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7/23/2019 Lecture-Heart Lung Sounds 2015.PDF (Dr Simon Ong)
http://slidepdf.com/reader/full/lecture-heart-lung-sounds-2015pdf-dr-simon-ong 1/48
SDPCN COURSE
PATIENT ASSESSMENT:
Modified Heart & Lung Sounds
26-8-15
2 – 5 pm (3 h)Simon Ong
7/23/2019 Lecture-Heart Lung Sounds 2015.PDF (Dr Simon Ong)
http://slidepdf.com/reader/full/lecture-heart-lung-sounds-2015pdf-dr-simon-ong 2/48
Overview
• Lecture (1h)
– Heart Sounds & murmurs
– Breath Sounds & adventitious sounds
• Simulator (2h)
– Heart Sounds & murmurs
– Breath Sounds & adventitious sounds
7/23/2019 Lecture-Heart Lung Sounds 2015.PDF (Dr Simon Ong)
http://slidepdf.com/reader/full/lecture-heart-lung-sounds-2015pdf-dr-simon-ong 3/48
7/23/2019 Lecture-Heart Lung Sounds 2015.PDF (Dr Simon Ong)
http://slidepdf.com/reader/full/lecture-heart-lung-sounds-2015pdf-dr-simon-ong 4/48
Auscultatory Areas
7/23/2019 Lecture-Heart Lung Sounds 2015.PDF (Dr Simon Ong)
http://slidepdf.com/reader/full/lecture-heart-lung-sounds-2015pdf-dr-simon-ong 5/48
S1S2
7/23/2019 Lecture-Heart Lung Sounds 2015.PDF (Dr Simon Ong)
http://slidepdf.com/reader/full/lecture-heart-lung-sounds-2015pdf-dr-simon-ong 6/48
Carotid Pulse
7/23/2019 Lecture-Heart Lung Sounds 2015.PDF (Dr Simon Ong)
http://slidepdf.com/reader/full/lecture-heart-lung-sounds-2015pdf-dr-simon-ong 7/48
S1 S1 S1 S1 S1S2 S2 S2 S2 S2
S1(Carotid Pulse)S2
7/23/2019 Lecture-Heart Lung Sounds 2015.PDF (Dr Simon Ong)
http://slidepdf.com/reader/full/lecture-heart-lung-sounds-2015pdf-dr-simon-ong 8/48
S1 S1 S1 S1 S1S2 S2 S2 S2 S2
S1S2
7/23/2019 Lecture-Heart Lung Sounds 2015.PDF (Dr Simon Ong)
http://slidepdf.com/reader/full/lecture-heart-lung-sounds-2015pdf-dr-simon-ong 9/48
S1
MitralValve
Closure
S2
AorticValve
Closure
Heart Sounds Due to Valve Slamming Shut
7/23/2019 Lecture-Heart Lung Sounds 2015.PDF (Dr Simon Ong)
http://slidepdf.com/reader/full/lecture-heart-lung-sounds-2015pdf-dr-simon-ong 10/48
S1
MitralValve
Closure
“lub”
S2
AorticValve
Closure
“dub”
7/23/2019 Lecture-Heart Lung Sounds 2015.PDF (Dr Simon Ong)
http://slidepdf.com/reader/full/lecture-heart-lung-sounds-2015pdf-dr-simon-ong 11/48
S1
“lub”
S2
“dub”
SYSTOLE
(ventricular
contraction)
7/23/2019 Lecture-Heart Lung Sounds 2015.PDF (Dr Simon Ong)
http://slidepdf.com/reader/full/lecture-heart-lung-sounds-2015pdf-dr-simon-ong 12/48
S1
“lub”
S2
“dub”
SYSTOLE
(ventricular
contraction)
DIASTOLE
(ventricular
relaxation)
DIASTOLE
(ventricular
relaxation)
7/23/2019 Lecture-Heart Lung Sounds 2015.PDF (Dr Simon Ong)
http://slidepdf.com/reader/full/lecture-heart-lung-sounds-2015pdf-dr-simon-ong 13/48
S1
“lub”
Split S2
“d-dub”
SYSTOLE
(ventricular
contraction)
DIASTOLE
(ventricular
relaxation)
DIASTOLE
(ventricular
relaxation)
A2 P2
7/23/2019 Lecture-Heart Lung Sounds 2015.PDF (Dr Simon Ong)
http://slidepdf.com/reader/full/lecture-heart-lung-sounds-2015pdf-dr-simon-ong 14/48
S1
“lub”
Split S2
“d-dub”
SYSTOLE
(ventricular
contraction)
DIASTOLE
(ventricular
relaxation)
DIASTOLE
(ventricular
relaxation)
A2 P2
S3
“ta”
S3 = dilated left ventricle, e.g. heart failure
7/23/2019 Lecture-Heart Lung Sounds 2015.PDF (Dr Simon Ong)
http://slidepdf.com/reader/full/lecture-heart-lung-sounds-2015pdf-dr-simon-ong 15/48
S1
“lub”
Split S2
“d-dub”
SYSTOLE
(ventricular
contraction)
DIASTOLE
(ventricular
relaxation)
DIASTOLE
(ventricular
relaxation)
A2 P2
S3
“ta”
S4
“ta”
S4 = non-compliant left ventricle, e.g. LVH or MI
7/23/2019 Lecture-Heart Lung Sounds 2015.PDF (Dr Simon Ong)
http://slidepdf.com/reader/full/lecture-heart-lung-sounds-2015pdf-dr-simon-ong 16/48
Heart Sounds & Added Heart Sounds
• “lub, dub” (S1S2)
• “lub, d-dub” (S1, split S2)
•
“lub dub-ta” (S1S2 & S3) • “ta-lub dub” (S1S2 & S4)
7/23/2019 Lecture-Heart Lung Sounds 2015.PDF (Dr Simon Ong)
http://slidepdf.com/reader/full/lecture-heart-lung-sounds-2015pdf-dr-simon-ong 17/48
Left Ventricle
LEFT
VENTRICLE
MITRAL
VALVE
AORTIC
VALVE
7/23/2019 Lecture-Heart Lung Sounds 2015.PDF (Dr Simon Ong)
http://slidepdf.com/reader/full/lecture-heart-lung-sounds-2015pdf-dr-simon-ong 18/48
Normal Systole
LEFT
VENTRICLE
MITRAL
VALVE
AORTIC
VALVE
7/23/2019 Lecture-Heart Lung Sounds 2015.PDF (Dr Simon Ong)
http://slidepdf.com/reader/full/lecture-heart-lung-sounds-2015pdf-dr-simon-ong 19/48
Normal Systole
LEFT
VENTRICLE
MITRAL
VALVE
AORTIC
VALVE
7/23/2019 Lecture-Heart Lung Sounds 2015.PDF (Dr Simon Ong)
http://slidepdf.com/reader/full/lecture-heart-lung-sounds-2015pdf-dr-simon-ong 20/48
Normal Diastole
LEFT
VENTRICLE
MITRAL
VALVE
AORTIC
VALVE
7/23/2019 Lecture-Heart Lung Sounds 2015.PDF (Dr Simon Ong)
http://slidepdf.com/reader/full/lecture-heart-lung-sounds-2015pdf-dr-simon-ong 21/48
Normal Diastole
LEFT
VENTRICLE
AORTIC
VALVE
MITRAL
VALVE
7/23/2019 Lecture-Heart Lung Sounds 2015.PDF (Dr Simon Ong)
http://slidepdf.com/reader/full/lecture-heart-lung-sounds-2015pdf-dr-simon-ong 22/48
What Can Go Wrong During Systole?
LEFT
VENTRICLE
MITRAL
VALVE
AORTIC
VALVE
7/23/2019 Lecture-Heart Lung Sounds 2015.PDF (Dr Simon Ong)
http://slidepdf.com/reader/full/lecture-heart-lung-sounds-2015pdf-dr-simon-ong 23/48
Systolic Murmurs
LEFT
VENTRICLE
MITRAL
REGURGITATION
AORTIC
STENOSIS
CANNOT
OPEN FULLY
CANNOT
CLOSE FULLY
7/23/2019 Lecture-Heart Lung Sounds 2015.PDF (Dr Simon Ong)
http://slidepdf.com/reader/full/lecture-heart-lung-sounds-2015pdf-dr-simon-ong 24/48
What Can Go Wrong During Diastole?
LEFT
VENTRICLE
AORTIC
VALVE
MITRAL
VALVE
7/23/2019 Lecture-Heart Lung Sounds 2015.PDF (Dr Simon Ong)
http://slidepdf.com/reader/full/lecture-heart-lung-sounds-2015pdf-dr-simon-ong 25/48
Diastolic Murmurs
LEFT
VENTRICLE
MITRAL
STENOSIS
AORTIC
REGURGITATION
CANNOT
CLOSE FULLY
CANNOT
OPEN FULLY
7/23/2019 Lecture-Heart Lung Sounds 2015.PDF (Dr Simon Ong)
http://slidepdf.com/reader/full/lecture-heart-lung-sounds-2015pdf-dr-simon-ong 26/48
Classification of Murmurs
• Systolic murmurs
– Aortic Stenosis
– Mitral regurgitation
• Diastolic murmurs
– Aortic regurgitation
– Mitral stenosis
7/23/2019 Lecture-Heart Lung Sounds 2015.PDF (Dr Simon Ong)
http://slidepdf.com/reader/full/lecture-heart-lung-sounds-2015pdf-dr-simon-ong 27/48
S1
“lub”
S2
“dub”
SYSTOLE
(ventricular
contraction)
DIASTOLE
(ventricular
relaxation)
DIASTOLE
(ventricular
relaxation)
SYSTOLIC
MURMURS
7/23/2019 Lecture-Heart Lung Sounds 2015.PDF (Dr Simon Ong)
http://slidepdf.com/reader/full/lecture-heart-lung-sounds-2015pdf-dr-simon-ong 28/48
S1
“lub”
S2
“dub” SYSTOLE
(ventricular
contraction)
DIASTOLE
(ventricular
relaxation)
DIASTOLE
(ventricular
relaxation)
EJECTION
SYSTOLICMURMURS
Aortic Stenosis
7/23/2019 Lecture-Heart Lung Sounds 2015.PDF (Dr Simon Ong)
http://slidepdf.com/reader/full/lecture-heart-lung-sounds-2015pdf-dr-simon-ong 29/48
S1
“lub”
S2
“dub” SYSTOLE
(ventricularcontraction)
DIASTOLE
(ventricularrelaxation)
DIASTOLE
(ventricularrelaxation)
PAN
SYSTOLICMURMURS
Mitral Regurgitation
7/23/2019 Lecture-Heart Lung Sounds 2015.PDF (Dr Simon Ong)
http://slidepdf.com/reader/full/lecture-heart-lung-sounds-2015pdf-dr-simon-ong 30/48
S1
“lub”
S2
“dub” SYSTOLE
(ventricularcontraction)
DIASTOLE
(ventricularrelaxation)
DIASTOLE
(ventricularrelaxation)
DIASTOLIC
MURMURS
DIASTOLIC
MURMURS
7/23/2019 Lecture-Heart Lung Sounds 2015.PDF (Dr Simon Ong)
http://slidepdf.com/reader/full/lecture-heart-lung-sounds-2015pdf-dr-simon-ong 31/48
S1
“lub”
S2
“dub” SYSTOLE
(ventricularcontraction)
DIASTOLE
(ventricularrelaxation)
DIASTOLE
(ventricularrelaxation)
DIASTOLIC
MURMURS
EARLY
DIASTOLICMURMURS
Aortic Regurgitation
7/23/2019 Lecture-Heart Lung Sounds 2015.PDF (Dr Simon Ong)
http://slidepdf.com/reader/full/lecture-heart-lung-sounds-2015pdf-dr-simon-ong 32/48
S1
“lub”
S2
“dub” SYSTOLE
(ventricularcontraction)
DIASTOLE
(ventricularrelaxation)
DIASTOLE
(ventricularrelaxation)
DIASTOLIC
MURMURS
MID
DIASTOLICRUMBLE
Mitral Stenosis
7/23/2019 Lecture-Heart Lung Sounds 2015.PDF (Dr Simon Ong)
http://slidepdf.com/reader/full/lecture-heart-lung-sounds-2015pdf-dr-simon-ong 33/48
Classification of Murmurs
• Systolic murmurs
– Aortic Stenosis (ESM)
– Mitral regurgitation (PSM)
• Diastolic murmurs
– Aortic regurgitation (EDM)
– Mitral stenosis (MDM)
7/23/2019 Lecture-Heart Lung Sounds 2015.PDF (Dr Simon Ong)
http://slidepdf.com/reader/full/lecture-heart-lung-sounds-2015pdf-dr-simon-ong 34/48
ESM
• Aortic stenosis (AS)
• Crescendo-decrescendo
murmur midway between
S1 and S2
• Best heard at aortic area
• Radiates up the carotids
7/23/2019 Lecture-Heart Lung Sounds 2015.PDF (Dr Simon Ong)
http://slidepdf.com/reader/full/lecture-heart-lung-sounds-2015pdf-dr-simon-ong 35/48
PSM
• Mitral regurgitation (MR) or
ventricular septal defect
(VSD)
• Uniform blowing sound
heard throughout S1 to S2
• MR best heard at mitral
• VSD best hear at LSE
7/23/2019 Lecture-Heart Lung Sounds 2015.PDF (Dr Simon Ong)
http://slidepdf.com/reader/full/lecture-heart-lung-sounds-2015pdf-dr-simon-ong 36/48
EDM
• Aortic regurgitation (AR)
• High-pitched sighing sound
immediately past S2
• Best heard at left sternal
edge, sitting up and in full
expiration
7/23/2019 Lecture-Heart Lung Sounds 2015.PDF (Dr Simon Ong)
http://slidepdf.com/reader/full/lecture-heart-lung-sounds-2015pdf-dr-simon-ong 37/48
MDM
• Mitral stenosis (MS)
• Low pitched rumbling
sound
• Best heard at mitral using
bell
• Occurs shortly after S2
7/23/2019 Lecture-Heart Lung Sounds 2015.PDF (Dr Simon Ong)
http://slidepdf.com/reader/full/lecture-heart-lung-sounds-2015pdf-dr-simon-ong 38/48
Summary
• Systolic murmurs
– ESM @ aortic area,
radiation up carotids
(AS)
– PSM @ mitral area (MR)
– PSM @ LSE (VSD)
• Diastolic murmurs
– MDM @ mitral area
(MS)
–
EDM @ LSE, sitting up, infull expiration (AR)
7/23/2019 Lecture-Heart Lung Sounds 2015.PDF (Dr Simon Ong)
http://slidepdf.com/reader/full/lecture-heart-lung-sounds-2015pdf-dr-simon-ong 39/48
Breath Sounds
7/23/2019 Lecture-Heart Lung Sounds 2015.PDF (Dr Simon Ong)
http://slidepdf.com/reader/full/lecture-heart-lung-sounds-2015pdf-dr-simon-ong 40/48
Classification of Breath Sounds
• Normal breath sounds
– Vesicular
– Bronchial
– Abnormal
• Vocal resonance (this is a transmitted soundrather than a breath sound)
•
Adventitious breath sounds – Continuous (rhonchi)
– Discontinuous (crackles)
7/23/2019 Lecture-Heart Lung Sounds 2015.PDF (Dr Simon Ong)
http://slidepdf.com/reader/full/lecture-heart-lung-sounds-2015pdf-dr-simon-ong 41/48
Normal Breath Sounds
• Vesicular – Soft, blowing and low-
pitched sounds
– No pause
– Fade away about one third
of the way throughexpiration
• Bronchial – Loud, hollow and high-
pitched sounds
– A short pause – Expiratory sounds last
longer than inspiratorysounds
7/23/2019 Lecture-Heart Lung Sounds 2015.PDF (Dr Simon Ong)
http://slidepdf.com/reader/full/lecture-heart-lung-sounds-2015pdf-dr-simon-ong 42/48
Normal Breath Sounds
• Vesicular
– Heard over normal lung
field
•
Bronchial – Heard over normal large
airway
7/23/2019 Lecture-Heart Lung Sounds 2015.PDF (Dr Simon Ong)
http://slidepdf.com/reader/full/lecture-heart-lung-sounds-2015pdf-dr-simon-ong 43/48
Abnormal Breath Sounds
• Decreased breath
sounds
– Caused by decreased air
flow (e.g. pulmonary
collapse, airway
obstruction)
– Caused by masking (e.g.
pleural effusion,
pneumothorax)
7/23/2019 Lecture-Heart Lung Sounds 2015.PDF (Dr Simon Ong)
http://slidepdf.com/reader/full/lecture-heart-lung-sounds-2015pdf-dr-simon-ong 44/48
Abnormal Breath Sounds
• Bronchial breath sounds
– Breath sounds become
better conducted when
air is replaced by “solid”
– Can be heard in
pneumonia due to
consolidation
7/23/2019 Lecture-Heart Lung Sounds 2015.PDF (Dr Simon Ong)
http://slidepdf.com/reader/full/lecture-heart-lung-sounds-2015pdf-dr-simon-ong 45/48
Vocal Resonance
• Increased when there is
consolidation because
“solid” transmits sound
(patient’s voice) well • Decreased when there
is an insulation (pleural
effusion,
pneumothorax) to thetransmission of sound
(patient’s voice)
7/23/2019 Lecture-Heart Lung Sounds 2015.PDF (Dr Simon Ong)
http://slidepdf.com/reader/full/lecture-heart-lung-sounds-2015pdf-dr-simon-ong 46/48
Continuous Adventitious Sounds
• Inspiratory rhonchi(stridor)
– Caused by narrowing oflarge airways
–Upper airway obstruction
• Expiratory rhonchi
– Caused by narrowing ofsmall airways
– Asthma, COPD, heartfailure, bronchiectasis,carcinomatosislymphangitis
7/23/2019 Lecture-Heart Lung Sounds 2015.PDF (Dr Simon Ong)
http://slidepdf.com/reader/full/lecture-heart-lung-sounds-2015pdf-dr-simon-ong 47/48
Discontinuous Adventitious Sounds
• Fine crackles
– Caused by small airways
opening against a
resistance, hence
inspiratory
– Heart failure, COPD,
pulmonary fibrosis
• Coarse crackles
– Caused by secretions
– Bronchiectasis
7/23/2019 Lecture-Heart Lung Sounds 2015.PDF (Dr Simon Ong)
http://slidepdf.com/reader/full/lecture-heart-lung-sounds-2015pdf-dr-simon-ong 48/48
Thank You