear or volumetric); 3) A viscosity of a blood. • Murmurs, auscultated above the cardiac area and large vessels, are divided into intracardiac and extracardiac. Organic systolic murmurs • They arise in atrioventricular valves insufficiency, aortic and the pulmonary stenosis. • Systolic murmur at the heart apex is listened in mitral valve insufficiency. • Murmur is loud, rough, long, has decreasing character, radiates in the left axillary fossa, it is combined with weakened I sound, and not frequently with III tone. Murmur increases in the position of patient on the left side, in a delay of breath on an exhalation, after physical loading. Normal blood flow Abnormal closed valve Mitral valve The murmur of mitral regurgitation Sy Se • Systolic murmur on an aorta is listened in: 1. Aortic stenosis - ejection murmur. The characteristic finding is a rough, loud, low, long systolic murmur over the 2nd interspace transmitted into the neck on the carotids, with a corresponding thrill and a diminished or absent 2nd aortic sound; 2. Systolic murmur connected with atherosclerotic changes of aortic valves can be listened in older persons on an aorta. • Organic systolic murmur over pulmonary trunk is listened rarely. The reasons of it can be: pulmonic stenosis, atrial septal defect (soft, short murmur), patent ductus arteriosus (systolodiastolic murmur, where systolic component is a rough, loud transmitted to all precardial area, neck vessels and axillary fossa). • Systolic murmur in tricuspid regurgitation is best heard over tricuspid area, it has decreasing character, it is not always combined with the weakened first sound, transmitted to both sides from a sternum, and it may became louder with inspiration (Carvallos sign). • The loudest and rough systolic murmur of ventricular septal defeat is heard best in the 3rd and 4th left intercostal spaces, transmitted to the axillary fossa and interscapular space. The murmur of tricuspid regurgitation Sa Sz Sa Sa Expiration Inspiration Diastolic murmurs • They are heard due to narrowing of atrioventricular orifices, aortic and pulmonic insufficiency. • Diastolic murmur at the heart apex is heard in mitral stenosis. The murmur has a decrescendo quality through early and middiastole. During the latter third of diastole the gradient increases sharply due to atrial contraction causing a presystolic accentuation of the murmur. It is usually heard on the limited area with the patient rolled onto his left side, it is combined with a “triple rhythm”: an accentuated 1st sound, 2nd sound and mitral opening snap. Normal valve Leakage operation of valve Timing of diastolic murmurs Aortic r Valve closes after Valve does not close 4 ml left ventricle pumps completely, leaking ee blood into aorta blood into heart Diastolic murmurs. Tricuspid stenosis. Pulmonary regurgitation Functional murmurs • All functional murmurs are conditionally divided into three groups: 1) Dynamic murmurs, the basis of which is substantial growth of the rate of a bloodstream at the absence of any organic diseases of the heart (for example, dynamic murmurs in a thyrotoxicosis, a neurosis of the heart, feverish conditions). 2) Anaemic murmurs, which reason is the decreasing of a viscosity of a blood and some acceleration of a bloodstream in patients with anaemia of different origin. 3) Murmurs of relative insufficiency of valves or relative stenosis of valval apertures are caused by various infringements of the function of the valval device, including in patients with organic diseases of the heart. Remember: 1) The relative insufficiency of the mitral valve, caused by dilation of fibrous ring, can develop at dilatation of the left ventricle in patients: • with arterial hypertension of any origin; • with aortal heart diseases, mainly in a stage of a decompensation (so-called the mitralization of an aortal defect); • with a heart failure of any origin (due to the myogenic dilatation of the left ventricle). 2) The relative insufficiency of the tricuspid valve, caused by the dilation of a fibrous ring, can develop in patients with appreciable dilatation of the right ventricle: • in late stages of a mitral stenosis; • in the decompensative cor pulmonale (due to myogenic dilatation of a right ventricle). • II. The second reason of murmurs of the relative insufficiency is the dysfunction of the valval device (chordas and papillary muscles). The prolapse (a diverticulum, a caving) of one of cusps in a cavity of an atrium during a systole of ventricles develops in an infarct of the papillary muscle, congenital elongation or the acquired break of one of chords of atrioventricular valves. It leads to incomplete closing of cusps and to development of the relative insufficiency of the atrioventricular valve. Thus a short systolic murmur (more often meso- or late systolic) is heard. It is usual at the kept I sound. • III. The third reason of functional murmurs of the relative insufficiency of valves or a relative stenosis of valval apertures is hemodynamic displacements of cusps of valves, dilatation of aorta or pulmonary artery and some other reasons. • Graham-Still’s murmur is the functional diastolic murmur of the relative insufficiency of the valve of the pulmonary artery, arising at long increasing of the pressure in a pulmonary artery (for example, in patients with a mitral stenosis, primary pulmonary hypertension, cor pulmonale). In the II intercostal space to the left of the sternum and by a left edge of a sternum it is auscultated thus the silent, decreasing diastolic murmur beginning at once with the II sound. Flint’s murmur Systole of an atrium Flint’s murmur Organic murmur of aortic regurgitation • Coombs murmur is functional mesodiastolic murmur caused by a relative stenosis of the left atrioventricular aperture, arising in patients with the expressed organic insufficiency of the mitral valve under condition of the appreciable dilatation of the LV and LA and the absence of the dilation of the fibrous ring of the valve. Under these conditions the heart (LV and LA) reminds under the form a sand-glass with rather narrow intersection in the field of the left atrioventricular aperture. This aperture for the short time becomes rather narrow for the enlarged volume of a blood in the LA during the moment of the emptiness of the LA atrium in the phase of the fast filling and there is a relative stenosis of the left atrioventricular aperture with a turbulent stream of a blood from the LA to the LV. At a heart apex, besides organic systolic murmur of mitral insufficiency it is possible to listen to the short and silent mesodiastolic murmur caused by a functional mitral stenosis. Coombs murmur Organic murmur Coombs murmur The extracardiac murmurs • Pericardial friction murmur appears when the layers of a pericardium becomes rough. It is observed in: a) a dry (fibrinous) pericarditis; b) an aseptic pericarditis in patients with an acute myocardial infarction; c) an uremic pericarditis in patients with the renal failure. • Pericardial friction murmur is auscultated during systole and diastole and resembles a crunch of a snow, a rustle of a paper or a gnash, scratching. • Remember: • Pericardial friction murmur differs from the endocardiac murmurs by the following signs: 1) it is auscultated on the circumscribed site more often, it is usual in a zone of the absolute cardiac dullness, and it is not irradiated anywhere; 2) it amplifies at pressing by a phonendoscope on anterior thoracic wall; 3) it is very changeable sound phenomenon; 4) it is auscultated in both phases of a cardiac activity. • Pleuropericardial friction murmur appears in an inflammation of pleura, immediately adjoining to the heart, due to the friction of layers of pleura with each other synchronously with cardiac contractions. As a matter of fact the pleuropericardial friction sound represents a pleural friction sound, auscultated on the circumscribed site. • Remember: • Pleuropericardial friction murmur should be distinguished from a pericardial friction murmur by the following signs: 1) it is auscultated usually by a left border of relative cardiac dullness; 2) it amplifies at the height of a deep inspiration; 3) it is weakened or disappears at the maximal exhalation and a breath holding. Thank you for attention