PROPEDEUTIC OF INTERNAL MEDICINE

Auscultationof the
heart: normal tones
of the heart

Assistant of department Makoyda Iryna Yaremivna

Chambers of the heart

Aorta
Pulmonary
trunk

LA
RA
LV
RV

Borders of the heart

1 Left ventricle
2 - right ventricle
3 right atrium
4 Left atrium
5 Pulmonary artery
6 - Aorta
7 Vena cava superior

Systole

Diastole

Features of cardiophony :
1. A doctor is situated from the right side of patient
2. Hearing is conducted in horizontal and vertical
positions of patient
3. A patient during an auscultation must detain
breathing
4. It is expedient to conduct an auscultation after
physical activity (if allows the state of patient)
5. The heart it does not follow to hearken to hastily
6. Hearing needs to be conducted with periodic pauses,
that gives an optimal effect

A projection of valves of heart

is on a thorax

L
M

Aortal valve
valves of
pulmonary artery
M mitral valve
tricuspid valve

Points of auscultation of the valves

mitral
b, c aorta
d pulmonary artery
e tricuspid valve

Order of cardiophony
Hearing is conducted in a certain sequence:
1- is an area of apex push (description of I tone)
2 - II intercostal space on the right near the
edge of breastbone (description of II tone)
3 - II intercostal space on the left near the edge
of breastbone (description of II tone)
4 is lower bottom of breastbone, basis of
processus xyphoideus (description of I sink)
5 is a point of Botkin - Erb : place of attachment
of III - IV of rib to the left edge of breastbone
(additional point of auscultation of aortic
valve)

A sequence is predefined by frequency of defeat of valves

First tone (systolic)

- the sum of the voice

phenomena that arise up in a
heart during a systole folds

It arises up as a result of vibrations:

atrium at their contraction - auricle
component
Walls of aorta and pulmonary artery an initial
period of entering of blood from ventricles

vessels

component

closed leaves of mitral and tricuspid valves

valve component
ense to the muscle of ventricles

muscular component

tone

Second tone (diastolic) :

Vibration of walls of aorta and pulmonary
artery an initial period of entering of blood
from ventricles

vessels

component

closing and vibrations that arise up at closing

of valves of aorta and pulmonary artery

valvular component
II tone connecting with diastole

tone

Excellent signs of I and II of tones of

heart

I tone

II tone

Apex of the heart

Base of the heart

Comes after a large

pause

Comes after small

pause

Duration

0,09 0,12

0,05-0,07

Connecting with apex

push

connecting

Comes after apex push

Connectin with pulse on

arteria carotica

connecting

Not connecting

Main criteria
Place of main
auscultation
Attitude is toward the
pause of heart

Determination of I tone on an apex push () and on

a pulse on a carotid (B)

The third tone is predefined by the vibrations

of walls of ventricles, mainly left (at the rapid
filling by their blood at the beginning of diastole)

- heard at a direct auscultation on the

apex of heart or something middle from
her, thus better in lying position of
patient,
this tone is very quiet
better heard for the persons of young
age (in most cases near-by an apex
push)

Fourth tone is the result of vibrations of walls of

ventricles at their rapid filling at the end of diastole
due to reduction of atriums

- heard rarely

Changes of tones of heart

- weakening of sonority of one of them or two
- is strengthening of sonority of one of them or two
- are changes of timbre
- to duration
- is breaking up or split
- on occasion is an origin of additional tones

Accent of tone is determined by comparison of

volume and timbre of tone on a pulmonary artery and
aorta
second tone in II
int.cost.space in right-

second tone in II
int.cost.space in left -

accent . On aorta

accent . jn PA

- increased of AP in
large circle

- increased of AP in
small circle

If at a cardiophony instead of one of tones

hearkened to two short, following friend by a friend
through the small interval of time, then it testifies
to the split of tone
If a difference in time of origin of these components
is insignificant and there is not the impression about
a split, speech goes about breaking up of tone

breaking up is an initial phase

split - more expressed violation of unity of tones

Three-membership rhythm (first, second and additional

third tones), that reminds the tramp of horse that bruises
along - "rhythm of gallop"

"scream of heart is about a help"

- protodiastolic
- mesodiastolic
- presystolic

In connecting with phase of

diastone

Rhythm of quail
1. "slamming" I tone
2. additional tone that arises
up during opening of mitral
valve valve at mitral stenosis
3. tone

Rhythm of quail

"Gun tone" of Stragesko

Complete AV block

FCG
ECG

intervals - same
intervals RR - same

predefined by simultaneous contraction of atrium and

ventricles
(an auricle and ventricles grow short each in the rhythm,
but in some loop their reductions gather)