Assessment of the circulatory system, inclusive of auscultation of heart sounds, is a component of the physical therapist (PT) curriculum. However, I have often observed omission of this assessment by home healthcare therapists. Two potential reasons for this omission come to mind: 1) therapists may not feel confident in their ability to accurately perform this assessment and/or 2) assessment of heart sounds may have reduced importance, either actual or perceived, in clinical decision making related to a therapist's plan of care.
Although PTs do not commonly form clinical diagnoses using heart sound auscultation in isolation, they certainly may use findings in cluster with other signs and symptoms gathered during an examination (American Physical Therapy Association [APTA], 2018).
The first (S1) and second heart sounds (S2) are considered normal heart sounds. The S1 heart sound is created when the mitral and tricuspid valves close. It is congruent with the onset of ventricular systole and can be described as a "LUP" sound. The S2 heart sound "DUP" is generated by closure of the aortic and pulmonic valves and associated with the onset of ventricular diastole. As the sounds are created by valve closure, anything that impairs movement of the heart valves or the ability of the valves to function in a predictive fashion could result in abnormal heart sounds or murmurs (Hillegass, 2017).
Precursors to abnormal heart sounds include valvular stenosis or regurgitation, cardiac muscle impairment, and fluid overload (Hillegass, 2017). Although a third heart sound (S3) can be a benign occurrence in healthy children, young adults, and in pregnancy, it is also a sign of heart failure (HF). The S3 sound is an extra sound heard early in ventricular diastole. The fourth heart sound (S4) is commonly heard late in diastole or presystole. The S4 sound is most commonly associated with a resistance to cardiac filling as would be present in hypertension or stenosis. Systolic and diastolic murmurs can be heard between the normal heart sounds and may suggest the presence of cardiac muscle dysfunction with associated valvular ejection or regurgitation dysfunctions (Hillegass).
A personal patient encounter involving an individual with multiple comorbidities illustrates the importance of auscultating heart sounds. My plan of care evolved around impaired strength, balance, and endurance that limited the patient's ability to ambulate. Three weeks into the episode of care, I arrived at the home to find the individual with increased confusion and fatigue. My assessment identified a decline in cognitive and physical function, and fine bilateral crackles in the lungs. Blood pressure, heart rate, and saturation were within normal limits. Edema in the lower extremities of this individual was common and further assessment of abdominal girth and weight gain was difficult to assess due to decreased ability to get out of the bed. Auscultation of the heart revealed an additional heart sound I believed to be S3. This ended up being the puzzle piece that precipitated an emergency room visit and ultimately a hospital admission for exacerbation of HF.
Review of auscultatory technique may be helpful to PTs to improve their assessment skills. One free resource can be found at Medical Training and Simulation, LLC (Keroes & Lieberman, 2017). Additionally, the APTA Home Health Section offers online and in-person learning modules to address assessment skills inclusive of heart sounds (APTA, n.d.).
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