Antipyretics for children are prescribed by a pediatrician. But there are emergency situations with fever when the child needs to be given medicine immediately. Then the parents take responsibility and use antipyretic drugs. What is allowed to be given to infants? How can you lower the temperature in older children? What medications are the safest?
When assessing heart sounds, you should try to listen to each component separately cardiac cycle: 1st tone and systolic interval, and then 2nd tone and diastolic interval.
The sound of heart sounds can change under the influence of various reasons. Normally, heart sounds are clear. They can gradually weaken, becoming muffled or dull (obesity, hypertrophy of the chest muscles, emphysema, fluid accumulation in the pericardial cavity, severe myocarditis) or intensify (asthenics, people with a thin chest, tachycardia).
The first sound is formed as a result of vibrations of the cusps of the mitral and tricuspid valves when they close, as well as vibrations of the myocardium itself and large vessels.
Therefore, the 1st tone consists of three components:
Valvular (closing of the mitral and tricuspid valves), giving the main contribution to the intensity of 1 tone;
Muscular, associated with vibrations of the heart muscle during isometric contraction of the ventricles;
Vascular, caused by vibrations of the walls of the aorta and pulmonary artery at the beginning of the expulsion period.
The 1st sound is assessed at the apex of the heart, where it is healthy person always louder, longer than the 2nd tone and lower in frequency. It coincides with the apical impulse and pulsation of the carotid arteries.
Factors that determine the intensity of the 1st tone include:
The position of the valves at the beginning of systole,
The tightness of the ventricular chamber during the period of isovolumetric contraction (closeness of the valves),
Valve closing speed
Mobility of the valves,
The speed (but not the strength!) of ventricular contraction (the value of the end-diastolic volume of the ventricles, the thickness of the myocardium, the intensity of metabolism in the myocardium);
It follows that the higher the valve closing speed, the louder the 1st tone will be (amplification of 1 tone). So, with tachycardia, when the filling of the ventricles is reduced and the amplitude of movement of the valves increases, the 1st tone will be loud. When an extrasystole appears, the 1st sound intensifies (Strazhesko's cannon tone) due to the low diastolic filling of the ventricles. With mitral stenosis, due to fusion and thickening of the valve leaflets, which slam quickly and loudly, 1 tone will also be amplified (slamming 1 tone).
Weakening of the 1st sound can occur with ventricular dilatation (mitral and aortic valve insufficiency); damage to the heart muscle (myocarditis, cardiosclerosis), with bradycardia (due to increased filling of the ventricles and a decrease in the amplitude of oscillation of the heart muscle).
Vibrations of the valve flaps of the aorta and pulmonary artery at the moment of their closure and the walls of the supravalval sections of the aorta and pulmonary artery lead to the appearance of a 2nd tone, therefore, this tone consists of 2 components - valvular and vascular. The quality of its sound is assessed only on the basis of the heart, where it is louder, shorter and higher than the 1st tone and follows after a short pause.
The assessment of the second tone is carried out by comparing the intensity of its sound on the aorta and pulmonary artery.
Normally, the second sound in the aorta and pulmonary artery sounds the same. If it sounds louder in the second intercostal space on the right, then they speak of an emphasis of the 2nd tone on the aorta, and if in the second intercostal space on the left - an emphasis of the 2nd tone on the pulmonary artery. The reason for the accentuation is most often an increase in pressure in the systemic or pulmonary circulation. When the cusps of the aortic valve or pulmonary artery are fused or deformed (with rheumatic heart defects, infective endocarditis), a weakening of the second tone occurs over the affected valve.
Splitting and bifurcation of tones. Heart sounds consist of several components, but upon auscultation they are heard as one sound, because The human hearing organ is not capable of perceiving two sounds separated by an interval of less than 0.03 seconds. If the valves do not close simultaneously, then during auscultation two components of the 1st or 2nd tones will be heard. If the distance between them is 0.04 - 0.06 seconds, then this is called splitting, if more than 0.06 s - bifurcation.
For example, a split first sound is often heard with right bundle branch block due to the fact that the right ventricle begins to contract later and the tricuspid valve closes later than normal. With blockade of the left bundle branch, the bifurcation of the 1st sound is heard much less frequently, since the delay in the oscillation of the mitral component coincides in time with the delay in the tricuspid component.
There is a physiological splitting/bifurcation of the second tone, which does not exceed 0.06 seconds. and appears only during inspiration, which is associated with a prolongation of the period of blood expulsion by the right ventricle due to an increase in its filling during inspiration. It should be emphasized that the pulmonary component of the second sound is often heard in a limited area: in the 2nd – 4th intercostal space along the left edge of the sternum, so it can only be assessed in this area.
For diseases accompanied by a significant increase in pressure in the small or big circle blood circulation (stenosis or insufficiency mitral valve, some birth defects heart), a pathological split of the second tone occurs, which is clearly audible both on inhalation and exhalation.
In addition to the main heart sounds (1st and 2nd), the physiological 3rd and 4th sounds can also be heard normally. These are low-frequency tones that arise when the walls of the ventricles (usually the left) vibrate as a result of passive (III sound) and active (IV) filling. Physiological muscle tones are found in children (up to 6 years old - IV tone), adolescents, young people, mostly thin, under the age of 25 (III tone). The appearance of the third sound is explained by the active expansion of the left ventricle during its rapid filling at the beginning of systole. It is heard at the apex of the heart and at the fifth point.
In patients with damage to the heart muscle, pathological 3rd and 4th heart sounds are heard, which are usually combined with a weakening of the sonority of the 1st tone above the apex and tachycardia, therefore a so-called gallop rhythm is formed. Since the third sound is recorded at the beginning of diastole, it is called the protodiastolic gallop rhythm. The pathological IV tone occurs at the end of diastole and is called the presystolic gallop rhythm.
When auscultating additional heart sounds, it should be remembered that muscle tones are difficult to hear through the membrane, so it is better to use a “bell” to auscultate them.
Extratons. In addition to muscle tones, an additional sound can be heard in diastole - the opening tone of the mitral valve (mitral click), which is determined immediately after the second sound with mitral stenosis. It is better heard in the patient's position on the left side and during exhalation in the form of a short high-frequency sound. The combination of the “clapping” 1st tone, 2nd tone and mitral click leads to the appearance of a specific three-part rhythm (“quail rhythm”), reminiscent of the phrase “time to sleep” - with an emphasis on the first word
In addition, during diastole, a rather loud tone can be heard, very similar to a mitral click - this is the so-called pericardial tone. It is heard in patients with constrictive pericarditis and, unlike the opening sound of the mitral valve, is not combined with the “popping” 1st sound.
In the middle or at the end of the systolic period, an additional sound may also be heard - a systolic click or “click”. It may be caused by sagging (prolapse) of the mitral valve leaflets (less commonly, tricuspid valve leaflets) into the atrium cavity or friction of the pericardial leaves in adhesive pericarditis.
The systolic click has a characteristic sound, a short and high-pitched tone, similar to the sound that occurs when the lid of a tin can bends.
Lecture No. 10.
Auscultation of the heart. Heart sounds are normal and pathological.
Listening (auscultation) of sound phenomena produced by the work of the heart is usually performed using a stethophonendoscope. This method has a great advantage over direct listening, since it makes it possible to clearly localize various sounds and, thanks to this, determine the location of the formation.
Listening to the patient should be carried out in a warm room and with a warm instrument. When working in a cold room or with a cold tool, the patient experiences muscle tremors. In this case, a lot of side sounds arise, which significantly complicate the assessment of the auscultatory picture. The patient is listened to while breathing calmly. However, in many situations, when the doctor detects weak sound phenomena, he asks the patient to hold his breath during the phase of maximum exhalation. At the same time, the volume of air-containing lungs around the heart decreases, breathing noises arising in the lungs disappear, and the sound picture of the beating heart is more easily perceived.
In what body position should the patient be listened to? It all depends on the auscultatory picture and the patient’s condition. Typically, auscultation is carried out in an upright position of the patient's body (standing, sitting) or lying on his back. However, many sound phenomena, such as pericardial friction noise, are better heard when the patient is tilted forward or in a position on the left side, when the heart fits more tightly to the anterior chest wall. If necessary, auscultation is carried out with a deep breath with straining (Valsalva maneuver). In many cases, cardiac auscultation is repeated after physical stress. To do this, the patient is asked to sit or lie down, do 10–15 squats, etc.
Along with listening to sound phenomena that occur during the work of the heart, the phonocardiography technique is now widely used. Phonocardiography is a graphic recording on paper tape of sound phenomena occurring during the work of the heart, perceived by a sensitive microphone. Sound phenomena are depicted in the form of vibrations of various amplitudes and frequencies. Simultaneously with the recording of sound phenomena, an electrocardiogram is recorded in one standard lead, usually in the second. This is necessary to determine in which phase of cardiac activity the recorded sound occurs. Currently, phonocardiography involves recording sounds in 3 to 5 different sound frequency ranges. It allows you to document not only the very fact of the presence of a particular sound, but also its frequency, shape, amplitude (loudness). Given the undoubted diagnostic value of the technique, it should be taken into account that the sound picture perceived by ear sometimes turns out to be more informative than the graphically recorded one. In some situations, during phonocardiography, sound energy is distributed over 3 to 5 recorded channels and is encrypted as background, while a clear, diagnostically significant sound picture is determined by ear. Therefore, phonocardiography, undoubtedly, should be considered valuable, but additional method research.
When listening to the heart, tones and noises are distinguished. According to scientific terminology, those sound phenomena that are commonly called tones do not deserve this name, because they, like heart murmurs, are produced by irregular, aperiodic sound vibrations (the intervals between vibrations of each tone are not equal). In this sense, even many heart murmurs (so-called musical murmurs) are much closer to real tones.
Normally, physiologically, 2 tones are heard above the heart. Of these, the 1st corresponds in time to the beginning of ventricular systole - the period of closed valves. It is called systolic tone. The second corresponds in time to the very beginning of the diastole of the heart and is called diastolic.
Origin of the first tone complex. The formation of 1 heart sound begins at the very beginning of cardiac systole. As is known, it begins with the systole of the atria, which pushes the remaining blood into the ventricles of the heart. This component is 1 tone, atrial, quiet, low-amplitude on the phonocardiogram, short-lived. If our ear could separately perceive sounds very close to each other, we would listen to a separate weak tone of the atria and a stronger tone formed during the systole phase of the ventricles. But under physiological conditions, we perceive the atrial component of the 1st tone together with the ventricular one. In pathological conditions, when the systole of the atria and ventricles are separated in time by more than usual, we listen to the atrial and ventricular components of the 1st sound separately.
In the phase of asynchronous contraction of the heart, the process of excitation of the ventricles, the pressure in which is still close to “0”, the process of ventricular contraction covers all myocardial fibers and the pressure in them begins to increase rapidly. At this time, a long-lasting ventricular or muscle component of tone 1. The ventricles of the heart at this moment of heart systole are 2 completely closed bags, the walls of which tensed around the blood contained in them and, due to this, began to vibrate. All parts of the walls vibrate, and they all give a tone. From this it is clear that complete closure of the ventricles of the heart from all sides is the main condition for the formation of the first sound.
The main loudness component of the 1st tone occurs at the moment when the closure of the two and tricuspid heart valves occurs. These valves have closed, but the semilunar valves have not yet opened. The tone of that part of the walls that is most capable of oscillating, namely the tone of the thin elastic leaf valves, valve component 1 tone will be dominant in volume. With significant insufficiency of the leaflet valves, the sound of the corresponding ventricle will completely disappear by ear.
The first sound is not only carried out from the ventricles and leaflet valves, but also occurs due to sudden tension and vibration of the walls of the aorta and pulmonary artery when the blood of their ventricles enters them. This component of tone 1 is called vascular. Since this occurs already in the phase of the beginning of ventricular emptying, the first tone also covers the period of the beginning of the expulsion of blood from the ventricles.
So, 1 heart sound consists of 4 components - atrial, muscular, valvular and vascular.
The period of blood expulsion from the ventricles of the heart consists of two phases - fast and slow blood expulsion. At the end of the slow ejection phase, the ventricular myocardium begins to relax and diastole begins. Blood pressure in the ventricles of the heart decreases, and blood from the aorta and pulmonary artery rushes back into the ventricles of the heart. She closes the semilunar valves and appears second or diastolic heart sound. The first tone is separated from the second tone by a short pause with an average duration of about 0.2 seconds. The second tone has two components, or two components. The main volume is valve a component formed by vibrations of the leaflets of the semilunar valves. After the slamming of the semilunar valves, blood rushes into the arteries of the systemic and pulmonary circulation. The pressure in the aorta and pulmonary trunk gradually decreases. All pressure drops and blood movement in the aorta and pulmonary artery are accompanied by vibrations of their walls, forming a second, less loud, component of 2 tones - vascular component.
The time from the beginning of ventricular relaxation to the closure of the semilunar valves is called protodiastolic period equal to 0.04 seconds. The blood pressure in the ventricles at this time drops to zero. The leaflet valves are still closed at this time, the volume of blood remaining in the ventricles and the length of the myocardial fibers have not yet changed. This period is called period of isometric relaxation equal to 0.08 seconds. Towards its end, the cavities of the ventricles of the heart begin to expand, the pressure in them becomes negative, lower than in the atria. The leaflet valves open and blood begins to flow from the atria into the ventricles of the heart. Begins period of filling the ventricles with blood, lasting 0.25 seconds. This period is divided into 2 phases of fast (0.08 seconds) and slow (0.17 seconds) filling of the ventricles with blood.
At the beginning of the rapid flow of blood into the ventricles, due to the impact of the incoming blood on their walls, a third heart sound. It is dull, best heard above the apex of the heart with the patient in the left lateral position and follows at the beginning of diastole approximately 0.18 seconds after the 2nd sound.
At the end of the phase of slow filling of the ventricles with blood, in the so-called presystolic period, lasting 0.1 seconds, atrial systole begins. Vibrations of the walls of the heart, caused by atrial systole and additional flow into the ventricles of blood pushed out from the atria, lead to the appearance fourth heart sound. Normally, a low-amplitude and low-frequency 4th tone is never heard, but can be detected on FCG in individuals with bradycardia. With pathology, it becomes high, high-amplitude and, with tachycardia, forms a gallop rhythm.
During normal auscultation of the heart, only the 1st and 2nd heart sounds are clearly audible. The 3rd and 4th tones are normally inaudible. This is due to the fact that in a healthy heart, the blood entering the ventricles at the beginning of diastole does not cause sufficiently loud sound phenomena, and the 4th tone is actually the initial component of the 1st tone and is perceived inseparably from the 1st tone. The appearance of the 3rd tone can be associated both with pathological changes in the heart muscle, and without pathology of the heart itself. Physiological 3rd tone is more often heard in children and adolescents. In people over 30 years old, the 3rd tone is usually not heard due to a decrease in the elasticity of their heart. It appears in cases where the tone of the heart muscle decreases, for example, with myocarditis, and the blood entering the ventricles causes vibration of the ventricular myocardium that has lost its tone and elasticity. However, in cases where the heart muscle is not affected by inflammation, but its tone simply decreases, for example, in a physically very trained person - a skier or football player of a high sports level, who is in a state of complete physical rest, as well as in young people, in patients with disorders autonomic tone, blood entering the relaxed ventricles of the heart can cause the appearance physiological 3 tones. The physiological 3rd tone is best heard directly by the ear, without the use of a phonendoscope.
The appearance of the 4th heart sound is clearly associated with pathological changes in the myocardium - with myocarditis, conduction disturbances in the myocardium.
Places for listening to heart sounds. Despite the fact that heart sounds occur in a limited space, due to their strength they are heard over the entire surface of the heart and even beyond its borders. However, for each of the tones there are places on the chest wall where they are heard better, and sounds arising in other places in the cardiac region interfere least.
One might assume that the places of best listening to heart sounds correspond to the points of their origin. However, this assumption is valid only for the pulmonary artery tone. In reality, the points of best listening to the heart valves do not coincide with the points of their projection onto the chest wall. In addition to the proximity of the place of origin of sounds, the distribution of sounds along the bloodstream and the tightness of contact with the chest wall of the part of the heart in which the sounds are formed also play a big role. Since there are 4 valve openings in the heart, there are also 4 places to listen to heart sounds and noises arising in the valve apparatus.
The mitral valve is projected onto the area of attachment of the 3rd left costal cartilage to the sternum, but the relatively thick layer of lung tissue, characterized by poor sound conductivity, and the proximity of the semilunar valves make it unfavorable to listen to the mitral valve, which forms the 1st tone, in this place. First heart sound best heard at the apex of the heart. This is explained by the fact that in the area of the apex of the heart we place a phonendoscope on that part of the chest behind which lies the apex of the heart, formed by the left ventricle. Left ventricular systolic tension is greater than right ventricular tension. The chordae of the mitral valve are also attached in the area close to the apex of the heart. Therefore, 1 tone is heard better in the area adjacent to the chest of the apex of the left ventricle.
With the expansion of the right ventricle and the displacement of the left ventricle posteriorly, 1 sound begins to be heard better over the right ventricle of the heart. The tricuspid valve, which generates the first sound, is located behind the sternum on the line connecting the place of attachment to the sternum of the 3rd costal cartilage on the left and the 5th cartilage on the right. However, it is better heard slightly below the site of projection of the atrioventricular tricuspid valve onto the chest wall, at the lower end of the body of the sternum, since in this place the right ventricle is directly adjacent to the chest wall. If the patient’s lower part of the sternum is somewhat depressed, it is not possible to firmly place the phonendoscope on the chest in this place. In this case, you should move the phonendoscope slightly to the right at the same level until it fits snugly to the chest.
Second heart sound best heard at the base of the heart. Since the second sound is predominantly valvular, it has 2 points of best auscultation - at the point of auscultation of the pulmonary artery valves and at the point of auscultation of the aortic valves.
The sound phenomena of the pulmonary artery valve, forming the 2nd heart sound, are best heard above the place of the chest wall that is located closest to the mouth of the pulmonary artery, namely in the second intercostal space to the left of the sternum. Here, the initial part of the pulmonary artery is separated from the chest wall only by a thin edge of the lung.
The aortic valves are located deeper than them, located slightly inward and below the pulmonary artery valves, and are also covered by the sternum. Tone produced by slamming aortic valves, transmitted through the blood column and the walls of the aorta. In the 2nd intercostal space, the aorta comes closest to the chest wall. To evaluate the aortic component of the 2nd tone, a phonendoscope should be placed in the second intercostal space to the right of the sternum.
When performing cardiac auscultation, a certain listening order is observed. There are 2 rules (orders) for auscultation of the heart - the “eight” rule and the “circle” rule.
The “rule of eight” involves listening to the heart valves in descending order of frequency of their damage in rheumatic lesions. The heart valves are listened to using the “rule of eight” in the following sequence:
1 point – the apex of the heart (the point of listening to the mitral valve and the left atrioventricular orifice),
2nd point – 2nd intercostal space at the right edge of the sternum (the point of listening to the aortic valve and the mouth of the aorta),
3rd point – 2nd intercostal space at the left edge of the sternum (the point of listening to the pulmonary valve and its mouth),
4th point – the base of the xiphoid process (the point of listening to the tricuspid valve and the right atrioventricular orifice).
5th Botkin-Erb point -3rd intercostal space at the left edge of the sternum (an additional point for listening to the aortic valve, corresponding to its projection).
When auscultating according to the “circle” rule, first listen to the “internal” heart valves (mitral and tricuspid), and then to the “external” heart valves (aortic and pulmonary artery), then listen to the 5th Botkin-Erb point. The heart valves are listened to according to the “circle” rule in the following sequence:
1 point – apex of the heart,
2nd point – base of the xiphoid process,
3rd point – 2nd intercostal space at the right edge of the sternum,
4th point – 2nd intercostal space at the left edge of the sternum,
5th Botkin-Erb point – 3rd intercostal space at the left edge of the sternum.
Listening to heart sounds, determine the correctness of the rhythm, the number of basic tones, their timbre, the integrity of the sound, the ratio of the volume of 1 and 2 tones. When additional tones are identified, their auscultatory features are noted: relation to the phases of the cardiac cycle, volume and timbre. To determine the melody of the heart, you should mentally reproduce it using syllabic phonation.
Difference between 1 and 2 heart sounds. 1st tone is longer and slightly lower than 2nd tone. At the sites where the leaflet valves are auscultated, it is usually stronger than 2 tones. The 2nd tone, on the contrary, is somewhat shorter, higher and stronger than the 1st tone at the sites where the semilunar valves are heard. At the base of the heart, heart sounds are best expressed in syllables Bu" = tu" p,
and on the ventricles Boo"=stupid.
It should be noted that in some completely healthy people the 2nd tone is stronger than the 1st and at the sites of auscultation of the leaflet valves. Sometimes, with rapid and, especially, irregular, arrhythmic heart activity, the 1st sound can be difficult to distinguish from the 2nd.
Change in the strength of heart sounds.
Heart sounds can change in strength, in character, bifurcate, additional tones may appear and peculiar heart rhythms may form. Changes in heart sounds may depend on the following main factors: 1. Changes in the contractile function of the ventricles, 2. Changes physical properties valves, 3. Changes in the level of blood pressure in the aorta and pulmonary artery, 4. From the non-simultaneous occurrence of individual components, 5. From external factors - changes in the properties of the sound-conducting medium - the lungs and chest wall, the state of organs adjacent to the heart.
Decreased heart sounds. The strength of heart sounds is weakened, first of all, in healthy people with a thick chest wall, with powerful muscle development and, especially, with excessive development of subcutaneous fatty tissue, in patients with edema, subcutaneous emphysema in the heart area. The development of pulmonary emphysema is even more important for weakening the volume of heart sounds, since emphysematous lung tissue has low sound conductivity. With severe pulmonary emphysema, heart sounds become barely audible. In patients with hydrothorax, pneumothorax, and hydropericardium, there is also a sharp decrease in the volume of heart sounds.
Weakening of heart sounds can be associated not only with causes external to the heart, but also with cardiac pathology. Heart sounds weaken with a decrease in the speed and force of contractions of the ventricles of the heart due to myocardial weakness. This can be observed in severe infectious diseases that occur with high myocardial intoxication, in myocarditis, in patients with hypertrophy and dilatation of the ventricles of the heart. Since the loudest component of any heart sound is the valvular component, if the closure of one or another heart valve is disrupted, the tone formed during the operation of the valve sharply weakens, until it disappears completely. In patients with mitral or tricuspid valve insufficiency, 1 tone sharply weakens. In patients with insufficiency of the aortic or pulmonary artery valves, weakening of the 2nd tone is observed. A weakening of the 2nd heart sound is observed in patients with a drop in blood pressure in the systemic or pulmonary circulation, when the semilunar valves close weaker than usual.
Strengthening all heart sounds observed with: 1) a thin chest wall, 2) when the heart is adjacent to the chest wall with a larger than usual area, for example, with shrinkage of the lungs, 3) with anemia, when, due to a decrease in blood viscosity, heart sounds become flapping, sharp, 4) in those cases when the speed and force of myocardial contraction increases, for example with physical activity, in patients with thyrotoxicosis, with neuropsychic agitation. If the ventricles are insufficiently filled with blood, for example, with narrowing (stenosis) of the mitral orifice, the opening of the tricuspid valve, or with an extraordinary contraction of the heart (with extrasystole), contractions of the weakly filled ventricles of the heart with blood occur faster than usual. Therefore, in such patients there is also a sharp increase in tone 1.
Gain 2 tones, or as they say more often, the accent of 2 tones over the aorta and pulmonary artery, is common and has significant diagnostic value. In children and people under 20 years of age, the 2nd sound over the pulmonary artery is normally louder than over the aorta. In older people, the 2nd tone above the aorta becomes louder than above the pulmonary artery. Strengthening of the 2nd tone above the aorta, its accent, is noted with an increase in blood pressure. When the aortic valve leaflets harden and, especially, when the aorta itself is sclerotic, tone 2 reaches significant strength and acquires a metallic tint. Similarly, an emphasis of the 2nd tone will appear on the pulmonary artery in patients with pulmonary hypertension of any origin - with heart defects, with acute or chronic pulmonary pathology, ranging from lobar pneumonia to pulmonary emphysema.
Split tones. Split tones is a phenomenon when one of the two heart sounds is split into two parts, which are easily perceived by our ear as separate sounds. If this gap is very small and is not perceived by ear as separate sounds, then they speak of tone splitting. All transitions are possible between the splitting of a tone and its splitting, so there is no clear distinction between them.
Split 2 tones. Non-simultaneous closure of the semilunar valves is the result of different durations of systole of the left and right ventricles. Systole ends the sooner the less blood the ventricle has to transfer to the aorta or pulmonary artery, the easier it is to fill them and the lower the blood pressure in them.
Above the base of the heart, bifurcation of 2 tones can occur in a healthy person at the end of inhalation and at the beginning of exhalation as a physiological phenomenon. As a pathological phenomenon, bifurcation is often observed with mitral valve defects, and especially often with mitral orifice stenosis. This bifurcation of the 2nd tone is best heard in the 3rd intercostal space on the left at the sternum. With mitral valve stenosis, the left ventricle is poorly filled with blood during the diastole phase and less blood than usual is ejected into the aorta. Consequently, the systole of the left ventricle of the heart decreases over time compared to the usual value. At the same time, these patients have high pulmonary hypertension, which means that the systole of the right ventricle lasts longer than usual. As a result of these changes in hemodynamics, non-simultaneous closure of the valves of the aorta and pulmonary trunk occurs, heard as a bifurcation of 2 tones. Thus, the bifurcation of 2 tones in the aorta and pulmonary artery is caused by the following conditions: 1) a rise in pressure in one of the vessels and normal pressure in the other, 2) low pressure in one of the vessels and normal in the other, 3) high pressure in one vessel and low in the other, 4) increased blood filling in one of the ventricles, 5) reduced blood filling of one of the ventricles, 6) increased filling of one of the ventricles and decreased filling of the other ventricle of the heart.
Split 1 tone. It is heard when a normal tone is always followed by a weak abnormal tone. This phenomenon can occur in 10% of healthy people during auscultation in a supine position. As a pathological phenomenon, splitting of the 1st tone occurs with aortic sclerosis and with increased blood pressure in the systemic circulation.
Mitral valve opening tone. In patients with mitral stenosis with the correct heart rhythm (without atrial fibrillation) there is an increase in the number of heart sounds, reminiscent of a bifurcation of the 2nd tone, since the third additional tone quickly follows the 2nd normal heart sound. This phenomenon is best heard over the apex of the heart. In healthy people, during the phase of rapid filling of the ventricles of the heart with blood, the mitral valve leaflets are silently pushed to the sides by blood. In patients with mitral valve stenosis, at the beginning of the diastole phase, when the ventricles begin to rapidly fill with blood, the shortened and sclerotic leaflets of the mitral valve form a funnel-shaped diaphragm. They cannot open freely and move towards the walls of the ventricle, they sharply tense up under the pressure of blood and generate the sound of the mitral valve opening. In this case, a peculiar three-membered heart rhythm is formed, called quail rhythm. The first component of this three-part rhythm is the first tone. It is followed at the usual time interval by a second tone. Almost immediately after the second tone, the sound of the uterine valve opening follows after a short interval. A rhythm arises that can be transmitted by sounds Ta-tara, reminiscent, in the figurative expression of old clinicians, of the cry of a quail “it’s time to go to bed.” The quail rhythm is heard with normo- or bradycardia. Only in the absence of tachycardia can one distinguish by ear the difference in intervals between the first - second and second - third components of the resulting three-part rhythm.
Gallop rhythm. The splitting of the first tone is sometimes very sharp. The part split off from the main tone is separated from it by some clearly perceptible interval and is heard as a separate independent tone. This phenomenon is no longer called a split tone, but a gallop rhythm, reminiscent of the clatter of the hooves of a galloping horse. This peculiar three-part rhythm appears against the background of tachycardia. The intervals between the first - second and second - third tones are perceived by ear as the same, the interval between the third and the following first sound of the next triad is perceived as somewhat larger. The emerging rhythm can be transmitted by sounds like ta-ra-ra, ta-ra-ra, ta-ra-ra. The gallop rhythm is best determined above the apex of the heart and in the 3rd to 4th intercostal spaces to the left of the sternum. It can be heard better directly with the ear than with a phonendoscope. The gallop rhythm intensifies after light physical effort, when the patient moves from a vertical to a horizontal position, as well as at the end of inhalation - at the beginning of exhalation in a slowly and deeply breathing person.
The additional third tone during the gallop rhythm usually sounds dull and short. It can be positioned in relation to the fundamental tones as follows.
An additional tone can be heard during a long pause closer to the first tone. It is formed by the separation of the atrial and ventricular components of the first sound. It is called the presystolic gallop rhythm.
An additional tone can be heard in the middle of a long pause of the heart, i.e. in mid-diastole. It is associated with the appearance of the 3rd heart sound and is called the diastolic gallop rhythm. Phonocardiography made it possible to distinguish protodiastolic (at the beginning of diastole) and mesodiastolic (mid-diastole) gallop rhythms. The protodiastolic gallop rhythm is caused by severe damage to the ventricular myocardium, most often by failure of the previously hypertrophied left ventricle. The appearance of an additional tone in diastole is caused by the rapid straightening of the flabby muscle of the left ventricle when it is filled with blood. This variant of the gallop rhythm can occur with normo- and even bradycardia.
An additional tone can be heard immediately after the first tone. It is caused by different simultaneous excitation and contraction of the left and right ventricles of the heart due to conduction disturbances along the branches of the His bundle or along their branches. It is called the systolic gallop rhythm.
If, with high tachycardia, there are 3 and 4 heart sounds, then a short interval between them can lead to the fact that the four-member heart rhythm recorded on the phonocardiogram is perceived by ear as a three-member rhythm and a summed mesodiastolic gallop rhythm occurs (the summation of 3 and 4 sounds).
Heart sounds are a sound manifestation of the mechanical activity of the heart, determined by auscultation as alternating short (percussive) sounds that are in a certain connection with the phases of systole and diastole of the heart. Heart sounds are formed in connection with the movements of the heart valves, chords, cardiac muscle and vascular wall, generating sound vibrations. The audible volume of tones is determined by the amplitude and frequency of these vibrations.
Components of the first (systolic) tone:
Valvular - vibrations of the atrioventricular valve leaflets
Muscular – vibrations of the ventricular myocardium
Vascular - vibrations of the initial segments of the aorta and pulmonary trunk when they are stretched by blood during the expulsion period.
Atrial – oscillations during atrial contraction
Components of II (diastolic) tone:
Valvular - slamming of the semilunar leaflets of the aortic valve and pulmonary trunk
Vascular - vibrations of the walls of the aorta and pulmonary trunk
Sometimes III and IV sounds are heard. The third tone is caused by fluctuations that appear during rapid passive filling of the ventricles with blood from the atria, damaging the diastole of the heart.
IV sound appears at the end of ventricular diastole and is associated with their rapid filling due to atrial contractions.
Phonocardiography (from the Greek phone - sound and cardiography), diagnostic method graphic registration of heart sounds and heart murmurs. It is used in addition to auscultation (listening), it allows you to objectively assess the intensity and duration of tones and noises, their nature and origin, and record the 3rd and 4th tones that are inaudible during auscultation.
A special apparatus for phonocardiography - a phonocardiograph - consists of a microphone, an amplifier of electrical oscillations, a system of frequency filters and a recording device. The microphone is applied to different points of the chest above the heart area. After amplification and filtering, electrical vibrations are sent to various recording channels, which allows selective recording of low, medium and high frequencies. FCG recording is carried out in a soundproofed room while holding the breath while exhaling (if necessary, at the height of inhalation) in a lying position, after the subject has rested for 5 minutes. On the FCG, a straight (isoacoustic) line reflects systolic and diastolic pauses. The normal 1st tone consists of 3 groups of oscillations: initial (low frequency), caused by contraction of the ventricular muscles; central (larger amplitude), due to the closure of the mitral and tricuspid valves; final (small amplitude), associated with the opening of the aortic and pulmonary artery valves and vibrations of the walls of large vessels. The 2nd tone consists of 2 groups of oscillations: the first (large in amplitude) is due to the closure of the aortic valves, the second is associated with the closure of the pulmonary artery valves. Normal 3rd (associated with muscle vibrations during rapid filling of the ventricles) and 4th (less common, caused by atrial contraction) tones are detected mainly in children and athletes. Characteristic changes in PCG (weakening, strengthening or splitting of the 1st and 2nd sounds, the appearance of pathological 3rd and 4th sounds, systolic and diastolic murmurs) help to recognize heart defects and some other diseases.
When listening to the heart, two sounds are clearly distinguished, which are called heart sounds.
Heart sounds are usually listened to using a stethoscope or phonendoscope.
A stethoscope is a tube made of wood or metal, the narrow end of which is applied to the chest of the person being examined, and the wide end to the ear of the listener. A phonendoscope is a small capsule covered with a membrane. Rubber tubes with tips extend from the capsule. When listening, the capsule is applied to the chest, and rubber tubes are inserted into the ears.
The first sound is called systolic, as it occurs during ventricular systole. It is drawn-out, dull and low. The nature of this tone depends on the trembling of the leaflet valves and tendon threads and on the contraction of the muscles of the ventricles.
The second sound, diastolic, corresponds to ventricular diastole. It is short and tall and occurs when the semilunar valves close, which occurs as follows. After systole, blood pressure in the ventricles drops sharply. In the aorta and pulmonary artery at this time it is higher, from the vessels it rushes back to the side of lower pressure, i.e., to the ventricles, and under the pressure of this blood the semilunar valves slam shut.
Heart sounds can be listened to separately. The first sound, heard at the apex of the heart - in the fifth intercostal space, corresponds to the activity of the left ventricle and bicuspid valve. The same tone, heard on the sternum between the attachment of the IV and V ribs, will give an idea of the activity of the right ventricle and tricuspid valve. The second sound, heard in the second intercostal space to the right of the sternum, is determined by the slamming of the aortic valves. The same tone, heard in the same intercostal space, but to the left of the sternum, reflects the slamming of the valves of the pulmonary artery.
It should be noted that heart sounds in the indicated areas reflect sounds that arise not only during the operation of the above parts of the heart; sounds from other parts are mixed in with them.
However, in certain areas one sound or another predominates.
Heart sounds can be recorded on photographic film or photographic paper using a special phonocardiograph device, consisting of a highly sensitive microphone that is applied to the chest, an amplifier and an oscilloscope.
Phonocardiography
The so-called heart sound recording technique allows you to record heart sounds and compare it with an electrocardiogram and other data characterizing the activity of the heart. The figure shows a phonocardiogram.
At various diseases heart, especially with heart defects, the tones change: noise is mixed in with them, and they lose their purity. This is due to a violation of the structure of the heart valves. With heart defects, the valves do not close tightly enough, and part of the blood ejected from the heart returns back through the remaining gaps, which creates an additional sound - murmur. Noises also appear when the holes closed by the valve apparatus narrow, and for other reasons. Listening to heart sounds is of great importance and is an important diagnostic method.
Heart beat
If you put your hand on the left fifth intercostal space, you can feel the heart beat. This impulse depends on the change in the position of the heart during systole. During contraction, it becomes almost solid, turns slightly from left to right, the left ventricle presses against the chest, pressing on it. This pressure is felt as a push.
Heart size and weight
The most common way to determine the size of the heart is percussion. When tapping in the places where the lung lies, a duller sound is heard than in those parts of the chest to which the lung is adjacent. The boundaries of the heart are more accurately determined by X-ray examination. The size of the heart increases in certain diseases (heart defects) and in people who engage in heavy physical labor for a long time. The weight of the heart in healthy people ranges from 250 to 350 g (0.4-0.5% of weight).
Heart rate
In a healthy person, it contracts an average of 70 times per minute. Heart rate is subject to many influences and often changes even throughout the day. The heart rate is also affected by the position of the body: the highest heart rate is observed in a standing position, in a sitting position it is lower, and when lying down the heart contracts even more slowly. The heart rate increases sharply during physical activity; among athletes, for example, during a competition it even reaches 250 per minute.
Heart rate depends on age. In children under the first year it is 100-140 per minute, at 10 years old - 90, at 20 years old and older - 60-80, and in old people it increases again to 90-95.
In some people, the heart rate is rare and ranges from 40-60 per minute. This rare rhythm is called bradycardia. It most often occurs in athletes at rest.
There are people with a more frequent rhythm, when the heart rate fluctuates between 90-100 and can reach 140-150.
This rapid rhythm is called tachycardia.
The heartbeat increases when inhaling, emotional arousal (fear, anger, joy, etc.).
Article on the topic Heart sounds
The first sound is low, prolonged, occurs during ventricular systole and is best heard in the fifth intercostal space on the left at the site of the cardiac impulse. In the genesis of the first tone, the main place is occupied by the contraction of the ventricular muscles, the closure of the atrioventricular valves and the vibration of the walls of the aorta at the moment of blood entering it.The second heart sound is shorter and higher-pitched and occurs at the beginning of heart diastole. It is caused by the closing of the semilunar valves of the aorta and pulmonary artery, the opening of the atrioventricular valves, vibration of the walls of the aorta of the pulmonary artery and fluctuation of the blood stream. It is best heard in the second intercostal space at the edge of the sternum: on the right - for the aortic valves and on the left - for the pulmonary valves.
The third tone is determined above the area of the apex of the heart and in the zone of absolute dullness after a deep breath and after slight physical activity, but can also be heard when the child is lying down.
This tone is soft, somewhat dull in timbre. The origin of the third heart sound is associated with passive stretching of the ventricles at the time of their rapid filling. The tone is better heard in children asthenic build and among athletes. There are physiological and pathological III tone.
Physiological III tone is a sign of a healthy heart, good activity and tone of the myocardium. The maximum sound of the physiological III tone is determined when the child moves from a vertical to a horizontal position, i.e. under conditions of increased venous inflow. Typically, the physiological III sound is best heard in the area of the apex of the heart or medially from this area, closer to the left edge of the sternum. This tone is affected by breathing, physical activity and changes in body position. It is best heard during inspiration, when cardiac activity accelerates. This tone cannot be heard in an upright position or sitting.
Pathological III tone - occurs as a result of a sharp decrease in the tone of the heart muscle and increased blood flow to the ventricles. Immediately after the II tone, a pathological III tone is determined, which is best heard after physical activity or when the patient quickly moves from a vertical position to a left lateral position, i.e. when additional conditions are created for increased blood flow to the heart. Pathological III tone is determined in a number of diseases: hypertrophy and loss of cardiac muscle tone in combination with myocardial failure; with sclerotic changes in the heart muscle (cardiosclerosis).
IV (atrial) sound is a sound phenomenon formed by contraction of the atrial myocardium, in particular contraction of the left auricle. During auscultation, due to its low intensity and very low frequency (about 20 Hz), the atrial tone is not normally detected by the ear. It is recorded only on a phonocardiogram. With age, the frequency of the atrial tone decreases.
Increased I and II heart sounds
The main extracardiac factors are: thin rib cage, fever, anemia, nervous tension, thyrotoxicosis, taking drugs that stimulate cardiac activity, tumors of the posterior mediastinum. Cardiac factors are increased cardiac activity during physical activity and cardiosclerosis.
Weakening of the 1st and 2nd heart sounds
May occur by various reasons. The main extracardiac causes include obesity, developed chest muscles, tumors of the anterior chest wall, pulmonary emphysema, and left-sided effusion pleurisy. Cardiac causes may be fainting, collapse, circulatory failure, myocardial infarction, myocarditis, effusion pericarditis.
Strengthening the first tone
Stenosis of the left atrioventricular orifice (popping first sound is a specific sign), extrasystole.
Weakening of the first tone
Mitral valve insufficiency, aortic valve insufficiency, tricuspid valve insufficiency, pulmonary valve insufficiency.
Velvet tone (synonin - Dmitrienko's symptom). A sign of primary rheumatic carditis: a special soft velvety tone of the first tone at the 2-3rd, less often 5-6th week of the disease. Its timbre is reminiscent of the sound of a drumstick hitting tightly stretched velvet.
Strengthening the 2nd tone
Arterial hypertension, pulmonary hypertension (metallic accent II tone), corrected transposition of the great vessels, patent ductus arteriosus, coarctation of the aorta, triatrial heart.
Accent II tone
The predominance of loudness of the second tone during comparative auscultation of the aorta and pulmonary artery.
Weakening of the second tone
Aortic valve insufficiency, pulmonary valve insufficiency, severe aortic stenosis, left atrioventricular orifice stenosis, right ventricular insufficiency.
Bifurcation (splitting) of the first tone
The heart tone seems to consist of two short sounds, quickly following one after the other and together making up the given heart tone. It is observed in all situations of asynchronous contraction of the ventricles of the heart (arrhythmias, conduction disturbances), pressure differences in the systemic and pulmonary circulation, arterial or pulmonary hypertension.
Splitting (bifurcation) of the 2nd tone
It is observed as physiological splitting in healthy children during deep inspiration, exhalation or during physical activity. May be observed with arterial hypertension, mitral valve defects.
Tone of exile
A sharp high-frequency sound that occurs at the beginning of systole immediately after the first heart sound. It develops with stenosis of the semilunar valves or in conditions characterized by dilatation of the aorta or pulmonary artery. The aortic ejection sound is best heard at the apex of the left ventricle and in the second intercostal space on the right. The pulmonary ejection tone is best heard during exhalation at the upper edge of the sternum.
Clicks (clicks) systolic
Not associated with the expulsion of blood (ejection sounds), they arise due to tension of the chords during maximum deflection of the valves into the atrium cavity or sudden bulging of the atrioventricular valves. Clicks are observed in mesosystole or late systole. Usually heard with prolapse of the mitral and tricuspid valves, small aneurysms of the interatrial or interventricular septum.
Gallop rhythm symptom
Auscultatory phenomenon consisting in the presence of extratone (or extratones) of the heart. The gallop rhythm gets its name from the fact that it resembles the sound made by the hooves of a galloping horse hitting the pavement. Depending on the time of occurrence of the extratone, the gallop rhythm is distinguished: diastolic, mesodiastolic, atrial, presystolic, protodiastolic and systolic.
Systolic gallop rhythm. Occurs with non-simultaneous contraction of the right and left ventricles, conduction disturbances in one of the bundle branches. Can be observed during myocardial infarction due to asynchronous contraction of the ventricles.
Diastolic gallop rhythm. Caused by relaxation of the tone of the heart muscle: myocarditis, cardiomyopathies, congestive heart failure.
Protodiastolic gallop rhythm. The most common type of diastolic gallop is caused by an increase in the third tone due to flabbiness of the muscles of the left ventricle. Protodiastolic gallop is observed in severe acute and chronic myocarditis, cardiosclerosis, in severe myocardial intoxication, infarction, in patients with valvular heart disease, and in advanced cardiopulmonary failure. The same gallop rhythm can occur with decompensation of a previously hypertrophied left ventricle.
Noise intensity according to Levin
I degree - weak noise, heard with concentrated auscultation.
II degree - weak noises.
III degree - noise of average strength.
IV degree - loud noises.
V degree - very loud noises.
VI degree - noise heard at a distance (distance noise).
Holosystolic (pansystolic) murmur
It occurs when there is a communication between two cavities in which a large pressure difference remains throughout the entire systole. Main reasons:
Mitral valve insufficiency;
Tricuspid valve insufficiency;
Ventricular septal defect;
Aortopulmonary fistulas.
Mesosystolic murmur
Noise having an ascending (crescendo) and descending (decrescendo) diamond shape. Main reasons:
Aortic stenosis;
Pulmonary artery stenosis.
Early systolic murmur
A murmur heard only at the beginning of systole. Main reasons:
Small ventricular septal defect;
Large ventricular septal defect with pulmonary hypertension.
Late systolic murmur
Murmurs heard after expulsion of blood and not merging with heart sounds. Main reasons:
Mitral valve prolapse;
Subvalvular aortic stenosis.
Still's vibrator noise (Still's murmur)
The most characteristic systolic murmur, not associated with heart disease, is caused by vibration of the pulmonary artery leaflets during systolic ejection, physiological narrowness of the right ventricular outflow tract, and, less commonly, abnormal chordae of the right ventricle. Usually heard at the age of 2-6 years.
Early diastolic murmur
Occurs immediately after the second sound, when the pressure in the ventricle becomes lower than in the great vessels. Main reasons:
Aortic valve insufficiency;
Pulmonary valve insufficiency.
Average diastolic murmur
Occurs during the period of early filling of the ventricles due to a mismatch between the valve lumen and blood flow. Main reasons:
- relative stenosis of the left atrioventricular orifice with a ventricular septal defect;
Relative stenosis of the right atrioventricular valve with atrial septal defect.
Carey-Coombs murmur is a type of mid-diastolic murmur associated with acute rheumatic fever. It occurs due to inflammation of the edges of the mitral valve leaflets or excessive accumulation of blood in the left atrium due to mitral regurgitation.
Systole-diastolic (continuous) murmur
Occurs when maintaining constant blood flow between the high and low pressure. Main reasons:
- patent ductus arteriosus;
Systemic arteriovenous fistulas;
Coarctation of the aorta;
Rupture of the sinus of Valsalva into the right side of the heart.
Bisystole. Described by Obraztsov in 1908. Additional tone in systole in patients with aortic valve insufficiency. Its origin is associated with contraction of the left ventricle in two steps. An additional tone during bisystole is determined by palpation in the fourth and fifth intercostal spaces as a rolling or double apical impulse, and by auscultation it is determined as a soft additional tone in presystole.
Botkin's symptom III (quail rhythm). It is a sign of mitral stenosis: against the background of sinus tachycardia, a flapping 1st sound is heard, an accent of the 2nd tone over the pulmonary artery and a click of the opening of the mitral valve.
Galaverdin's symptom (systolic extratony). A sign of pleuropericardial adhesions or residual effects after pericarditis: a special, superficial, sharp and short additional sound, heard during ventricular systole between the first and second sounds. In most cases, extratone creates the impression of close proximity to the ear and has a unique timbre that distinguishes it not only from normal tones, but also from other sound symptoms of the heart. The best location for auscultation is the apex of the heart or the area between the apical impulse and the xiphoid process and, in rare cases, over the base of the heart or over Traube's space. This tone can be so loud that it is heard over the entire precordial region. Systolic extratone is best heard during exhalation, often during the transition from horizontal position in a vertical position, its sonority decreases sharply and may even disappear completely. Basically, the symptom is determined in patients with pericarditis, pleuropneumonia and pleurisy.
Gorlina symptom. A sign of relative stenosis of the aortic opening with aortic valve insufficiency: a systolic murmur, usually heard in the second intercostal space to the right of the sternum, which is carried out to the vessels or into the jugular fossa. The murmur, usually high-pitched, sometimes producing a loud, often louder than diastolic sound, occurs as a result of relative stenosis of the aortic opening, since the valve opening, located between the dilated left ventricle and the dilated aorta, is a narrower place in the path of blood flow.
Durozier-Vinogradov symptom. Sign of aortic valve insufficiency: double murmur in large peripheral arteries. When pressing on the artery with a stethoscope, a longer and louder systolic murmur and a shorter, weaker diastolic murmur are heard, which is heard only at a certain optimal pressure on the artery. It is generally accepted that the double Durozier-Vinogradov murmur is caused by blood flowing from the heart to the periphery during systole and in the opposite direction during diastole.
Carvallo symptom I. Sign of tricuspid insufficiency: systolic murmur at the apex of the heart increases with deep inspiration and weakens until it completely disappears with exhalation. The increase in noise is explained by an increase in regurgitation and acceleration of the backflow of blood due to a significant decrease in pressure in the chest cavity during inspiration.
Carvalho symptom II. Sign of tricuspid valve stenosis: extra diastolic sound, also called tricuspid valve opening sound. This tone is less intense than the mitral click, shorter, sharper, it can easily be confused with the sound of the mitral valve opening if the latter is carried out in the area of auscultation of the tricuspid valve. The sound of the opening of the tricuspid valve is best heard in the fourth intercostal space on the right at the edge of the sternum or at the site of attachment of the xiphoid process to the sternum. It is located closer to the second sound than the opening tone of the mitral valve, is better heard during inspiration, and its duration is no more than 0.02 s. The interval from the beginning of the second tone to the appearance of a click of the tricuspid valve does not exceed 0.06-0.08 s.
Kerner-Roger symptom. Sign of an isolated ventricular septal defect (Kerner-Roget noise). A loud, drawn-out, very sharp, even rude noise, accompanied, as a rule, by a noticeable “cat’s purr.” The maximum of both noise and “cat purring” is most often determined in the third and fourth intercostal spaces at the edge of the sternum. The murmur usually covers the first heart sound and occupies the entire systolic period; sometimes it can cover tone II. It is characterized by the fact that during systole it does not decrease or weaken, but maintains its intensity throughout the entire ventricular systole and is abruptly interrupted at the beginning of ventricular diastole. The noise is carried out from the epicenter in all directions, very well audible on the ribs, collarbone, head humerus and even the olecranon process. Quite often the noise is heard on the back in the interscapular space and under the shoulder blades, especially under the left one. This is one of the loudest noises and can often be heard from a distance. “Cat purring” and noise intensify when lying down.
Rabbit heart rhythm (caniclocardia). Described by Muller in 1911. The rabbit rhythm occurs as a result of a decrease in vascular tone, systemic pressure and circulating blood mass, while the diastolic tone disappears and only the systolic tone is heard against the background of severe tachycardia. This auscultatory combination is very similar to the heart rhythm of a rabbit, in which only a systolic tone is always heard, with a high heart rate per minute. Usually, the rabbit rhythm is detected during collapse in patients with pneumonia, diphtheria, peritonitis, as well as during blood loss, coma (diabetic, hepatic), intoxication (cancer, household, industrial), terminal conditions occurring with a sharp drop in blood pressure.
Coombs' sign (Coombs' murmur). Sign of significant dilatation of the left ventricle: diastolic murmur associated with relative stenosis of the left atrioventricular orifice. The occurrence of Coombs' noise is possible only in cases where functional mitral stenosis is combined with increased blood flow through the left atrioventricular orifice. The best place to hear the murmur is the zone of absolute dullness of the heart near the apex. Coombs's noise is short, of a soft timbre, appears immediately after the second sound and, as a rule, is heard only in the presence of the third sound, which indicates increased filling of the left ventricle. It is determined more often in children, adolescents and young adults. Coombs' murmur can be detected with severe mitral valve insufficiency, hemodynamically significant ventricular septal defect, patent ductus arteriosus, dilated cardiomyopathy and secondary cardiodilation syndromes.
Potain's symptom IV. A sign of mitral stenosis: above the apex and at the left edge of the sternum in the fourth intercostal space, an opening click of the mitral valve is heard - an additional pathological sound in protodiastole. The opening tone of the mitral valve is perceived as an echo of the second tone.
Steel's symptom. Sign of mitral stenosis: in patients with mitral stenosis and pronounced pulmonary hypertension, a functional diastolic murmur is heard above the pulmonary artery - soft, blowing, high-pitched. It occurs as a result of expansion of the pulmonary artery cone, which leads to the formation of relative insufficiency of the semilunar leaflets of the pulmonary valve.
Strazhesko symptom II (“Strazhesko’s cannon tone”). A sign of complete atrioventricular block: increased first sound, heard above the apex of the heart, accompanied by a systolic murmur, which is caused by relative insufficiency of the mitral or tricuspid valve. If you observe the jugular vein on the right during auscultation, you can note its strong swelling during the period when the “cannon” tone appears. This is due to impaired emptying of the right atrium, resulting in congestion in the jugular vein. While listening to the “cannon” tone, a sharply intensified apical impulse is noted, which the patient perceives as a blow and shaking of the chest wall. N.D. Strazhesko explained this phenomenon by the simultaneous contraction of the atria and ventricles. However, F.D. Zelenin and L.I. Fogelson, based on electrophonocardiographic studies, showed that the “cannon” tone occurs when atrial contraction somewhat precedes ventricular contraction and the closure phases of the atrioventricular valves come closer.
Traube's symptom. A sign of aortic valve insufficiency: a double murmur is heard on the large arteries, which can also be heard over the spleen. The first of the two sounds is caused by a sharp systolic distension, and the second by a rapid and significant collapse of the arterial wall.
Flint symptom. Sign of aortic insufficiency: short functional presystolic murmur at the apex of the heart. The mechanism of diastolic murmur is associated with a stream of blood flowing back from the aorta into the left ventricle, which pushes the anterior leaflet of the mitral valve towards the atrioventricular opening and causes its narrowing during the period of emptying of the left atrium, i.e. functional mitral stenosis occurs. Flint's noise is usually of a soft timbre, not accompanied by a clapping I tone and a “cat purr”.
Friedreich's symptom II. Sign of adhesive pericarditis: additional protodiastolic heart sound. This tone is often louder than the normal heart sounds with which it creates a three-part rhythm. Sometimes the tone can reach extraordinary volume (“cannon shot”). The best place to listen is the apex of the heart, as well as the area between the apex beat and the left edge of the sternum, the lower third of the sternum and even the area at the xiphoid process on the left. Often it is heard over the entire precordial region.
The noise of a top. Sign of anemia: continuous systolic murmur heard over the jugular vein. It is best heard on the right above the bulbus v. jugularis, above the sternal end of the clavicle, mainly in the vertical position of the patient. When you turn your head in the opposite direction and during inhalation, it intensifies. Somewhat less frequently, the noise of a top is detected on the left in a symmetrical place, as well as above the upper half of the sternum. The stethoscope should be placed very carefully to avoid pressure noise. The sound of the spinning top is heard continuously, almost regardless of heart contractions, and only slightly intensifies during systole and diastole. The nature of the venous noise is musical, muffled, low. In the origin of the spinning top noise, an important role is played by changes in the rheological properties of the blood and hemodynamics (acceleration of blood flow), as well as the ability of the veins to oscillate (age factor).
Embryocardia according to Yushar (pendulum-like rhythm). As the heart rate increases, the relationship between systole and diastole changes. Due to the shortening of the latter, the duration of the cardiac cycle sharply decreases, and systole and diastole become equal in time. If in this case the I and II tones have the same intensity, then a heart rhythm occurs that resembles the intrauterine rhythm of the fetal heart. This type of heart rhythm is heard during tachycardia, acute myocardial infarction, diffuse myocarditis, febrile temperature, and severe peripheral circulatory failure.
