Heart Sounds

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harley -> Heart Sounds (April 2, 2005 10:45:00 AM)
1. In Abnormal Heart Sounds: S3 CHF S4 Myocardial Infarction My question is, if px has myocardial ISCHEMIA would is also be S4? 2. Is rattling sounds same with crackles or rales seen in CHF? Reply greatly appreciated. Thanks!

Andrew M. Ball PT PhD -> Re: Heart Sounds (April 5, 2005 5:20:00 PM)
Harley, I'm not sure that your premise is correct. The physiologic fourth heart sound (S4) is a very soft, low-pitched noise occurring in late diastole, just before S1. S4 generation is related to the ventricular filling by atrial systole. Associated with this event are vibrations in the left ventricle wall and mitral apparatus which are heard as the S4. A physiologic S4 may be heard in infants, small children, and adults over the age of 50. It is usually heard only at the apex with the patient placed in the left semilateral position. A physiologic S4 is poorly transmitted and is rarely accompanied by a shock (when the S4 can be felt as well as heard). Wide transmission of a loud S4 associated with a shock is pathologic and is referred to as an S4 gallop. Although considered to be a normal finding in older subjects by some investigators. Many other experienced cardiologists, however, feel strongly that a definite S4 in a middle- or older person is not likely to br a normal event. A physiologic S4 is barely audible, even to the most experienced of clinicians. I think what you're talking about in an S4 gallop, which is always pathologic, and is usually caused by decreased ventricular compliance, such as ventricular hypertrophy (such as is associated with aortic stenosis or pulmonary hypertension), or Iscemic heart disease (as in angina, acute MI, or old MI). What I didn't remember and had to look up, is that excessively rapid late diastolic filling secondary to vigorous atrial systole (e.g. hyperkinetic states, anemia, or AV fistula) can cause and S4 gallop too, as can acute atrioventricular valve incompetence, arrhthmia, or heart block. We just had a patient a few days ago get SOB after doing some light therex. Her PT ausculated her and we heard the classic "Ten-ne-see" S4 gallop sound. The patient had some cardiac issues, but was being treated for a NMS problem. Just to be sure, but thinking the MD was sure to have known about it, the PT put in a call to the MD. Well, the MD wasn't aware of it and care ended up being enhanced by the PCP's decision to foward the patient to a cardiologist. Drew

Dr.Wagner -> Re: Heart Sounds (April 10, 2005 5:12:00 AM)
Differential diagnosis of heart sounds is EXTREMELY difficult. It takes lots and lots of practice to auscultate well...daily practice. So to be quite honest, don't rely on them. Some of the MOST reliable heart sounds is aortic stenosis and the simple midsytolic "click" of MVP. But to be honest, don't rely on the heart sounds. Now in CHF, audible rales in the base of the lungs is pretty obvious...yep they are the same as "crackles". The sound of CHF rales are "wet" vs. the "dry" sounds heard in COPD. Once again this takes daily practice. DO NOT let your abilities to auscultate guide your practice, allow your clinical judgement to guide practice. In many events it causes confusion. The best guide is to speak with the nurse (if you are in a hospital or ECF) and ask how their clinical exam has been lately.

Andrew M. Ball PT PhD -> Re: Heart Sounds (April 10, 2005 9:36:00 AM)
I think I agree with what Dr. Wagner is saying. The message is, "When in doubt, refer it out." No one expects, or should expect, for a (D)PT to identify all s4 gallops. As Dr. Wagner implies, as a profession, our specificity in doing so isn't nearly that of the cardiologist --- but I think I'd disagree with the implied tone that (D)PT's aren't trained at a level with which they can be trusted to pick up an s4 gallop with fairly good sensitivity. That is to say, in layman's terms, that a (D)PT should be expected to be right that they hear something abnormal upon ausculatation (that's not to say that PT's are all that great at knowing what it is that we're hearing or if an abnormal sound is pathologic), and if that is communicated by the (D)PT to a referring MD or PCP, that should be taken seriously. However, I'd agree that we should not be expected to hear all subtle sounds, and should remember with humility that just because our untrained ears don't hear an abnormal sound doesn't mean that a pathologic condition doesn't exist. Drew

chiroortho -> Re: Heart Sounds (April 10, 2005 10:25:00 AM)
Drew, when did PTs start auscultating chests for heart sounds? Is this something taught in PT school?

Andrew M. Ball PT PhD -> Re: Heart Sounds (April 10, 2005 12:29:00 PM)
I can't answer when PT's STARTED auscultating chests for heart sounds. All I can tell you is that it was a six credit course for my MSPT degree 10 years ago, and I can only speak for me that I ausculatate as part of my exam fairly regularly in my senior citizen patients --- primarily so as to have a baseline should a patient present with changes in other cardiopulmonary symptoms (dypsnea, orthopenia, etc.) at some future date during physical therapy intervention. I was under the impression, however, that it was something that had pretty much been part of the program since the program was a BS program as far back as the 1940's --- but now that you mention it, the Barach studies --- showing that contrary to the standard of medical care of the day - - - that there might be physiologic response to exercise training in patients with COPD based on the "progressive improvement in the ability to talk without dyspnea," was published in 1951, so I'm guessing that physical therapy's involvement with cardiopulmonary care, including ausculation, percussion, suctioning, postural drain, chest physical therapy, and rehabiliation, must have had it's birth sometime in the mid-1940's or so. My understanding is that cardiopulmonary rehab/cariopulmonary physical therapy is an area of practice that, like so many other skills, PT's were more involved with previously, but gave away to other then-emerging professions. The better question, therefore, isn't "when did PT's start," but rather "why and when did so many PT's stop?" Do chiropractors generally ausculatate? Drew

Dr.Wagner -> Re: Heart Sounds (April 10, 2005 4:24:00 PM)
My honest suggestion...DON'T TRUST YOUR EARS. Listen as much as you want, it is a fantastic learning experience. But to learn you must have a teacher, one that is at the very least experienced. Heart sounds are just VERY VERY difficult and most doctors will agree that it takes years of daily listening to feel competent. For TEST purposes, a heart murmur may be a helpful clue, but in real life...I hear hundreds but they RARELY add to the clinical exam except in the most acute environment, and then...heart sounds aren't likely what you need to be listening to. Once again, if you are in the hospital, ask the nurse what she heard...she will likely be very very helpful. Best of luck!

chiroortho -> Re: Heart Sounds (April 10, 2005 5:57:00 PM)
Drew, the only auscultating that I do these days is for cervical bruits. I agree with Dr Wagner that auscultation is a very perishable skill, and has to be learned correctly in the first place. My two cents.

JLS_PT_OCS -> Re: Heart Sounds (April 11, 2005 9:57:00 AM)
Although I was trained to listen to these sounds in PT school, my Ortho Sports experiences to date have not let me practice too much. I don't have as much confidence as Drew does about his ability to hear an abnormal sound, but it sounds like he has recently trained and is getting the daily experience that I agree you need. I take vitals sometimes in clinic (a rarity in the young population I treat) but I wouldn't trust my ears to hear anything other than whether or not the heart was beating! And I'm pretty sure I could hear that... :)

Andrew M. Ball PT PhD -> Re: Heart Sounds (April 11, 2005 2:36:00 PM)
Jason, Maybe I'm being unclear, don't trust what my ears hear beyond the obvious --- which is to say when to know that I MUST communicate the suspician to an MD. After the first visit, unless a patient presents with a reason to ausculatate and compare to initial eval, I don't usually do so again. What I don't trust, is what I don't hear/what I miss. Drew

JLS_PT_OCS -> Re: Heart Sounds (April 12, 2005 2:55:00 AM)
Drew, that's what I thought. But again, willing to bet I could only tell whether it was beating or not... :) J

Dr.Wagner -> Re: Heart Sounds (April 13, 2005 6:45:00 AM)
Jason, I think that is an overall GOOD thing. Generally ATC's use their stethoscopes for the taking of BP and listening for overt abnormalities (large murmurs or the obliteration of distinct heart sounds, an irregular rhythm, or wheezing during a pulmonary exam) Those are the most important findings...not distinct murmurs for specific patholgies. So in essence, your distinction of simply hearing the heart beat is vital.

JLS_PT_OCS -> Re: Heart Sounds (April 13, 2005 8:11:00 AM)
Sure, I just don't think I'm comfortable with any more than the overt abnormalities, as I surely am better educated than an ATC. I think that use of a stethoscope is only one part of a good screening exam done by PTs to determine if medical referral is indicated. As was covered previously, we probably if anything are overcautious in this regard, something for which I have never heard a single family physician complain. They usually like the communication, and it often opens the door for them to ask questions and refer to me, and a good working relationship usually develops. J

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