Auscultation of the heart: listening points, methods and results
Heart ... Let many say that this is just a pump, but how amazing is this organ. Throughout his life, it works tirelessly, pumping blood in the human body (it’s about the human “pump” that is being said), then slowing down, then speeding up its pace, adjusting to different life situations. But no matter how tireless our heart “motor” is, it is undoubtedly subject to all kinds of pathologies. To identify these violations, to determine their nature, to make a clear diagnosis and further treatment, doctors use various diagnostic methods. This is an electrocardiography (ECG), ultrasound of the heart and listening to it - auscultation.
What is auscultation, how is it performed?
During the work of the heart and the transfer of blood, various sounds arise in it - in medicine it is accepted to call them tones.But some sounds are the absolute norm and speak of a healthy heart (based only on the results of this study it is impossible to assert that there is no disease), and some do not promise anything good. The task of the specialist doctor is to listen to the tones, compare with the norm and make a diagnosis. Listening to tones is auscultation.
This procedure is carried out using a special device - a phonendoscope (most often) or a stethoscope. The difference of the phonendoscope is the presence of a membrane that enhances the sound vibrations. The device consists of several parts: a head that receives vibrations, a rubber tube that conducts sound, and headphones. This device is used by many doctors, from emergency medical assistant to anesthesiologist and resuscitator.
When listening to the tones of the heart, the head of the device is applied to special places on the human breast - the auscultation points of the heart.
In order to determine the auscultation points of the heart, it is necessary to understand its structure and the ways of blood flow. Like all mammals, the human heart is four-chamber and consists of two atria and two ventricles.Having passed a big circle of blood circulation, the blood poor in oxygen gets to the right auricle. By contracting, the atrium pushes blood into the ventricle, which in turn pushes it into the arteries of the pulmonary circulation. Here the blood passes through the capillaries of the lungs, is saturated with oxygen and returns to the heart, only in the left atrium. From it, the liquid is transported to the left ventricle and is pushed into the aorta - the artery of the circulation; it passes through the body, saturating all the cells with nutrients and oxygen, taking carbon dioxide (carbon dioxide) and other waste. Parallel to this, it is saturated with nutrients in the intestinal capillaries, and is filtered in the kidney and liver cells.
But so that during the contraction of the heart the blood does not go back, there are valves. They work on the principle of a water tap (most likely, the valve works on the principle of heart valves), passing blood in one direction and not letting it back. The operation and malfunction of these valves can also be heard with a phonendoscope.
There are special areas on the chest for listening to the heart - auscultation points, the location of which depends on the projection of the sounds of the four valves.There is also a special point used for additional hearing of the aortic valve.
The first auscultation point of the heart is normally located in the second intercostal space (that is, after the second rib), to the right (if you look at yourself) 2-3 cm from the sternum. At this point, the work of the aortic valve is monitored.
The second point, like the first, is in the second intercostal space, only this time it is located to the left of the sternum. At this place is a projection of the sounds of the pulmonary valve, that is located at the junction of the pulmonary artery and the right ventricle.
The third auscultation point of the heart valves is already in the fifth intercostal space on the left, but already more distant from the sternum - under the nipple. If the patient is a woman (girl), you need to ask her to hold her own mammary gland, for normal hearing. The location of the head of the phonendoscope here will allow you to hear how the mitral valve or its noise (if any) works. It does not allow blood to go back from the left atrium to the left ventricle, therefore it is located at the junction of the corresponding atria and ventricles.
And finally, the fourth of the main points.This point of auscultation of the heart is responsible for the tones produced by the tricuspid valve. His Latin name translates as triple sail, that is, three-leaved. This valve is located on the right side of the heart and connects the atrium and the ventricle (it is important to remember that blood must always move from the atrium to the ventricle). And the fourth point is located in the fourth (convenient for memorization, isn't it?) Intercostal space to the right of the sternum, to the right of the first point.
In the book "Knock, heart!" German cardiologist Johannes von Borstel was offered a rather interesting way of memorizing the location and functions of these auscultation (listening) points of the heart. The method consists in the following phrase: Anton pokert mit Tom um 22:54. Literally, the phrase is translated from German: "Anton plays poker with Tom at 22:54." The first letters of each word correspond to the first letters of the valves (aortic, pulmonary, mitral and tricuspid), and the numbers refer to the intercostal space of the auscultation points corresponding to these valves. Also, remember the sequence in relation to the sternum: right-left-left-right. This method of memorization helps to remember only the location of the valves, but not the order of auscultation.This process differs only in that the projection of the mitral valve is in second place.
This is an additional auscultation point of the heart. With its separate listening, it is impossible to diagnose anything, because its main purpose is to clearly listen to the aortic valve noises when they are detected, since in this place they are heard more clearly. This point of auscultation of the heart is located in the third intercostal space. It is also called the Botkin-Erb point.
Auscultation of the heart in the fetus
In addition, you can hear the heartbeat of the fetus in a pregnant woman. But to do this with a simple stethoscope is quite problematic, so obstetricians use a special obstetric stethoscope. Auscultation of the heart of the fetus is an important indicator of the health of the future newborn. It is carried out at each examination of the pregnant at the gynecologist, in the prone position. During labor, this procedure is carried out on average every fifteen minutes.
Points of listening (auscultation) of the heart and the rate of sound are determined by the doctor, since it depends on the location of the fetus in the uterus. When listening, the doctor must distinguish extraneous sounds from the fetal heartbeat,since maternal intestinal noise can be heard (usually bubbling and irregular), the sound of blood passing through the uterine vessels and the aorta (the volume rhythmically increases / decreases, coinciding with the mother's pulse). The baby’s heart rate is usually 140 beats per minute.
What else can be heard
If you listen to the work of the heart as a whole, then using a phonendoscope, you can measure the heart rate. To do this, count the number of strokes for a certain period of time - in children per minute, in adults, thirty seconds (then multiply the result by two). In this way, the number of heartbeats per minute is recognized.
The same method can be used to identify and diagnose arrhythmia. In this case, the time interval between contractions (in the patient's calm state) will constantly change. It is important to know that arrhythmia is not always a pathology and may be present even in a person with a healthy heart, for example, respiratory arrhythmia.
As with the auscultation points of the heart, the tones are the same in all people. There are only four of them. Each is different in nature and sound. The first tone occurs while reducing the ventricles.Its occurrence coincides with the pulsation of the carotid artery.
The second tone is less than the first in duration, but higher and louder in sound and does not coincide with the pulse of the carotid artery. This sound occurs when the aortic and pulmonary valves are closed, those that are between the left ventricle and aorta, and the right ventricle and pulmonary artery, respectively. Moreover, the closure of the aortic valve occurs earlier.
The first tone is better heard (and, accordingly, estimated) around the base of the heart, that is, at the listening points of the mitral and tricuspid valves. The second - aortic and pulmonary.
During diastole (resting of the heart), the mitral and tricuspid valve does not close, so the blood from the atria gradually merges into the ventricles. At the same time the sounds that make up the third tone are formed. And the fourth occurs as a result of the contraction of both atria and active transfusion into the ventricles. If a patient (middle-aged) has a third and / or fourth tone, this already speaks of pathology.
Points of auscultation of the heart in children (norm), tones
When listening to the heart of children need to know a few features:
- All sounds are brighter and louder as the chest is thinner than that of an adult.
- In the first days of life, tones may be deaf, and noises indicate congenital malformations. The pendulum rhythm of the first two tones is also the norm.
- At the age of two years, the splitting of the second tone does not promise the disease.
- And during puberty, functional (non-pathological) noise can be observed.
You should also be aware that the third and fourth tone in children is the norm.
Pathology. Disturbed tones
Now you can talk about possible diagnoses that can be identified with the help of a phonendoscope. Attention! All diagnoses are approximate and presumptive! Only an expert can deliver it.
Possible disturbances in the weakening / amplification of tones:
If the tones are split, then this can speak both about the rate and blockade of the bundle of the His bundle. In the case of blockade, there are also other signs of this disease, for example, deformation of the QRS complex on the electrocardiogram, but this is a completely different story.
Pathology. The appearance of the third and fourth tones in adults
As already mentioned, these tones should not appear in a healthy adult heart. If they have appeared, then it can talk about the following:
The appearance of the third tone:
- Failure flaps.
- Myocarditis, heart attack, heart failure.
- Arterial hypertension, aortic stenosis.
The appearance of the fourth tone:
- Failure flaps.
- Myocarditis, heart attack, heart failure.
The manifestation of one and the other tone:
- Expansion of the aorta.
- Mitral valve prolapse.
Noise is the appearance of sounds that are not typical of any tones. Often this is due to anemia of a different nature of origin, a violation of blood viscosity, that is, not due to heart disease. But noise can also occur due to improper valve operation.
Love the heart!
The heart is a unique organ, the most reliable and enduring. It is better that it does not hurt at all, and if a problem arises, then diagnosis and treatment are mandatory. This can help auscultation as one of the diagnostic methods. Take care of your heart, there will be no other! And if there will be, then its certainly not replace.