LEARNING ISSUES

7)

What is the significance of determining the auscultation of the heart?

What Is Auscultation?

Auscultation is the medical term for when your doctor uses a stethoscope to
listen to the sounds inside your body. During this simple test, the stethoscope
acts as a doctors extra ears, allowing him or her to hear what is happening
inside your body.
Sites of Chest Auscultation
Blood flowing across the heart valves is laminar flow so that no sound is
produced. The sounds heard on auscultation are the sound of the valve cusps
snapping shut at the end of diastole (when the AV valves shut producing the
1st heart sound) and at the end of systole (when the Aortic Pulmonary valves
shut producing the 2nd heart sound).
There are four main regions of interest for auscultation, and a brief knowledge
in human anatomy is crucial to pinpoint them.
The 4 pericardial areas are examined with diaphragm[5], including:
Aortic region (between the 2nd and 3rd intercostal spaces at the right sternal
border) (RUSB right upper sternal border).
Pulmonic region (between the 2nd and 3rd intercostal spaces at the left sternal
border) (LUSB left upper sternal border).
Tricuspid region (between the 3rd, 4th, 5th, and 6th intercostal spaces at the
left sternal border) (LLSB left lower sternal border).
Mitral region (near the apex of the heard between the 5th and 6th intercostal
spaces in the mid-clavicular line) (apex of the heart).
The four pericardial areas relate to the heart sounds and can detect various
abnormalities in the heart such as the valve stenosis or incompetence which
are diagnostic for many diseases in the cardiovascular system.

Aortic Stenosis
This is a systolic murmur that indicates a physiological defect. The word
stenosis refers to the abnormal turbulent flow of blood due to a narrow

damaged blood vessel. Stenosis in the aorta results in this murmur sound
which occurs between S1 and S2. In addition to this other sounds may be
heard such as S4 which results from the heavy work required by the left
ventricle to pump the blood though the stenotic valve. Also because S2 is
caused by the sudden closing of the aortic valve ,a weaken poorly functioning
stenotic valve may cause S2 to be very discreet or even inaudible. This
murmur is usually best heard over the aortic area.it is important to note that
this is a sharp murmur with notable start and finishing points within a systole.
We can usually tell how serious the stenosis is by listening to the timing of the
murmur. An early peaking murmur is usually a less serious case of stenosis ,
while a late peaking murmur indicates more serious stenosis, because the
stenotic valve is quite weak and the ventricle takes a lot more time to build the
strength to pump the blood out of the heart.
Mitral valve prolapse
This sound is thought to e caused by the failure of the papillary muscles
and/or chordae to maintain tension during the late systole. As the left
ventricle decreases in size the papillary muscles and/or the chordae dont
tether the valve resulting in the mitral valve remaining slightly open and a
slight regurgitation period into the atium. The sound is formed during systole
just when the valve prolapses and consists of a mid-systolic click just after a
normal S1 sound. This sound alone is enough for diagnosis, however MVP is
often followed by a murmur best heard at the apex of the heart. In addition to
this ,it can be enhanced or decreased by certain manoeuvres. Standing the
patient up will decrease the volume of the left ventricle and cause the MVP to
occur more frequently. If the patients squats the opposite effect is seen ,the
ventricle volume is increased and more tension is put on the papillary muscles
and chordae which help close the valve. This condition is common in young
adult women and causes symptoms of light-headedness, anxiety and
palpitation attacks. Symptoms are usually mild but patients with evidence of
the MVP should be given antibiotic prophylaxis when undergoing any invasive
procedures to help avoid the risk of bacterial endocarditis.
Pulmonary Stenosis
This is similar to aortic stenosis in that it takes longer for the right ventricle to
pump the blood out of the heart through the stenotic pulmonary valve. This
results in a delay in the valve closing and causes a split in S2. This splitting of
S2 is heard because the aortic valve shuts before the stenotic pulmonary valve

at the end of the systole. T he splitting is best heard in the pulmonic area, the
second intercostal space along the left sternal border. Maneuvers such as a
heavy inspiration can increase the intensity of this murmur.

DIAGNOSTIC TEST
1. BUN (blood urea nitrogen) (pt high : 23 mg/dL)
common blood test, the blood urea nitrogen (BUN) test reveals
important information about how well your kidneys and liver are
working. A BUN test measures the amount of urea nitrogen that's in
your blood.
Here's how your body typically forms and gets rid of urea nitrogen:
Your liver produces ammonia which contains nitrogen after it
breaks down proteins used by your body's cells.
The nitrogen combines with other elements, such as carbon, hydrogen
and oxygen, to form urea, which is a chemical waste product.
The urea travels from your liver to your kidneys through your
bloodstream.
Healthy kidneys filter urea and remove other waste products from your
blood.
The filtered waste products leave your body through urine.
A BUN test can reveal whether your urea nitrogen levels are higher than
normal, suggesting that your kidneys or liver may not be working
properly.
Results of the blood urea nitrogen test are measured in milligrams per
deciliter (mg/dL) in the United States and in millimoles per liter (mmol/L)

internationally. In general, 7 to 20 mg/dL (2.5 to 7.1 mmol/L) is

considered normal. But normal ranges may vary, depending on the
reference range used by the lab, and your age. Ask your doctor to
explain your results.
Urea nitrogen levels tend to increase with age. Infants have lower levels
than other people do, and the range in children varies.
Generally, a high blood urea nitrogen level means your kidneys aren't
working well. But elevated urea nitrogen can also be due to:
Urinary tract obstruction
Congestive heart failure or recent heart attack
Gastrointestinal bleeding
Dehydration, resulting from not drinking enough fluids or for other
reasons
Shock
Severe burns
Certain medications, such as corticosteroids and some antibiotics
A high protein diet
2)

serum creatinine ( pt normal : 1.1 mg/dL)

A creatinine test reveals important information about your kidneys.

Creatinine is a chemical waste product that's produced by your muscle
metabolism and to a smaller extent by eating meat. Healthy kidneys
filter creatinine and other waste products from your blood. The filtered
waste products leave your body in your urine.
If your kidneys aren't functioning properly, an increased level of
creatinine may accumulate in your blood. A serum creatinine test
measures the level of creatinine in your blood and gives you an estimate
of how well your kidneys filter (glomerular filtration rate). A creatinine
urine test can measure creatinine in your urine.
3)

fasting glucose ( pt normal : 90 mg/dL)

The glucose challenge test measures your body's response to sugar

(glucose). The glucose challenge test is done during pregnancy to screen
for gestational diabetes diabetes that develops during pregnancy.
The glucose challenge test is done in two steps. First you drink a sugary
solution. One hour later, your blood sugar level is measured. The results
of the glucose challenge test indicate whether you might have
gestational diabetes.
If the test results are above normal, you'll need to have further testing
to determine the diagnosis.
4)

potassium

This test measures the amount of potassium in the fluid portion (serum)
of the blood. Potassium (K+) helps nerves and muscles communicate. It
also helps move nutrients into cells and waste products out of cells.
Potassium levels in the body are mainly controlled by the hormone
aldosterone.
Your doctor may order this test to diagnose or monitor kidney disease.
The most common cause of high potassium levels is kidney disease.
Potassium is important to heart function.
Your doctor may order this test if you have signs of high blood pressure
or heart problems.
Small changes in potassium levels can have a big effect on the activity of
nerves and muscles, especially the heart.
Low levels of potassium can lead to an irregular heartbeat or other
electrical malfunction of the heart.
High levels cause decreased heart muscle activity.
Either situation can lead to life-threatening heart problems.

It may also be done if your doctor suspects metabolic acidosis (for

example, caused by uncontrolled diabetes) or alkalosis (for example,
caused by excess vomiting).
Sometimes, the potassium test may be done in persons who are having
an attack of paralysis.

5)

cholesterol test (triglyceride abnormal- high 170 mg/dL)

A complete cholesterol test also called a lipid panel or lipid profile

is a blood test that can measure the amount of cholesterol and
triglycerides in your blood. A cholesterol test can help determine your
risk of the buildup of plaques in your arteries that can lead to narrowed
or blocked arteries throughout your body (atherosclerosis). High
cholesterol levels usually don't cause any signs or symptoms, so a
cholesterol test is an important tool. High cholesterol levels often are a
significant risk factor for heart disease.
A complete cholesterol test, referred to as a lipid panel or lipid profile,
includes the calculation of four types of fats (lipids) in your blood:
Total cholesterol. This is a sum of your blood's cholesterol content.
High-density lipoprotein (HDL) cholesterol. This is sometimes called the
"good" cholesterol because it helps carry away LDL cholesterol, thus
keeping arteries open and your blood flowing more freely.
Low-density lipoprotein (LDL) cholesterol. This is sometimes called the
"bad" cholesterol. Too much of it in your blood causes the buildup of
fatty deposits (plaques) in your arteries (atherosclerosis), which reduces
blood flow. These plaques sometimes rupture and can lead to a heart
attack or stroke.
Triglycerides. Triglycerides are a type of fat in the blood. When you eat,
your body converts any calories it doesn't need into triglycerides, which
are stored in fat cells. High triglyceride levels are associated with several
factors, including being overweight, eating too many sweets or drinking
too much alcohol, smoking, being sedentary, or having diabetes with
elevated blood sugar levels.

High triglycerides are often a sign of other conditions that increase the
risk of heart disease and stroke as well, including obesity and metabolic
syndrome a cluster of conditions that includes too much fat around
the waist, high blood pressure, high triglycerides, high blood sugar and
abnormal cholesterol levels.