Harvey DLX Double Head and Triple Head Stethoscopes Guide

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Designed to enable the medical professional to obtain superior and accurate auscultation. The Harvey DLX Double Head and Triple Head Stethoscopes were designed after extensive research and testing. The critical design of the tubing, proper weight and sizing of the chestpiece and rotatable binaurals, combine to make the Harvey Stethoscopes exceptional instruments for auscultation. The final testing, of course, was on the patient. The Harvey Stethoscopes will give you the ability to identify the lowest frequencies that the human ear can detect, such as a faint diastolic gallop or rumble, as well as the higher frequencies of the faint early blowing aortic diastolic murmur. Furthermore, with over five decades of experience using stethoscopes, Dr. W. Proctor Harvey has designed his stethoscopes to meet the comfort and portability needs which physicians demand.

Chestpieces

Triple Head

Double Head Both the double head and triple head offer a flat diaphragm and bell. The triple head also utilizes a corrugated diaphragm for additional auscultatory capabilities. Selection is accomplished by holding the chestpiece stem in one hand and rotating the chestpiece until a click is heard or felt.

Flat Diaphragm “The workhorse.” Excellent for all sounds and murmurs. Best for higher frequencies (such as faint diastolic murmur of aortic regurgitation). Also ideal to identify splitting of sounds, systolic clicks and ejection sounds. 4.76 cm diameter. 2

Corrugated Diaphragm Amplifying quality. Excellent for an overview of heart sounds. Especially good for low-frequency gallop sounds and murmurs. 4.76 cm diameter.

Bell Provides excellent detection and clarity for low and mediumfrequency heart sounds and murmurs (such as a faint gallop or diastolic rumble). 2.79 cm diameter.

Headset Adjustment Your new Harvey Stethoscopes are designed to give you the maximum ability to adjust for your personal comfort and acoustic fit. A. Select the correct size and texture eartip. For maximum acoustic seal, two sizes of “soft” and “hard” eartips are provided. Choose the size which best seals off your outer ear canal and feels the most comfortable. As a rule the larger size is best for the majority. B. To adjust the C. Make sure that the angle of the binaural tubes are binaurals, hold pointed slightly the spring in one forward going into hand and rotate the ear canal. each binaural to the correct angle. 3

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D. To reduce spring tension, grasp each eartube at its bend and gently pull outwards.

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E. To increase spring tension, squeeze the eartubes together.

and replace with new disc. Thread the ring back on to chestpiece.

Care and Maintenance

Warranty

• It is important to clean and disinfect your stethoscope to prevent possible cross-contamination. • Eartubes and tubing can be wiped down with alcohol or mild soapy water. • Eartips may be removed for thorough cleaning with alcohol or mild soapy water. • Diaphragm replacement: Under normal use you should rarely need to remove the rim and diaphragm for cleaning purposes. The exterior of the diaphragm can be cleaned with alcohol or mild soapy water. However, if you do need to remove diaphragm:

Your Harvey DLX Stethoscope comes with a 10-year warranty against parts and manufacturing defects. Should a material or workmanship defect be discovered, Welch Allyn will repair or replace the product at no charge.

A. Hold the bell and turret section in one hand, and exert pressure on the back of the diaphragm. Grip the threaded ring of the diaphragm with your other hand and turn the ring counterclockwise to loosen.

B. Separate the threaded ring from the turret section.

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C. Simply press the diaphragm disc out of the metal ring

This warranty does not cover damage in shipment or failure caused by tampering, obvious carelessness or abuse. Return the unit for service, to any of the Welch Allyn Service Centers below: • Welch Allyn, Repair Dept., 95 Old Shoals Rd., Arden, NC 28704. • Welch Allyn, Repair Dept., Postfach 31, Zollerstrasse 2-4 D-72417 Jungingen/Deutschland. • Welch Allyn, Repair Dept., 160 Matheson Blvd. East, Unit 2, Mississauga, Ontario, Canada L4Z1V4. • In Latin America, send to MD, International Repair Dept., 7324 SW 48th St., Miami, Florida 33155. • Welch Allyn, Repair Dept., 21-09 Golden Mile Tower 6001, Beach Road, Singapore 199589, Rep. of Singapore. • Welch Allyn, Repair Dept., Ground Floor, 18-20 Orion Road, Lane Cove, NSW 2066, Australia. • In Japan, send to IMI Co., 3-3-12 Ryutsu-danchi, Koshigaya-shi Saitama, 343 Japan.

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Ordering Information All Welch Allyn brand stethoscopes and accessory parts can be purchased from an authorized distributor in your area. Call Welch Allyn directly for the name of the dealer near you. 5079-321 5079-325 5079-315 5079-113 5079-66 5079-233 5079-314 5079-121 5079-120 5079-316 5079-317 5079-318 5079-319 5079-104 5079-05 5079-319

Harvey DLX Triple Head, Black Tubing Harvey DLX Double Head, Black Tubing Accessory Kit Hard Eartips, Extra Large Hard Eartips, Large Soft Eartips, Large Soft Eartips, Medium Binaural/Spring Assembly Tubing, Black Pediatric Chestpiece Assembly Adult Flat Chestpiece Assembly Bell Chestpiece Corrugated Chestpiece Assembly Flat Diaphragm Disc Only Adult Corrugated Diaphragm Disc Only Adult Corrugated Chestpiece Assembly

F r a n ç a i s... 7

A u s c u l t a t i o n... 37

Stéthoscopes double et triple tête DLX de Harvey 6

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Informações para encomendas Todos os estetoscópios e peças de acessórios da Welch Allyn podem ser adquiridas junto a um distribuidor autorizado em sua região. Telefone diretamente para a Welch Allyn para obter o nome do revendedor mais próximo. 5079-321 5079-325 5079-315 5079-113 5079-66 5079-233 5079-314 5079-121 5079-120 5079-316 5079-317 5079-318 5079-319 5079-104 5079-05 5079-319

Cabeçote triplo Harvey DLX, tubo negro Cabeçote duplo Harvey DLX, tubo negro Kit de acessórios Extremidades auriculares duras, extra-grande Extremidades auriculares duras, grande Extremidades auriculares macias, grande Extremidades auriculares macias, média Conjunto de haste binaural e mola Tubo, negro Conjunto de porção torácica pediátrico Conjunto de porção torácica plano Porção torácica com campana Conjunto de porção torácica corrugado Somente o disco do diafragma plano Somente o disco do diafragma corrugado Conjunto de porção torácica corrugado

Auscultation of the Heart Preparing for the Exam Auscultation of the heart can be mastered. Develop a pattern or sequence which becomes like second nature. The room should be quiet and free of distractions. The patient should be comfortable and disrobed properly to enable adequate contact between the stethoscope and skin. A complete exam should include listening to the patient while in the following positions: supine, left lateral recumbent and sitting, as well as listening over the point of maximum impulse of the left ventricle. The standing and squatting positions are frequently utilized. Also listen rou-tinely over areas on the neck, back, and abdomen. The great majority prefer to examine the patient from the right side.

Supine

Left Lateral Recumbent

Sites of Auscultation There are specific sites on the chest wall most principally used for cardiac auscultation. 1. Aortic Area (Base Right) Located at the 2nd intercostal space to the right of the sternum. Sounds and murmurs of the aortic valve and aorta are well heard in this area. Aortic events are often also well heard at the Apex.

Sitting

2. Pulmonic Area (Base Left) Located at the 2nd intercostal space to the left of the sternum. Sounds and murmurs from the pulmonic valve are usually best heard in this area, or at the 3rd left sternal border. 36

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3. Left Sternal Border Located at the 3rd intercostal space to the left of the sternum. Usually the best area to detect aortic diastolic murmurs. 4. Right Sternal Border Located at the 3rd intercostal space to the right of the sternum. The best area to detect the “right-sided” aortic diastolic murmur. 5. Lower Left Sternal Border (Tricuspid Area) Located at the 4th left intercostal space. Good for evaluation of the first heart sound, systolic clicks, gallops and tricuspid murmurs. 6. Between the Lower Left Sternal Border and Apex Especially good for sounds and murmurs of mitral valve origin. Base Left (Pulmonic Area)

Base Right (Aortic Area)

Left Sternal Border Right Sternal Border

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Left Lower Sternal Border (Tricuspid Area)

Apex (Mitral Area)

7. Apex (Mitral Area) Normally located at the 5th left intercostal space in the midclavi-cular line. Usually best for identification of sounds and murmurs (both systolic and diastolic) of mitral valve origin. Aortic ejection sounds are often discernible here.

In the normal sequence of auscultation, Dr. Harvey suggests that one routinely begin at one area and then carefully explore the other areas. He begins at the lower left sternal border (LLSB), where an overview of the heart sounds and murmurs is obtained. He then listens specifically to the various auscultatory events in the area, enabling best analysis and sound identification. The majority of heart sounds and murmurs can be heard at more than one area. Use both the diaphragm and bell chestpieces over these areas.

aorta

Heart Sounds and Murmurs

superior vena cava

pulmonary vein

pulmonary artery

left atrium mitral valve aortic valve

The first and second heart right atrium sounds are vibrations inferior produced by the closure of vena cava valves. The way in which we identify these sounds evolves around the two pulmonic tricuspid valve valve phases of the cardiac cycle. The term “systole” refers to the phase when the ventricles contract and the mitral and tricuspid valves close. This produces the first heart sound or S1. “Diastole” refers to the relaxation phase when the ventricles are filling and pulmonic and aortic valves have closed. The second sound (S2) denotes the end of systole and is caused by closure of the aortic and pulmonic valves.

left ventricle

right ventricle

Murmurs result from the turbulence of blood flow through the heart. They can be normal (innocent murmurs) or significant and related to abnormal pathology of the valves and/or ventricles. Systolic murmurs occur when the heart contracts (systole). Diastolic murmurs occur in diastole. The accurate detection and identification of normal and abnormal heart sounds and murmurs will put you on the track to diagnosing the presence of heart disease. 39

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The Flat Diaphragm

The Corrugated Diaphragm

The flat diaphragm is the “workhorse” chestpiece and should be used on every patient. This chestpiece serves to filter out the lower frequencies and accent the higher range. The degree of pressure exerted on the diaphragm will directly impact the frequencies attenuated. As an example, to detect the faintest high-frequency murmur of aortic regurgitation, the patient should be sitting, leaning forward with breath held in deep expiration. The diaphragm should be positioned over the 3rd left sternal border and very firm pressure applied. Sufficient pressure should be used to leave a temporary imprint of the diaphragm on the chest wall. If firm pressure is not exerted, a faint grade 1 or 2 aortic or pulmonic murmur might be overlooked. Conversely, by using very light pressure on the diaphragm, low frequencies such as a gallop or diastolic rumble can be “brought out.” The key is to use varying degrees of pressure in order to tune in the various heart sounds. The flat diaphragm is also the chestpiece of choice in the detection and analysis of normal and abnormal breath and lung sounds. Be sure to listen over all areas of the precordium:

The original corrugated diaphragm has a unique principle of circular convex ridges. It is at first surprising to many that this diaphragm can not only amplify heart sounds and murmurs, but when used properly often leads the examiner to pick up the faintest low frequency gallop or diastolic rumble. It is excellent for the “overview” (or “overlisten”). As an initial move, place the corrugated chestpiece over the lower left sternal border; very light pressure is recommended. In fact, the weight of the stethoscope alone usually produces the proper amount of pressure, as well as contact with the chest wall to best amplify a low frequency gallop or rumble. The hand is often not necessary to exert pressure, although varying degrees can be utilized if desired. This chestpiece is also capable of identifying higher frequencies such as a diastolic blow of aortic regurgitation; firm pressure on the stethoscope is used, although the flat diaphragm is best for this. Because the corrugated chestpiece amplifies, it can aid those who have some hearing loss. Also, it may help in better detection of faint heart sounds and murmurs in those patients who have emphysema, are obese, or have increased musculature development of the chest wall over the heart. The corrugated piece detects and amplifies the characteristic normal sounds S1, S2, as well as the S3 and S4 diastolic gallops, ejection sounds and prosthetic valve sounds. Use this piece routinely on each patient examined and then switch to the bell and flat diaphragm to further analyze the various heart sounds and murmurs.

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LLSB (tricuspid area)

Apex (mitral area)

(pulmonic area)

(aortic area)

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The Bell The bell is particularly useful in detecting faint, low-frequency sounds and murmurs. Very light pressure with the bell, barely making an air seal with the skin of the chest wall, is required for correct auscultation. The bell on the Harvey Stethoscopes is specifically sized to fit between the ribs making an air seal, and fitting into spaces that the diaphragm cannot. This is particularly necessary when examining patients with bony chests and poor muscular development. The bell is also sized to fit into areas of the neck, such as: A-suprasternal notch, B-supraclavicular fossae, and C-carotid artery. A

B

C

The bell is also best suited to pick up the low-frequency third (S3) and fourth (S4) heart sounds. S3 is usually a left ventricular sound which occurs in early diastole and is best heard over the LLSB and Apex. In normal individuals under 35 years of age, the S3 can be normal and is called “physiologic.” In the abnormal, it is called an S3 (ventricular) gallop. S3 is a filling sound caused by blood rapidly filling and striking the ventricle in early diastole.

Helpful Hints Remember the great majority of patients having cardiovascular disease can be diagnosed in your office or at the bedside. The stethoscope is your most important instrument used in the physical exam to make this possible. The key to successful cardiac auscultation will be your ability to correctly characterize, interpret and identify the various heart sounds and murmurs.

Grading the Loudness of Murmurs (Systolic I-VI, Diastolic I-IV) Grade I: In order to accentuate or “bring out” the faint atrial or ventricular diastolic gallop, 3rd heart sound, or diastolic rumble of mitral stenosis, you will need to find the point of E maximal intensity of the left D ventricle. This maneuver is accomplished by using one’s index finger and 3rd finger to palpate, as shown in Figure D. 42

Very faint, must concentrate on several cycles to hear. Not heard immediately.

Grade II: A faint murmur but discernible immediately upon listening. Grade III: Intermediate. Louder than a Grade II, but cannot be palpated. Grade IV: A loud murmur often associated with a palpable thrill. Grade V: Very loud murmur which requires the stethoscope to be at least partially in contact with the skin, but not heard off the chest wall. Grade VI: A murmur loud enough to hear with the stethoscope not touching the chest wall. 43

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Sketching Heart Sounds and Murmurs

Maneuvers

A very effective way to improve your auscultatory ability, and accurately track the progress of a murmur is through sketching. Note the sketch of a late apical systolic murmur of mitral valve prolapse as shown below. It is suggested that you put these in your own records as well as in your write-ups of the patient’s cardiac exam in hospital charts.

When applicable, make use of the various simple maneuvers such as valsalva, handgrip and squatting. For example, with hypertrophic cardiomyopathy, the systolic murmur may decrease with squatting and become louder on standing, as shown in bottom sketch on page 44. In the case of mitral valve prolapse, on squatting the click(s) may move toward the second heart sound (S2 ). The murmur may become shorter in late systole and get louder as systole continues. This stethoscope also provides for accurate auscultation of the lungs. The flat diaphragm is usually best for this.

SM

S1

Pediatric Accessories A pediatric diaphragm chestpiece is included in the Accessory Kit. The pediatric diaphragm is 3.5 cm in diameter and allows for easier auscultation of infants and neonates.

S2

Mitral valve prolapse

SM

S1

SM

stand S2 squat

Hypertrophic cardiomyopathy

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Welch Allyn Worldwide Locations: Welch Allyn, Inc. 4341 State Street Road P.O. Box 220 Skaneateles Falls, NY 13153-0220 U.S.A. Telephone: 800-535-6663 (in USA) or 315-685-4100 Fax: 315-685-3361 Welch Allyn, Inc. 95 Old Shoals Road Arden, NC 28704-9739 U.S.A. Telephone: 828-684-4895 Fax: 828-687-1002 Welch Allyn, Inc. 1 Westchester Drive Milford, NH 03055-3056 U.S.A. Telephone: 603-672-0470 Fax: 603-672-0487 Welch Allyn, Inc. 7420 Carroll Road San Diego, CA 92121-2334 U.S.A. Telephone: 619-621-6600 Fax: 619-621-6610

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European Regulatory Manager Directeur de la réglementation européenne Europäischer Vertreter Director de Normativas Europeas European Regulatory Manager (Gerente Europeu de Regulamentação) Direzione normative europee Medical Division, Welch Allyn Ltd. Navan, Co. Meath, Republic of Ireland

95 Old Shoals Road Arden, NC 28704 Telephone: (828) 684-4895

95P413 Rev. C

Printed in U.S.A.