A detailed study of the functions of the human body is impossible without the use of additional devices. Auscultation is the basic method of objective examination of a patient, which involves active listening to breathing, peristalsis of the gastrointestinal tract. However, the most valuable is auscultation of the heart: assessment of rhythm, strength of tones, the presence of pathological murmurs. To amplify the sound, special membrane instruments are used - a phonendoscope and a stethophonendoscope.
Why listen to the heart
The study of circulatory sounds (hemodynamics) is a quick and technically simple procedure that helps to obtain a huge amount of information about the work of the heart structures.
Listening to tones is the main, but not the only purpose of auscultation. In the course of contact with the patient, the doctor assesses the heart rate, rhythm, timbre, pathological noises.
The listening technique is used to study such changes:
- hypertrophy of the ventricles;
- myocarditis;
- ischemic disease (IHD);
- heart defects;
- myocarditis;
- arrhythmia;
- pericarditis.
The auscultation technique is used for both adults and pediatric practice. An affordable and absolutely safe method helps to suspect deviations during the initial examination and promptly send the child for a detailed examination.
In addition, with the help of auscultation, the condition of the fetus is assessed, which is important in the early stages of pregnancy without risk to the child and mother. In the future, the cardiovascular system of the newborn is a new object of "listening" to the heart and lungs.
How to Auscultate Correctly
Auscultation is performed according to a strict algorithm, during which the doctor works with certain areas of the chest, studying the sounds at each point. The sequence of assessing cardiac tones is due to the pathophysiological mechanisms of the underlying diseases and the frequency of the spread of pathologies. There are established listening points for the heart valves - the places on the front wall of the chest where the doctor applies a stethoscope (see photo 1).
There are four main and two additional points of auscultation of the heart, which determine the order of the procedure:
- The first point is the apex (the zone of the cardiac impulse, which is determined by palpation), in the area of attachment of the fifth rib, slightly to the left of the sternum. The site corresponds to the projection of the mitral (bicuspid) valve onto the anterior wall.
- The second is the area between the second and third ribs to the right of the sternum, in which the activity of the aortic valve is examined.
- The third is the area of the second intercostal space on the left, where the sound of the functioning of the pulmonary valve (the vessel responsible for the delivery of blood from the right ventricle to the lungs) is carried out.
- The fourth is the attachment point of the xiphoid process to the sternum, which corresponds to the projection of the tricuspid valve.
Attachment of the fourth rib to the left of the sternum lies under the fifth point (listening to the work of the bicuspid valve). Sixth (additional) - Botkin-Erba, where the functional state of the aortic valve (third intercostal space to the left of the sternum) is assessed.
Photo 1:
Photo 1 - Options for listening to the operation of the valves:
- in the sitting (or standing) position of the patient;
- lying on the left or right side;
- inhaling deeply;
- after minor physical exercise.
Decoding the results
The results of auscultation of the heart in a healthy and sick person differ significantly. If the valves function is not disturbed, the doctor hears a "melody", which consists of alternating abrupt sounds. The strict sequence of tension and relaxation of the myocardium is called the cardiac cycle.
The physiology of a concept consists of three stages:
- Atrial systole. The first stage lasts no more than 0.1 seconds, during which the muscle tissue of the heart chamber is tensioned.
- Ventricular systole. Duration - 0.33 seconds. At the peak of myocardial contraction, the chamber takes on the shape of a ball and hits the chest wall. At this moment, the apical impulse is recorded. The blood is expelled from the cavities into the vessels, after which diastole begins and the fibers of the ventricular myocardium relax.
- The last phase - relaxation of muscle tissue for subsequent blood intake.
The above sounds are called tones. There are two of them: the first and the second. Each has acoustic parameters, which are due to the peculiarities of hemodynamics (blood circulation). The occurrence of the sound of a heart tone is determined by the speed of the myocardium, the degree of filling of the ventricles with blood and the functional state of the valves. The first tone - characterizes the systolic phase (expulsion of fluid from the cavities), the second - diastole (relaxation of the myocardium and blood flow). The heart rate is characterized by a high degree of synchronization: the right and left halves interact harmoniously with each other. Therefore, the doctor hears only first two tones Is the norm. In addition to the first two, there are additional sound elements - the third and fourth tones, the audibility of which indicates a pathology in an adult, depending on the listening points of the heart, where the violation is determined. Third is formed by the end of filling of the ventricles, almost immediately after the end of the second. There are several reasons for its formation:
- deterioration of muscle contractility;
- acute myocardial infarction;
- angina pectoris;
- atrial hypertrophy;
- neuroses of the heart;
- cicatricial organic tissue changes.
Fourth pathological tone is formed immediately before the first, and in healthy people it is extremely difficult to hear it. It is described as quiet and low frequency (20 Hz). Observe when:
- decrease in the contractile function of the myocardium;
- heart attack;
- hypertrophy;
- hypertension.
The sounds generated when blood moves through the narrowed lumen of blood vessels are called heart murmurs. Normally, noise does not arise and is heard only with valve pathology or various defects of the septa. Exists organic and functional noises. The former are associated with structural valve defects and vasoconstriction, and the latter with age-related changes in anatomy, which must be taken into account when auscultation of the heart in children. A child with such noises is considered clinically healthy.
Typical results of auscultation of the heart are normal (in an adult): clear, sonorous, rhythmic tones, no pathological murmurs.
Auscultation picture for various heart diseases
Cardiovascular pathologies in most cases are accompanied by a violation of intracardiac hemodynamics, which is determined by auscultatory examination. The appearance of changes is due to the reorganization (restructuring) of the myocardium, replacement of the structure of the vessel walls.
The most characteristic symptom of hypertensive auscultation is the accent (enhancement) of the second tone over the aorta, which is due to a significant increase in voltage in the left ventricle. With percussion in such a patient, an expansion of the boundaries of cardiac dullness is found. In the initial stages of the disease, the doctor hears an increase in the first tone in the apex location.
Heart defects - a set of pathologies that are caused by damage to the structural apparatus of the valve. In organic disturbances, deviations of the acoustic parameters of sound are observed. The strength of the tone changes against the background of a violent emotional shock, where a large amount of adrenaline is released.Often, with vices, doctors listen to specific signs:
- bicuspid valve weakness - disappearance of the first tone, strong systolic murmur in the apex zone - a standard auscultatory set for such a pathology;
- bicuspid stenosis - the first tone with a clapping character, the second bifurcates. The third tone is partly manifested in this;
- aortic weakness - noise in the sixth place of listening to heart valves, weakening of all tones;
- aortic valve stenosis - weakening of the tone, against the background of which there is a strong systolic murmur in the area of the second intercostal space on the right.
During a physical examination of a patient with arrhythmia, the doctor hears erratic and chaotic tones of varying volume, which do not always correspond to the heartbeat. More often the doctor observes systolic and diastolic murmur, quail rhythm is possible. The listening points of the heart valves during fibrillation are supplemented with auscultation of the vessels of the neck to determine the return flow of blood (regurgitation).
A more effective clinical tool in such a situation is an ECG with the conclusion of a functional diagnostician.
Additional physical examination methods: palpation and percussion
The initial reception of the patient is not limited to listening to heart sounds. For a more detailed diagnosis, methods of palpation and percussion are used, which do not require additional devices.
Palpation (probing) is a way to determine the soreness of external and deep structures, localization and changes in the size of organs. The execution technique involves the superficial identification of subcutaneous formations or the "immersion" of the doctor's fingers into soft tissues. The most informative method in the study of the abdominal organs.
In cardiology, palpation is used to assess the chest and cardiac (apical) impulse.
In case of deformities in the region of the heart, the following are palpated:
- "Cardiac hump" - a bulging of the chest caused by a long, progressive disease. The development of deformity is associated with the compliance of bone tissue in childhood under the influence of an enlarged heart cavity.
- In adults, the occurrence of pathological changes is due to the development of exudative pericarditis (accumulation of fluid in the pericardial sac) - manifested by smoothness or protrusion of the intercostal spaces.
- With aneurysm of the ascending aorta in patients, a visible pathological pulsation is determined in the area of the handle (upper part) of the sternum. On palpation, a soft, elastic formation is recorded, the movements of which coincide with the pulsation of the carotid or radial arteries.
Cardiac (apical) impulse - the projection of myocardial contraction on the anterior chest wall in the area of greatest contact. The doctor diagnoses by placing his palms in the region of the heart (to the left of the sternum in the fourth or fifth intercostal space), after an approximate determination, localizes with the help of the terminal phalanges of the index and middle fingers.
In patients with an average weight without concomitant pathology, it is fixed in the form of a limited (up to 2 cm2) pulsations in the area of 5 intercostal space on the left by 1.5-2 cm inside from the midclavicular line.
Orientation: in men, the fourth intercostal space is at the level of the nipple, in women - under it.
Border displacements occur when the cavities of the right or left ventricle expand. Area changes:
- spilled (more than 2 cm2) - with a high standing of the diaphragm (in pregnant women, patients with liver pathology, ascites), cardiomegaly, wrinkling of the lungs;
- limited - with a loose fit of the organ to the chest: hydro- or hemopericardium, pulmonary emphysema, pneumothorax.
In some cases, a "negative cardiac impulse" is diagnosed, which is manifested by retraction of the chest at the height of the pulsation of the peripheral arteries. The phenomenon is explained by a limited apical impulse, which is localized in the region of the rib: with a slight protrusion of the bone, a relative retraction of the adjacent area occurs.
Percussion is a method of objective examination of a patient to determine the placement of an organ (topographic) and changes in structure (comparative): the denser the tissue, the more “dull” the sound. The doctor gently strokes the chest with his finger: directly or using a plessimeter finger (a conductor to amplify the sound). In cardiology, the method is used to indirectly estimate the size of an organ through the areas of "dullness":
- absolute - the area of tight fit of the organ to the chest, quiet percussion is used to determine (without a plessimeter);
- relative (more often used in practice) - a projection onto the chest wall of the anterior surface of the organ.
The topography of the boundaries in a patient without pathologies of the cardiovascular system: upper - at the level of 3 ribs to the left of the sternum, right - along the right edge of the bone, left - 0.5 cm outward from the midclavicular line (in the 5th intercostal space).
The options and reasons for the displacement of the boundaries are presented in the table:
| The border | Reasons for displacement |
|---|---|
| Upper |
|
Left |
|
Right |
|
A general decrease in the area of the organ is observed in emphysema - the lungs swollen with air do not "pass" the percussion sound to the heart, from which the boundaries are shifted inward.
In addition, the width of the vascular bundle at the level of the second intercostal space (right and left) is determined using quiet percussion. A slight muffling of sound 0.5 cm outward from the edges of the sternum is designated as the diameter of the heart (normal values are 4.5-5 cm). The displacement of the left border indicates the pathology of the pulmonary artery, the right - of the aorta.
Conclusions
Auscultation is a method of studying the activity of the heart, which reveals the pathology of the cardiovascular system at the early stages of development and helps to obtain information for choosing further tactics of therapy. Among the advantages are a quick examination (the doctor needs a few minutes) and the absence of expensive equipment. The disadvantages include only the factor of human subjectivity.
