Introduction to Auscultation

Dr Zoltán Pozsonyi

3rd Dep. of Int. Med.

Semmelweis University

History

History

• before: ear on the chest

• Laennec- 1816:– rolled up piece of paper in case of an obese

female patient with suspicion of heart disease

• the first single ear stethoscope

• later: made of wood and plastic

Auscultation

• very important, simple, effective clinical technique to evaluate circulatory and respiratory system

• very useful in examination of arteries and abdomen

• understanding of underlying pathomechanisms and practice!!

Significance

• Nowadays (echo, X-ray, CT, MRI) the importance of auscultation is smaller

• limited access to imiging modalities

• auscultation is available anywhere

Technique of auscultation• quiet environment

– ER, other patients, computers; close the doors

• proper position– may need help; ICU

• stethoscope on the bare skin– rubbing

• proper size of diaphragm of the stethoscope– children; slim, skinny patients

Auscultation of the abdomen

• Bowel motility and abdominal complaints

• Searching for renal stenosis (hypertension)

• How to ...– supine position– place the stethoscope on the abdomen– bowel sounds:

• normal sounds: clicks and gurgles 5-30/min• wildly transmitted: one place is enough usually

Abnormal bowel sounds

• Increased intensity and frequency:– diarrhea– intestinal obstruction=obstructive ileus

• Decreased intensity and frequency, or on sounds at all:– paralytic ileus (dumb abdomen)– peritonitis

• Splash in ileus (lot of air and liquid)

Bruits over the abdomen

• Normally there is no bruit

• for stenosis of the renal artery:– listening for bruits (vascular sound; like heart

murmurs)– in each upper quadrant of the epigastrium– costovertebral angels

Bruits• Atherosclerosis--stenosis• Carotid artery (part of routine exam.)

– stenosis=bruits (not always)– ischaemic stroke, TIA, embolization– ask the patient to turn his/her neck back– ask the patient to stop breathing momently

• Femoral bruits (above the aorta, iliac arteries)– suspicion of insufficient arterial circulation of lower

extremities (pain, induced by walking; smoking; HT; DM)

Before auscultation of lungs

• Patients arms crossed in front of the chest

• Diaphragm of the stethoscope

• Ask the patient not to speak and to breathe deeply through the mouth

• Hyperventilation should be avoided (collapse)

• Always compare the two sides at the identical locations

• At least one full breath at each location

• In case of suspitous sounds, auscultate nearby

Location of auscultation

Topographic considerationsPosterior view Anterior view

Lung sounds

• Expiration is longer than expiration

• Normally expiration is less loud, so at auscultation it seems, these are at the same length

inspiration

pause

expiration

pause

Lung sounds-normal sounds Two forms

• Tracheal or bronchial breath sounds• Origin: turbulent airflow in central airways• Turbulence is less in expiration, so expiration is

more quiet• Not transmitted through air filled lung, but cab be

transmitted in atelectasy• Normally can not be heard• Can be heard in pneumonia, when lung tissue loses

air, or in case of large pleural effusions• Loud, high pitched, (like over the trachea, scapula)

Normal sounds

• Vesicular breath sounds

• Origin: distal to the trachea, proximal to the alveoli

• Normally vesicular sounds are over the lung

• Soft and low pitched

Abnormal soundsAbsent or decreased breath sounds

• Severe asthma bronchiale: decreased sounds

• Emphysema: decreased sounds

• Pneumothorax: absent or decreased sounds

• Bronchial: pneumonia, effusion

Adventitious breath sounds

• Crackles (rales), discontinuous, non-musical, brief sounds

• more commonly on inspiration.• fine (high pitched, soft, very brief)• or coarse (low pitched, louder,less brief).• Mechanical basis: small airways open during inspiration

and collapse during expiration causing the crackling sounds. (fine crackles)

• Another explanation for crackles is that air bubbles through secretions or incompletely closed airways during expiration (coarse crackles)

Crackles- conditions

• pneumonia

• ARDS

• bronchiectasis

• early CHF

• interstitial lung disease

• pulmonary edema

Wheeze

• continuous, high pitched, hissing sounds

• heard normally on expiration but also sometimes on inspiration

• produced when air flows through airways narrowed by secretions, foreign bodies, or obstructive lesions.

Wheeze-Conditions:

• asthma bronchiale

• CHF

• chronic bronchitis

• COPD

• pulmonary edema

Stridor

• inspiratory musical wheeze heard loudest over the trachea during inspiration

• stridor suggests an obstructed trachea or larynx

• constitutes a medical emergency that requires immediate attention

• foreign body

Pleural Rub

• creaking or brushing sounds produced when the pleural surfaces are inflamed and rub against each other

• may be discontinuous or continuous sounds

• usually localized at a particular place on the chest wall and are heard during both the inspiratory and expiratory phases

Pleural Rub-condition

• Pleuritis

• Pneumonia with pleuritis

• Postthoracothomy syndrome

Auscultation of the heart• bare skin; displace gently large left breast

• supine position first

• location– anatomic references: sternum, midclavicular

line, axillary lines, costal interspace

• timing– hard in case of tachycardia; intensity of heart

sounds may help

S1 S2 S1 S2 time

Apex:

systole diastole

Heart• Diaphragm: high pitched sounds:

– S1, S2, systolic murmurs (common)

• Bell: low pitched sounds: – S3, S4, diastolic murmurs (rare)

• Throughout the entire praecordium

• (stop breathing)

• Usually supine position, but:– mitral stenosis– aortic regurgitation

What to listen for• First heart sound (S1: closure of mitr. & tricusp.

valves)– intensity, splitting (PHT, BB)

• Second heart sound (S2: closure ao. & pulm valves)– intensity, splitting (respiratory cycle)

• Comparing intensity of S2• Systolic extra sound

– click, ejection sounds, • Diastolic extra sound

– S3, S4, opening snap• Diastolic and systolic murmurs (longer than sounds)

Examples• Expiratory slitting of S2 is abnormal

• Loud P2= pulmonary hypertension

• Systolic click: in mitral valve prolpase

Heart murmur, what should be described

• timing, shape, loc. of max. intensity, radiation, intensity, pitch, quality

Timing of a murmur

midsystolic murmur (aortic stenosis)

pansystolic murmur (mitral regurg)

late systolic murmur (mitral prolaps)

S1 S2 S1

S1 S2 S1

Timing of a murmur

early diastolic (aortic regurg)

mid-diastolic (mitral stenosis)

late diastolic= praesystolic (mitral stenosis)

• Continuous murmur

• Throughout in diastole and systole– pericardial friction rubs, patent ductus Botalli

Timing of a murmur

Shape of a murmur

crescendo

decrescendo

crescendo-decrescendo (diamond shaped)

platau murmur

Location of maximal intensity• The site where it can be heard best

– anatomic pos.

"Traditional areas"

Intensity of a murmurMurmur Grades

Grade Volume Thrill

1/6very faint, only heard in ideal

circumstancesNo

2/6 loud enough to be generally heard No

3/6 louder then grade 2 No

4/6 louder then grade 3 Yes

5/6heard with stethoscope partially off

chestYes

6/6heard with stethoscope entirely off

chestYes

Radiation of a murmur• radiation from the point of maximal intensity

– for ex.: AS to the carotid arteries (blood flow)

– high, medium, low

– blowing, harsh, rumbling, musical

Pitch

Quality

Aortic stenosisS1 S2 S1

Timing: midsystolic

Location: right 2nd intercostal space

Radiation: to the neck, carotid arteries

Intensity: often loud

Pitch: medium

Quality: often harsh

Mitral regurgitation

S1 S2 S1

Timing: systolic, holosystolic

Location: apex

Radiation: left axilla

Intensity: soft to loud

Pitch: medium to loud

Quality: blowing

What else is the stethoscope good for?

• look like a doctor

• blood pressure measurement

• to transmit infection from patient to patient– wash it sometimes, not just your hands

How to choose a stethoscope?when I was a 3rd y student

• good for decades

• if you want to be a cardiologist,..

• price

• size of the diaphragm

• digital is not better

• color