const AUSC_SITES=[{id:"mitral",n:1,zh:"\u4E8C\u5C16\u74E3\u533A",en:"Mitral area",short:["\u4E8C\u5C16","M"],x:212,y:139,locZh:"\u5FC3\u5C16\u640F\u52A8\u5904\uFF1A\u5DE6\u7B2C 5 \u808B\u95F4\u3001\u9501\u9AA8\u4E2D\u7EBF\u5185\u4FA7 0.5\u20131 cm",locEn:"Apex beat: 5th left intercostal space, just medial to the midclavicular line",tipZh:"\u949F\u578B\u542C S3 / S4 / \u9686\u9686\u6837\u6742\u97F3\uFF0C\u819C\u578B\u542C S1 \u4E0E\u5439\u98CE\u6837\u6742\u97F3\uFF1B\u5DE6\u4FA7\u5367\u4F4D\u66F4\u6E05\u695A",tipEn:"Bell for S3 / S4 and rumbles, diaphragm for S1 and blowing murmurs; clearer in the left lateral decubitus position"},{id:"pulmonic",n:2,zh:"\u80BA\u52A8\u8109\u74E3\u533A",en:"Pulmonic area",short:["\u80BA\u74E3","P"],x:168,y:69,locZh:"\u80F8\u9AA8\u5DE6\u7F18\u7B2C 2 \u808B\u95F4",locEn:"2nd left intercostal space at the sternal border",tipZh:"\u819C\u578B\uFF1B\u542C S2 \u5206\u88C2\u8BA9\u60A3\u8005\u5E73\u9759\u547C\u5438\uFF0C\u5438\u6C14\u65F6\u5206\u88C2\u53D8\u5BBD",tipEn:"Diaphragm; have the patient breathe quietly and listen for the S2 split widening on inspiration"},{id:"aortic",n:3,zh:"\u4E3B\u52A8\u8109\u74E3\u533A",en:"Aortic area",short:["\u4E3B\u74E3","A"],x:132,y:69,locZh:"\u80F8\u9AA8\u53F3\u7F18\u7B2C 2 \u808B\u95F4",locEn:"2nd right intercostal space at the sternal border",tipZh:"\u819C\u578B\uFF1B\u6742\u97F3\u662F\u5426\u5411\u9888\u90E8\u4F20\u5BFC\uFF0C\u542C\u8BCA\u5668\u987A\u7740\u9888\u52A8\u8109\u5F80\u4E0A\u632A",tipEn:"Diaphragm; inch the stethoscope up along the carotids to test radiation to the neck"},{id:"erb",n:4,zh:"\u4E3B\u52A8\u8109\u74E3\u7B2C\u4E8C\u542C\u8BCA\u533A",en:"Erb's point (2nd aortic area)",short:["Erb","E"],x:168,y:91,locZh:"\u80F8\u9AA8\u5DE6\u7F18\u7B2C 3 \u808B\u95F4",locEn:"3rd left intercostal space at the sternal border",tipZh:"\u819C\u578B\u91CD\u538B\uFF1B\u60A3\u8005\u5750\u4F4D\u524D\u503E\u3001\u547C\u6C14\u672B\u5C4F\u6C14",tipEn:"Diaphragm pressed firmly; patient sitting, leaning forward, breath held in expiration"},{id:"tricuspid",n:5,zh:"\u4E09\u5C16\u74E3\u533A",en:"Tricuspid area",short:["\u4E09\u5C16","T"],x:168,y:122,locZh:"\u80F8\u9AA8\u4E0B\u7AEF\u5DE6\u7F18\uFF1A\u80F8\u9AA8\u5DE6\u7F18\u7B2C 4\u20135 \u808B\u95F4",locEn:"Lower left sternal border: 4th\u20135th left intercostal space",tipZh:"\u53F3\u5FC3\u7684\u58F0\u97F3\u5728\u8FD9\u91CC\uFF0C\u5438\u6C14\u65F6\u589E\u5F3A\uFF08Carvallo \u5F81\uFF09",tipEn:"Right-heart sounds live here and get louder on inspiration (Carvallo sign)"}],AUSC_CIRCLED=["","\u2460","\u2461","\u2462","\u2463","\u2464"],AUSC_VALVE_PROJ={pulmonic:[160,80],aortic:[153,92],erb:[153,92],mitral:[166,104],tricuspid:[150,114]},AUSC_BASE={mitral:{s1:1,s2:.5,a2:1,p2:.15,split:0},pulmonic:{s1:.55,s2:1,a2:.9,p2:.9,split:.03},aortic:{s1:.5,s2:1,a2:1,p2:.3,split:0},erb:{s1:.7,s2:.85,a2:.9,p2:.6,split:.02},tricuspid:{s1:.85,s2:.6,a2:.8,p2:.4,split:0}},AUSC_PATH={normal:{},hf:{s1k:.8,s3:{mitral:.7,tricuspid:.35,erb:.2,pulmonic:.1,aortic:.1},s4:{mitral:.5,tricuspid:.25,erb:.1,pulmonic:.08,aortic:.08}},ms:{s1k:{mitral:1.5,tricuspid:1.2,erb:1.1},p2k:{pulmonic:1.3},os:{mitral:.8,tricuspid:.45,erb:.35,pulmonic:.2,aortic:.1},mur:{mitral:1,tricuspid:.3,erb:.15,pulmonic:.1,aortic:.05},shape:"rumble",seg:"S2"},mr:{s1k:{mitral:.6,tricuspid:.75},s3:{mitral:.4,tricuspid:.15},mur:{mitral:1,tricuspid:.55,erb:.4,pulmonic:.3,aortic:.2},shape:"holo",seg:"S1"},as:{s2k:{aortic:.35,erb:.5,pulmonic:.6,tricuspid:.7,mitral:.7},s4:{mitral:.45,tricuspid:.2,erb:.1},mur:{aortic:1,erb:.8,pulmonic:.6,tricuspid:.5,mitral:.55},shape:"diamond",seg:"S1",split:0},ar:{s1k:{mitral:.85},split:0,mur:{erb:1,aortic:.8,pulmonic:.5,tricuspid:.5,mitral:.35},shape:"decrescendo",seg:"S2",flint:{mitral:.35}},hfpef:{s4:{mitral:.7,tricuspid:.3,erb:.15,pulmonic:.1,aortic:.1},s2k:{aortic:1.25,erb:1.1,pulmonic:1.05}},mi:{s1k:.7,s4:{mitral:.6,tricuspid:.3,erb:.15,pulmonic:.1,aortic:.1}},exercise:{s1k:1.2,s2k:1.1,mur:{pulmonic:.35,aortic:.3,erb:.3,tricuspid:.2,mitral:.15},shape:"diamond",seg:"S1"},shock:{s1k:.6,s2k:.6},athlete:{s3:{mitral:.5,tricuspid:.2,erb:.1,pulmonic:.05,aortic:.05}}},AUSC_SRC={normal:"mitral",hf:"mitral",ms:"mitral",mr:"mitral",as:"aortic",ar:"erb",hfpef:"mitral",mi:"mitral",exercise:"mitral",shock:"mitral",athlete:"mitral"};function auscSiteById(e){return AUSC_SITES.find(s=>s.id===e)||AUSC_SITES[0]}function auscDist(e,s){const t=auscSiteById(e),i=auscSiteById(s);return Math.hypot(t.x-i.x,t.y-i.y)}function auscModel(e,s){const t=AUSC_BASE[s]||AUSC_BASE.mitral,i=AUSC_PATH[e]||AUSC_PATH.normal,a=(r,c=0)=>r==null?c:typeof r=="number"?r:r[s]??c,o=AUSC_SRC[e]||"mitral",n=s===o?0:auscDist(s,o);return{s1:t.s1*a(i.s1k,1),s2:t.s2*a(i.s2k,1),a2:t.a2,p2:t.p2*a(i.p2k,1),split:i.split!=null?i.split:t.split,s3:a(i.s3),s4:a(i.s4),os:a(i.os),mur:a(i.mur),mur2:a(i.flint),shape:i.shape||null,seg:i.seg||null,src:o,lp:n===0?0:Math.round(900-500*Math.min(1,n/110))}}function auscSliceGain(e,s,t){const i=auscModel(e,s),a=auscModel(e,i.src),o=typeof STATES<"u"&&STATES[e]&&STATES[e].audio||e,n=!!(typeof STATES<"u"&&STATES[o]&&STATES[o].murmur),r=a.s3>0,c=a.s4>0,u=d=>t==="S1"?d.seg==="S1"&&n?.3*d.s1+.7*d.mur:d.s1:d.seg==="S2"&&n?.3*d.s2+.7*d.mur:r?.5*d.s2+.5*d.s3:c?.5*d.s2+.5*d.s4:d.s2,h=Math.max(.15,Math.min(1.4,u(i)/Math.max(1e-6,u(a))));return{gain:Math.round(h*1e3)/1e3,lp:i.lp}}function auscSynthGain(e,s){const t=auscModel(e,s),i=auscModel(e,t.src),a=(o,n)=>Math.max(.1,Math.min(1.6,n>0?o/n:1));return{S1:a(t.s1,i.s1),S2:a(t.s2,i.s2),S3:a(t.s3,i.s3),S4:a(t.s4,i.s4),OS:a(t.os,i.os),murmur:a(t.mur,i.mur)}}const AUSC_SAMPLES=400;function auscNoise(e){const s=Math.sin(e*12.9898+78.233)*43758.5453;return(s-Math.floor(s))*2-1}function auscWrap(e){return e=e%1,e>.5&&(e-=1),e<=-.5&&(e+=1),e}function auscBurst(e,s,t,i){const a=e/s;return Math.exp(-.5*a*a)*Math.sin(2*Math.PI*t*e*i)}function auscMurEnv(e,s,t,i){const a=o=>o/i;if(s==="holo")return e<t[1]+a(.01)||e>t[4]-a(.01)?0:1;if(s==="diamond"){const o=t[2]-a(.01),n=t[4]-a(.03);return e<=o||e>=n?0:Math.pow(Math.sin(Math.PI*(e-o)/(n-o)),1.5)}if(s==="decrescendo"){let o=e-t[4];return o<0&&(o+=1),o<a(.02)||e>t[1]&&e<t[4]?0:Math.exp(-(o-a(.02))/(.3*(1-t[4])))}if(s==="rumble"){if(e>t[1]&&e<t[4]+a(.09))return 0;let o=e-(t[4]+a(.09));o<0&&(o+=1);let n=auscWrap(t[1]-e);if(n<0&&(n+=1),n<a(.015))return 0;let r=.35+.55*Math.exp(-o/(.25*(1-t[4])));return n<a(.1)&&(r+=.8*(1-n/a(.1))),Math.min(1.3,r)}return 0}function auscFlintEnv(e,s,t){const i=e<s[1]?e+1:e,a=s[5]+.12/t,o=1+s[1]-.02/t;return i<=a||i>=o?0:Math.pow(Math.sin(Math.PI*(i-a)/(o-a)),1.2)}function auscWave(e,s,t,i,a){const o=r=>r/i;let n=0;if(n+=s.s1*(.85*auscBurst(auscWrap(e-t[1]),o(.02),42,i)+.45*auscBurst(auscWrap(e-t[1]-o(.028)),o(.016),42,i)),n+=s.s2*(s.a2*auscBurst(auscWrap(e-t[4]),o(.013),62,i)+s.p2*auscBurst(auscWrap(e-t[4]-o(s.split)),o(.011),62,i)),s.os&&(n+=s.os*auscBurst(auscWrap(e-t[4]-o(.07)),o(.006),120,i)),s.s3&&(n+=s.s3*auscBurst(auscWrap(e-t[4]-o(.14)),o(.022),24,i)),s.s4&&(n+=s.s4*auscBurst(auscWrap(e-t[1]+o(.085)),o(.022),22,i)),s.mur){const r=s.shape==="rumble"?(auscNoise(a)+auscNoise(a-1)+auscNoise(a-2))/3:auscNoise(a);n+=.6*s.mur*auscMurEnv(e,s.shape,t,i)*r}return s.mur2&&(n+=.5*s.mur2*auscFlintEnv(e,t,i)*(auscNoise(a)+auscNoise(a-1)+auscNoise(a-2))/3),n}function drawAuscMonitor(e,s,t,i,{stateId:a,siteId:o,tAbs:n,hr:r,lang:c}){const u=PHASE_BOUNDS,h=60/r,b=(typeof ECG_WINDOW_S=="number"?ECG_WINDOW_S:3)/h,k=t/b,T=k/h,m=13,g=(i-m-11)/5;e.setTransform(s,0,0,s,0,0),e.clearRect(0,0,t,i);const L=.04*T,V=.2*T;e.lineWidth=1,e.strokeStyle="rgba(34,49,63,0.10)",e.beginPath();for(let l=t;l>=0;l-=L)e.moveTo(l,m),e.lineTo(l,i-11);e.stroke(),e.strokeStyle="rgba(34,49,63,0.20)",e.beginPath();for(let l=t;l>=0;l-=V)e.moveTo(l,m),e.lineTo(l,i-11);for(let l=1;l<5;l++)e.moveTo(0,m+g*l),e.lineTo(t,m+g*l);e.stroke();const v=l=>t-(n-l)*k;e.font='8.5px "JetBrains Mono",ui-monospace,"SF Mono",Menlo,Consolas,"Liberation Mono",monospace',e.textAlign="center";const N=Math.floor(n-b)-1,R=Math.floor(n)+1;for(let l=N;l<=R;l++){const p=v(l+u[1]),S=v(l+u[4]);l+u[1]<=n&&p>30&&p<t-2&&(e.fillStyle="#A23B36",e.fillText("S1",p,9)),l+u[4]<=n&&S>30&&S<t-2&&(e.fillStyle="#1E3A5F",e.fillText("S2",S,9))}const W=Math.floor((n-b)*AUSC_SAMPLES)/AUSC_SAMPLES;let w=null;AUSC_SITES.forEach((l,p)=>{const S=auscModel(a,l.id),x=m+g*(p+.56),F=g*.4,f=l.id===o;e.strokeStyle=f?"#1E3A5F":"rgba(110,116,125,0.65)",e.lineWidth=f?1.5:1,e.lineJoin="round",e.shadowColor="rgba(30,58,95,0.30)",e.shadowBlur=f?3:0,e.beginPath();let P=!0,M=x;for(let C=0;;C++){const y=W+C/AUSC_SAMPLES;if(y>n+1e-9)break;const j=auscWave((y%1+1)%1,S,u,h,Math.round(y*AUSC_SAMPLES)),E=v(y),A=x-Math.max(-1.2,Math.min(1.2,j))*F;M=A,P?(e.moveTo(E,A),P=!1):e.lineTo(E,A)}e.stroke(),e.shadowBlur=0,f&&(w=M),e.fillStyle=f?"#16293F":"rgba(34,49,63,0.55)",e.font=(f?"700 ":"500 ")+(c==="en"?'9.5px "JetBrains Mono",ui-monospace,"SF Mono",Menlo,Consolas,"Liberation Mono",monospace':'10px Inter,"Microsoft YaHei",system-ui,sans-serif'),e.textAlign="left",e.fillText(AUSC_CIRCLED[l.n]+" "+(c==="en"?l.short[1]:l.short[0]),4,m+g*p+10)}),w!=null&&(e.fillStyle="#16293F",e.shadowColor="rgba(22,41,63,0.5)",e.shadowBlur=8,e.beginPath(),e.arc(t-2,w,2.4,0,Math.PI*2),e.fill(),e.shadowBlur=0),e.fillStyle="rgba(34,49,63,0.4)",e.font='8.5px "JetBrains Mono",ui-monospace,"SF Mono",Menlo,Consolas,"Liberation Mono",monospace',e.textAlign="right",e.fillText(c==="en"?"25 mm/s \xB7 schematic phonocardiogram":"25 mm/s \xB7 \u793A\u610F\u5FC3\u97F3\u56FE",t-6,i-3),e.textAlign="left"}const AUSC_INFO={normal:{mitral:["S1 \u5728\u8FD9\u91CC\u6700\u54CD\u3001\u6700\u4F4E\u6C89\uFF08\u4E8C\u5C16\u74E3\u5C31\u5728\u542C\u8BCA\u5668\u4E0B\u65B9\u5173\u95ED\uFF09\uFF0CS2 \u76F8\u5BF9\u8F7B\uFF1B\u6536\u7F29\u671F\u548C\u8212\u5F20\u671F\u90FD\u5B89\u9759\u3002\u5148\u7528\u819C\u578B\u542C S1\u3001S2\uFF0C\u518D\u6362\u949F\u578B\u786E\u8BA4\u6CA1\u6709\u4F4E\u8C03\u7684 S3\u3001S4\u3002","\u5FC3\u5C16\u542C\u8BCA\u662F\u672F\u524D\u57FA\u7EBF\uFF1A\u672F\u540E\u65B0\u51FA\u73B0\u7684\u6742\u97F3\u6216 S3 \u90FD\u8981\u548C\u5B83\u6BD4\u3002","S1 is loudest and lowest-pitched here (the mitral valve closes right under the stethoscope); S2 is softer, and both systole and diastole are silent. Use the diaphragm for S1 and S2, then the bell to confirm there is no low-pitched S3 or S4.","The apical exam is the pre-operative baseline: any new murmur or S3 after surgery is judged against it."],pulmonic:["S2 \u5728\u5FC3\u5E95\u6700\u54CD\uFF0C\u8FD9\u91CC\u80FD\u628A\u5B83\u62C6\u6210 A2 \u4E0E P2\uFF1A\u5438\u6C14\u65F6\u5206\u88C2\u53D8\u5BBD\uFF08\u7EA6 30 ms\uFF09\uFF0C\u547C\u6C14\u65F6\u5408\u62E2\uFF0C\u8FD9\u662F\u751F\u7406\u6027\u5206\u88C2\uFF1BS1 \u8F83\u5F31\u3002","P2 \u4EA2\u8FDB\u63D0\u793A\u80BA\u52A8\u8109\u9AD8\u538B\uFF0C\u662F\u74E3\u819C\u624B\u672F\u524D\u5FC5\u987B\u8BC4\u4F30\u7684\u98CE\u9669\uFF1B\u56FA\u5B9A\u5206\u88C2\u8981\u60F3\u5230\u623F\u95F4\u9694\u7F3A\u635F\uFF08\u53EF\u624B\u672F\u6216\u5C01\u5835\uFF09\u3002","S2 is loudest at the base and can be split into A2 and P2 here: the gap widens on inspiration (about 30 ms) and closes on expiration, which is physiological; S1 is soft.","A loud P2 means pulmonary hypertension, a risk that must be assessed before valve surgery; fixed splitting points to an atrial septal defect (surgical or device closure)."],aortic:["S2 \u4EE5 A2 \u4E3A\u4E3B\uFF0C\u5728\u8FD9\u91CC\u6700\u6E05\u8106\uFF1BS1 \u5F31\u3002\u6B63\u5E38\u6CA1\u6709\u6742\u97F3\uFF1B\u82E5\u51FA\u73B0\u6536\u7F29\u671F\u55B7\u5C04\u6027\u6742\u97F3\u5E76\u5411\u9888\u90E8\u4F20\u5BFC\uFF0C\u8981\u60F3\u5230\u4E3B\u52A8\u8109\u74E3\u72ED\u7A84\u6216\u786C\u5316\u3002","\u672F\u540E\u5728\u8FD9\u91CC\u8BC4\u4F30\u4EBA\u5DE5\u74E3\uFF1A\u673A\u68B0\u74E3\u6709\u6E05\u8106\u7684\u5F00\u95ED\u97F3\uFF0C\u751F\u7269\u74E3\u53EF\u6709\u8F7B\u5EA6\u55B7\u5C04\u6027\u6742\u97F3\uFF1B\u6742\u97F3\u53D8\u7C97\u6216\u65B0\u51FA\u73B0\u8212\u5F20\u671F\u6742\u97F3\u63D0\u793A\u74E3\u529F\u80FD\u969C\u788D\u3002","S2 here is mainly A2 and is crispest; S1 is soft. There is no murmur normally; a systolic ejection murmur radiating to the neck would suggest aortic stenosis or sclerosis.","This is where a prosthetic aortic valve is checked after surgery: mechanical valves give crisp opening and closing clicks, bioprostheses may have a soft ejection murmur; a harsher murmur or a new diastolic murmur suggests prosthesis dysfunction."],erb:["\u4E3B\u52A8\u8109\u74E3\u7B2C\u4E8C\u542C\u8BCA\u533A\uFF1AA2 \u4E0E P2 \u90FD\u542C\u5F97\u5230\uFF0CS1\u3001S2 \u5F3A\u5EA6\u63A5\u8FD1\u3002\u4E3B\u52A8\u8109\u74E3\u5173\u95ED\u4E0D\u5168\u7684\u8212\u5F20\u671F\u6742\u97F3\u5728\u8FD9\u91CC\u6700\u6E05\u695A\uFF0C\u6240\u4EE5\u6B63\u5E38\u65F6\u8981\u5728\u8FD9\u91CC\u786E\u8BA4\u8212\u5F20\u671F\u5B89\u9759\u3002","\u5FC3\u810F\u672F\u540E\u7684\u5FC3\u5305\u6469\u64E6\u97F3\u5728\u80F8\u9AA8\u5DE6\u7F18\u6700\u5E38\u542C\u5230\uFF0C\u4E0E\u6742\u97F3\u7684\u533A\u522B\u662F\u50CF\u6469\u64E6\u76AE\u9769\u3001\u4E0E\u5FC3\u640F\u4E0D\u5B8C\u5168\u540C\u6B65\u3002","At Erb's point both A2 and P2 are audible and S1 and S2 are about equal. The diastolic murmur of aortic regurgitation is clearest here, so in a normal heart this is where you confirm that diastole is silent.","A post-operative pericardial friction rub is most often heard along the left sternal border; unlike a murmur it sounds like creaking leather and is not fully locked to the heartbeat."],tricuspid:["S1 \u7531 M1 \u548C\u665A\u7EA6 30 ms \u7684 T1 \u7EC4\u6210\uFF0C\u5728\u80F8\u9AA8\u5DE6\u4E0B\u7F18\u6709\u65F6\u80FD\u542C\u51FA S1 \u5206\u88C2\uFF08\u751F\u7406\u6027\uFF09\uFF1BS2 \u5F31\u3002\u53F3\u5FC3\u7684\u58F0\u97F3\uFF08\u4E09\u5C16\u74E3\u53CD\u6D41\u3001\u53F3\u5BA4 S3\uFF09\u90FD\u5728\u8FD9\u91CC\uFF0C\u5438\u6C14\u65F6\u589E\u5F3A\u3002","\u80F8\u9AA8\u4E0B\u7AEF\u662F\u6B63\u4E2D\u5F00\u80F8\u7684\u4E0B\u754C\uFF1B\u672F\u540E\u6B64\u5904\u542C\u8BCA\u5E38\u53D7\u5207\u53E3\u3001\u5F15\u6D41\u7BA1\u5F71\u54CD\uFF0C\u53F3\u5FC3\u6742\u97F3\u8981\u5728\u5438\u6C14\u65F6\u91CD\u65B0\u6838\u5BF9\u3002","S1 is M1 followed about 30 ms later by T1, so a physiological split S1 is sometimes heard at the lower left sternal border; S2 is soft. Right-heart sounds (tricuspid regurgitation, RV S3) live here and get louder on inspiration.","The lower sternum is the lower limit of a median sternotomy; post-operative auscultation here is often hampered by the wound and drains, so right-heart murmurs are re-checked on inspiration."]},hf:{mitral:["S3 \u5954\u9A6C\u5F8B\uFF1AS2 \u540E\u7EA6 0.14 s \u7684\u4F4E\u8C03\u9644\u52A0\u97F3\uFF0C\u5FC3\u5C16\u6700\u54CD\uFF0C\u5DE6\u4FA7\u5367\u4F4D\u3001\u949F\u578B\u8F7B\u653E\u6700\u5BB9\u6613\u542C\u5230\uFF1B\u5E38\u4E0E S4 \u53E0\u6210\u56DB\u8054\u5F8B\uFF0C\u5FC3\u7387\u5FEB\u65F6\u5408\u6210\u91CD\u53E0\u5954\u9A6C\u5F8B\u3002S1 \u504F\u5F31\uFF08\u5DE6\u5BA4\u6536\u7F29\u529B\u5DEE\uFF09\u3002","\u6301\u7EED\u7684 S3 \u63D0\u793A\u5DE6\u5BA4\u529F\u80FD\u4E25\u91CD\u53D7\u635F\uFF0C\u662F\u624B\u672F\u98CE\u9669\u5206\u5C42\u4E0E\u673A\u68B0\u5FAA\u73AF\u8F85\u52A9\uFF08\u5982\u5DE6\u5BA4\u8F85\u52A9\u88C5\u7F6E\uFF09\u8BC4\u4F30\u7684\u4F9D\u636E\u4E4B\u4E00\u3002","S3 gallop: a low-pitched extra sound about 0.14 s after S2, loudest at the apex and easiest to hear with the bell lightly applied in the left lateral position; it often combines with S4 into a quadruple rhythm, or a summation gallop when the rate is fast. S1 is soft (poor LV contractility).","A persistent S3 indicates severely impaired LV function and feeds into surgical risk stratification and the work-up for mechanical support such as an LV assist device."],pulmonic:["S2 \u6B63\u5E38\u6216 P2 \u4EA2\u8FDB\uFF08\u80BA\u6DE4\u8840\u4F7F\u80BA\u52A8\u8109\u538B\u5347\u9AD8\uFF09\uFF1B\u5954\u9A6C\u5F8B\u4F20\u4E0D\u5230\u8FD9\u91CC\u3002","P2 \u4EA2\u8FDB\u63D0\u793A\u80BA\u52A8\u8109\u9AD8\u538B\uFF0C\u5F71\u54CD\u74E3\u819C\u624B\u672F\u4E0E\u5FC3\u810F\u79FB\u690D\u7684\u65F6\u673A\u548C\u98CE\u9669\u3002","S2 is normal or P2 is accentuated (pulmonary congestion raises pulmonary artery pressure); the gallop does not reach here.","A loud P2 flags pulmonary hypertension, which changes the timing and risk of valve surgery and transplantation."],aortic:["\u5FC3\u5E95\u542C\u4E0D\u5230\u5954\u9A6C\u5F8B\uFF0CS2 \u4EE5 A2 \u4E3A\u4E3B\uFF0C\u5FC3\u97F3\u6574\u4F53\u504F\u5F31\u3002\u5FC3\u7387\u5FEB\u65F6\u5148\u6570\u5FC3\u7387\u3001\u518D\u6309 S2 \u5B9A\u4F4D S1\u3002","\u4E3B\u52A8\u8109\u74E3\u533A\u5B89\u9759\u6709\u52A9\u4E8E\u6392\u9664\u4E3B\u52A8\u8109\u74E3\u72ED\u7A84\u8FD9\u7C7B\u53EF\u624B\u672F\u7EA0\u6B63\u7684\u5FC3\u8870\u75C5\u56E0\u3002","No gallop at the base; S2 is mainly A2 and the sounds are soft overall. With a fast rate, count the rate first and use S2 to locate S1.","A quiet aortic area helps exclude aortic stenosis, a surgically correctable cause of heart failure."],erb:["S3 \u5076\u53EF\u4F20\u5230\u8FD9\u91CC\u4F46\u5F88\u5F31\uFF1B\u8212\u5F20\u671F\u6CA1\u6709\u6742\u97F3\u3002","\u5FC3\u810F\u672F\u540E\u4F4E\u5FC3\u6392\u65F6\u8981\u5728\u8FD9\u91CC\u533A\u5206\u5954\u9A6C\u5F8B\u4E0E\u5FC3\u5305\u6469\u64E6\u97F3\u3002","S3 occasionally reaches here but faintly; there is no diastolic murmur.","In low-output states after cardiac surgery this is where a gallop must be told apart from a pericardial rub."],tricuspid:["\u53F3\u5BA4 S3 \u5728\u80F8\u9AA8\u5DE6\u4E0B\u7F18\uFF0C\u5438\u6C14\u65F6\u589E\u5F3A\uFF08\u53F3\u5FC3\u8870\u7AED\uFF09\uFF1B\u53F3\u5BA4\u6269\u5927\u53EF\u5E26\u6765\u529F\u80FD\u6027\u4E09\u5C16\u74E3\u53CD\u6D41\u7684\u6536\u7F29\u671F\u5439\u98CE\u6837\u6742\u97F3\u3002","\u53F3\u5FC3\u8870\u7684\u4F53\u5F81\u63D0\u793A\u672F\u540E\u53F3\u5BA4\u529F\u80FD\u4E0D\u5168\u98CE\u9669\u9AD8\uFF0C\u9700\u8981\u672F\u524D\u8BC4\u4F30\u53F3\u5BA4\u529F\u80FD\u4E0E\u80BA\u8840\u7BA1\u963B\u529B\u3002","An RV S3 is heard at the lower left sternal border and gets louder on inspiration (right heart failure); RV dilatation can add the blowing systolic murmur of functional tricuspid regurgitation.","Signs of right heart failure predict post-operative RV dysfunction, so RV function and pulmonary vascular resistance are assessed before surgery."]},ms:{mitral:["S1 \u4EA2\u8FDB\uFF08\u74E3\u53F6\u589E\u539A\u4F46\u4ECD\u67D4\u8F6F\uFF0C\u5173\u95ED\u7A81\u7136\uFF09\uFF1BS2 \u540E\u7EA6 0.07 s \u7684\u5F00\u74E3\u97F3\uFF08OS\uFF09\uFF1B\u968F\u540E\u8212\u5F20\u4E2D\u671F\u4F4E\u8C03\u9686\u9686\u6837\u6742\u97F3\uFF0C\u7AA6\u5F8B\u65F6\u6536\u7F29\u671F\u524D\u52A0\u5F3A\u3002\u949F\u578B\u3001\u5DE6\u4FA7\u5367\u4F4D\u3001\u547C\u6C14\u672B\u6700\u6E05\u695A\uFF0C\u8FD0\u52A8\u540E\u66F4\u54CD\u3002","OS \u79BB S2 \u8D8A\u8FD1\u72ED\u7A84\u8D8A\u91CD\uFF08\u5DE6\u623F\u538B\u8D8A\u9AD8\uFF09\u3002\u74E3\u53F6\u67D4\u8F6F\uFF08S1 \u4EA2\u8FDB\u3001OS \u6E05\u695A\uFF09\u9002\u5408\u7ECF\u76AE\u7403\u56CA\u4E8C\u5C16\u74E3\u6210\u5F62\uFF1B\u9499\u5316\u50F5\u786C\uFF08S1 \u51CF\u5F31\u3001OS \u6D88\u5931\uFF09\u503E\u5411\u6362\u74E3\u3002","Accentuated S1 (thickened but still pliable leaflets snap shut); an opening snap (OS) about 0.07 s after S2; then a low-pitched mid-diastolic rumble with presystolic accentuation in sinus rhythm. Bell, left lateral position, end-expiration; louder after exercise.","The shorter the S2\u2013OS interval, the tighter the stenosis (higher LA pressure). Pliable leaflets (loud S1, clear OS) suit percutaneous balloon mitral valvuloplasty; calcified rigid leaflets (soft S1, no OS) favour valve replacement."],pulmonic:["P2 \u4EA2\u8FDB\uFF08\u80BA\u52A8\u8109\u9AD8\u538B\uFF09\uFF0CS2 \u53EF\u5206\u88C2\uFF1B\u9686\u9686\u6837\u6742\u97F3\u4F20\u4E0D\u5230\u8FD9\u91CC\u3002","P2 \u4EA2\u8FDB\u7A0B\u5EA6\u53CD\u6620\u80BA\u52A8\u8109\u9AD8\u538B\uFF0C\u662F\u624B\u672F\u65F6\u673A\u4E0E\u98CE\u9669\u7684\u6307\u6807\uFF1B\u4E25\u91CD\u80BA\u52A8\u8109\u9AD8\u538B\u65F6\u53F3\u5BA4\u529F\u80FD\u8981\u4E00\u5E76\u8BC4\u4F30\u3002","Loud P2 (pulmonary hypertension) and S2 may be split; the rumble does not reach here.","How loud P2 is reflects the pulmonary hypertension and guides the timing and risk of intervention; with severe pulmonary hypertension RV function is assessed as well."],aortic:["A2 \u6B63\u5E38\uFF0C\u6CA1\u6709\u6742\u97F3\u3002\u4E8C\u5C16\u74E3\u72ED\u7A84\u7684\u6742\u97F3\u4E0D\u4F20\u5411\u5FC3\u5E95\uFF0C\u8FD9\u662F\u4E0E\u4E3B\u52A8\u8109\u74E3\u75C5\u53D8\u9274\u522B\u7684\u8981\u70B9\u3002","\u98CE\u6E7F\u6027\u75C5\u53D8\u5E38\u7D2F\u53CA\u591A\u4E2A\u74E3\u819C\uFF0C\u8FD9\u91CC\u5B89\u9759\u624D\u80FD\u6392\u9664\u5408\u5E76\u4E3B\u52A8\u8109\u74E3\u75C5\u53D8\uFF1B\u5408\u5E76\u65F6\u8981\u8003\u8651\u53CC\u74E3\u624B\u672F\u3002","A2 is normal and there is no murmur. The mitral stenosis rumble does not radiate to the base, a key point in distinguishing it from aortic valve disease.","Rheumatic disease often involves several valves; a quiet aortic area is needed to exclude coexisting aortic valve disease, which would call for double-valve surgery."],erb:["\u5F00\u74E3\u97F3\u6709\u65F6\u5728\u80F8\u9AA8\u5DE6\u7F18\u7B2C 3 \u808B\u95F4\u4E5F\u80FD\u542C\u5230\uFF08\u9AD8\u8C03\u3001\u77ED\u4FC3\uFF09\uFF1B\u6CA1\u6709\u8212\u5F20\u65E9\u671F\u9012\u51CF\u6742\u97F3\uFF08\u4E0E\u4E3B\u52A8\u8109\u74E3\u5173\u95ED\u4E0D\u5168\u9274\u522B\uFF09\u3002","\u82E5\u8FD9\u91CC\u6709\u9012\u51CF\u6027\u8212\u5F20\u671F\u6742\u97F3\uFF0C\u8BF4\u660E\u5408\u5E76\u4E3B\u52A8\u8109\u74E3\u5173\u95ED\u4E0D\u5168\uFF0C\u672F\u5F0F\u8981\u76F8\u5E94\u6539\u53D8\u3002","The opening snap is sometimes audible at the 3rd left interspace (high-pitched, brief); there is no early diastolic decrescendo murmur (distinguishes it from aortic regurgitation).","A decrescendo diastolic murmur here would mean coexisting aortic regurgitation and changes the operation."],tricuspid:["\u5355\u7EAF\u4E8C\u5C16\u74E3\u72ED\u7A84\u65F6\u8FD9\u91CC\u53EA\u6709\u4F20\u5BFC\u6765\u7684\u7A0D\u54CD S1 \u548C\u5F31\u7684\u5F00\u74E3\u97F3\uFF1B\u82E5\u5408\u5E76\u4E09\u5C16\u74E3\u72ED\u7A84\u6216\u53CD\u6D41\uFF0C\u53EF\u6709\u8212\u5F20\u671F\u9686\u9686\u6216\u6536\u7F29\u671F\u5439\u98CE\u6837\u6742\u97F3\uFF0C\u5438\u6C14\u589E\u5F3A\u3002","\u53F3\u5FC3\u53D7\u7D2F\uFF08\u529F\u80FD\u6027\u4E09\u5C16\u74E3\u53CD\u6D41\uFF09\u63D0\u793A\u9700\u540C\u671F\u505A\u4E09\u5C16\u74E3\u6210\u5F62\u3002","In isolated mitral stenosis only a transmitted, slightly loud S1 and a faint opening snap are heard here; with added tricuspid stenosis or regurgitation there is a diastolic rumble or a systolic blowing murmur that increases on inspiration.","Right-heart involvement (functional tricuspid regurgitation) suggests concomitant tricuspid repair."]},mr:{mitral:["\u5168\u6536\u7F29\u671F\u5439\u98CE\u6837\u6742\u97F3\u5728\u5FC3\u5C16\u6700\u54CD\uFF0C\u4ECE S1 \u4E00\u76F4\u5230 S2\u3001\u628A S1 \u76D6\u4F4F\uFF08S1 \u51CF\u5F31\uFF09\uFF0C\u5411\u5DE6\u814B\u4E0B\u548C\u5DE6\u80A9\u80DB\u4E0B\u4F20\u5BFC\uFF1B\u5927\u91CF\u56DE\u6D41\u518D\u51B2\u5165\u5DE6\u5BA4\u53EF\u4EA7\u751F S3\u3002\u819C\u578B\uFF0C\u5DE6\u4FA7\u5367\u4F4D\u66F4\u6E05\u695A\u3002","\u6742\u97F3\u54CD\u5EA6\u4E0E\u53CD\u6D41\u91CF\u4E0D\u5B8C\u5168\u5E73\u884C\uFF0C\u4F46\u51FA\u73B0 S3 \u6216\u6742\u97F3\u6027\u8D28\u6539\u53D8\u63D0\u793A\u53CD\u6D41\u52A0\u91CD\u3002\u5916\u79D1\u503E\u5411\u4E8C\u5C16\u74E3\u4FEE\u590D\u800C\u975E\u7F6E\u6362\uFF0C\u4FEE\u590D\u540E\u5FC3\u5C16\u6742\u97F3\u5E94\u6D88\u5931\uFF0C\u672F\u540E\u590D\u542C\u5728\u6B64\u5904\u3002","A holosystolic blowing murmur is loudest at the apex, running from S1 to S2 and burying S1 (which is soft), radiating to the left axilla and below the left scapula; the large volume returning to the LV can produce an S3. Diaphragm, clearer in the left lateral position.","Murmur loudness tracks regurgitant volume only loosely, but a new S3 or a change in the murmur suggests progression. Surgeons prefer mitral repair to replacement; after repair the apical murmur should disappear, and this is where it is re-checked."],pulmonic:["\u6742\u97F3\u4F20\u5230\u5FC3\u5E95\u8F83\u5F31\uFF1BP2 \u53EF\u4EA2\u8FDB\uFF08\u80BA\u52A8\u8109\u9AD8\u538B\uFF09\u3002","P2 \u4EA2\u8FDB\u63D0\u793A\u80BA\u52A8\u8109\u9AD8\u538B\uFF0C\u662F\u4E8C\u5C16\u74E3\u624B\u672F\u6307\u5F81\u8BC4\u4F30\u7684\u53C2\u8003\u6307\u6807\u4E4B\u4E00\u3002","The murmur is faint at the base; P2 may be loud (pulmonary hypertension).","A loud P2 flags pulmonary hypertension, one of the factors weighed when deciding on mitral surgery."],aortic:["\u6742\u97F3\u5728\u8FD9\u91CC\u5F31\u3001\u4E0D\u4F20\u5411\u9888\u90E8\uFF0C\u8FD9\u662F\u4E0E\u4E3B\u52A8\u8109\u74E3\u72ED\u7A84\u9274\u522B\u7684\u8981\u70B9\u4E4B\u4E00\uFF1BA2 \u6B63\u5E38\u3002","\u4E3B\u52A8\u8109\u74E3\u533A\u5B89\u9759\u6709\u52A9\u6392\u9664\u5408\u5E76\u4E3B\u52A8\u8109\u74E3\u75C5\u53D8\uFF1B\u5408\u5E76\u65F6\u8981\u8003\u8651\u53CC\u74E3\u624B\u672F\u3002","The murmur is faint here and does not radiate to the neck, one of the points separating it from aortic stenosis; A2 is normal.","A quiet aortic area helps exclude coexisting aortic valve disease, which would mean double-valve surgery."],erb:["\u6742\u97F3\u5728\u8FD9\u91CC\u5F31\uFF1B\u8212\u5F20\u671F\u5B89\u9759\u3002","\u4FEE\u590D\u6216\u6362\u74E3\u540E\u5728\u6B64\u5904\u542C\u4EBA\u5DE5\u74E3\u3001\u6210\u5F62\u73AF\u7684\u5F02\u5E38\u97F3\u4E0E\u5FC3\u5305\u6469\u64E6\u97F3\u3002","The murmur is faint here and diastole is silent.","After repair or replacement this is where abnormal prosthetic or annuloplasty-ring sounds and a pericardial rub are listened for."],tricuspid:["\u4E8C\u5C16\u74E3\u53CD\u6D41\u7684\u6742\u97F3\u5728\u8FD9\u91CC\u8F83\u5F31\u3001\u4E0D\u968F\u5438\u6C14\u589E\u5F3A\uFF1B\u82E5\u5408\u5E76\u529F\u80FD\u6027\u4E09\u5C16\u74E3\u53CD\u6D41\uFF0C\u80F8\u9AA8\u5DE6\u4E0B\u7F18\u53E6\u6709\u5438\u6C14\u589E\u5F3A\u7684\u6536\u7F29\u671F\u5439\u98CE\u6837\u6742\u97F3\uFF08Carvallo \u5F81\uFF09\u3002","\u5408\u5E76\u4E09\u5C16\u74E3\u53CD\u6D41\u65F6\u5E38\u540C\u671F\u505A\u4E09\u5C16\u74E3\u6210\u5F62\uFF0C\u672F\u524D\u8981\u5728\u5438\u6C14\u65F6\u5206\u6E05\u4E24\u4E2A\u6742\u97F3\u3002","The mitral murmur is faint here and does not increase on inspiration; with functional tricuspid regurgitation there is a separate blowing systolic murmur at the lower left sternal border that does increase on inspiration (Carvallo sign).","Coexisting tricuspid regurgitation is usually repaired at the same operation, so the two murmurs are separated on inspiration before surgery."]},as:{mitral:["\u6742\u97F3\u53EF\u4F20\u5230\u5FC3\u5C16\uFF0C\u800C\u4E14\u5728\u5FC3\u5C16\u53D8\u5F97\u8F83\u9AD8\u8C03\u3001\u4E50\u97F3\u6837\uFF08Gallavardin \u73B0\u8C61\uFF09\uFF0C\u5BB9\u6613\u8BEF\u4E3A\u4E8C\u5C16\u74E3\u53CD\u6D41\uFF1BS4 \u5728\u5FC3\u5C16\u6700\u6E05\u695A\uFF08\u5DE6\u5BA4\u80A5\u539A\u3001\u987A\u5E94\u6027\u4E0B\u964D\uFF09\u3002","S4 \u4E0E\u5DE6\u5BA4\u80A5\u539A\u63D0\u793A\u957F\u671F\u538B\u529B\u8D1F\u8377\uFF0C\u672F\u540E\u8981\u968F\u8BBF\u5DE6\u5BA4\u8D28\u91CF\u56DE\u9000\uFF1B\u5FC3\u5C16\u7684\u4E50\u97F3\u6837\u6742\u97F3\u4E0D\u8981\u5F53\u6210\u4E8C\u5C16\u74E3\u75C5\u53D8\u53BB\u5904\u7406\u3002","The murmur reaches the apex and becomes higher-pitched and musical there (Gallavardin phenomenon), easily mistaken for mitral regurgitation; S4 is clearest at the apex (LV hypertrophy, reduced compliance).","S4 and LV hypertrophy reflect long-standing pressure load, and regression of LV mass is followed after surgery; the musical apical murmur must not be treated as mitral disease."],pulmonic:["\u6742\u97F3\u4F20\u5230\u8FD9\u91CC\u4ECD\u54CD\uFF1BP2 \u6B63\u5E38\u3002\u91CD\u5EA6\u72ED\u7A84\u65F6 A2 \u5EF6\u540E\uFF0CS2 \u53EF\u5448\u9006\u5206\u88C2\uFF08\u547C\u6C14\u65F6\u5206\u88C2\u3001\u5438\u6C14\u65F6\u5408\u62E2\uFF09\uFF0C\u5728\u8FD9\u91CC\u6700\u5BB9\u6613\u542C\u51FA\u3002","\u9006\u5206\u88C2\u63D0\u793A\u5DE6\u5BA4\u5C04\u8840\u660E\u663E\u5EF6\u957F\uFF0C\u662F\u91CD\u5EA6\u72ED\u7A84\u7684\u7EBF\u7D22\u4E4B\u4E00\u3002","The murmur is still loud here; P2 is normal. In severe stenosis A2 is delayed and S2 may split paradoxically (split on expiration, single on inspiration), best appreciated here.","Paradoxical splitting means markedly prolonged LV ejection, one clue to severe stenosis."],aortic:["\u7C97\u7CD9\u7684\u6536\u7F29\u4E2D\u671F\u55B7\u5C04\u6027\u6742\u97F3\uFF08\u6E10\u5F3A\u6E10\u5F31\uFF0C\u83F1\u5F62\uFF09\u5728\u8FD9\u91CC\u6700\u54CD\uFF0C\u5411\u9888\u90E8\u4F20\u5BFC\uFF1BA2 \u51CF\u5F31\u6216\u6D88\u5931\uFF08\u74E3\u53F6\u9499\u5316\u50F5\u786C\uFF09\uFF1B\u53EF\u6709 S4\u3002","\u6742\u97F3\u5CF0\u503C\u540E\u79FB\u3001A2 \u6D88\u5931\u3001\u6536\u7F29\u671F\u5EF6\u957F\u63D0\u793A\u91CD\u5EA6\u72ED\u7A84\uFF0C\u662F\u8BC4\u4F30\u6362\u74E3\uFF08\u5916\u79D1\u6362\u74E3 SAVR \u6216\u7ECF\u5BFC\u7BA1 TAVI\uFF09\u6307\u5F81\u7684\u91CD\u8981\u5E8A\u8FB9\u7EBF\u7D22\uFF1B\u6709\u75C7\u72B6\u7684\u91CD\u5EA6\u72ED\u7A84\u9700\u624B\u672F\u3002","A harsh mid-systolic ejection murmur (crescendo\u2013decrescendo, diamond-shaped) is loudest here and radiates to the neck; A2 is soft or absent (calcified, rigid leaflets); an S4 may be present.","A late-peaking murmur, absent A2 and prolonged systole point to severe stenosis and are key bedside clues when weighing valve replacement (surgical SAVR or transcatheter TAVI); symptomatic severe stenosis needs intervention."],erb:["\u6742\u97F3\u5728\u80F8\u9AA8\u5DE6\u7F18\u7B2C 3 \u808B\u95F4\u540C\u6837\u6E05\u695A\uFF1B\u82E5\u8FD9\u91CC\u8FD8\u6709\u8212\u5F20\u65E9\u671F\u9012\u51CF\u6742\u97F3\uFF0C\u8BF4\u660E\u5408\u5E76\u4E3B\u52A8\u8109\u74E3\u5173\u95ED\u4E0D\u5168\u3002","\u72ED\u7A84\u5408\u5E76\u5173\u95ED\u4E0D\u5168\u65F6\u6362\u74E3\u6307\u5F81\u66F4\u660E\u786E\uFF0C\u672F\u524D\u8D85\u58F0\u8981\u91CF\u4E24\u8005\u3002","The murmur is equally clear at the 3rd left interspace; an added early diastolic decrescendo murmur here means coexisting aortic regurgitation.","Combined stenosis and regurgitation strengthens the case for replacement, and both are quantified by echo before surgery."],tricuspid:["\u6742\u97F3\u4F20\u5BFC\u5230\u80F8\u9AA8\u5DE6\u4E0B\u7F18\u8F83\u5F31\uFF1B\u53EF\u6709 S4\u3002","\u65E0\u7279\u6B8A\u5916\u79D1\u610F\u4E49\uFF1B\u672F\u540E\u5728\u6B64\u5904\u542C\u4EBA\u5DE5\u74E3\u7684\u4F20\u5BFC\u97F3\u3002","The murmur is faint at the lower left sternal border; an S4 may be heard.","No specific surgical implication; after surgery transmitted prosthetic sounds are heard here."]},ar:{mitral:["\u5FC3\u5C16\u53EF\u6709 Austin Flint \u6742\u97F3\uFF1A\u8212\u5F20\u4E2D\u665A\u671F\u4F4E\u8C03\u9686\u9686\u6837\uFF08\u53CD\u6D41\u8840\u51B2\u51FB\u4E8C\u5C16\u74E3\u524D\u53F6\u3001\u4F7F\u5176\u90E8\u5206\u5173\u95ED\uFF09\uFF0C\u6CA1\u6709\u5F00\u74E3\u97F3\u3001S1 \u4E0D\u4EA2\u8FDB\uFF0C\u53EF\u4E0E\u4E8C\u5C16\u74E3\u72ED\u7A84\u9274\u522B\uFF1BS1 \u53EF\u51CF\u5F31\uFF08\u4E8C\u5C16\u74E3\u63D0\u524D\u5173\u95ED\uFF09\u3002","Austin Flint \u6742\u97F3\u63D0\u793A\u91CD\u5EA6\u53CD\u6D41\uFF0C\u652F\u6301\u6362\u74E3\uFF1B\u672F\u540E\u5B83\u5E94\u6D88\u5931\u3002","An Austin Flint murmur may be heard at the apex: a low-pitched mid-to-late diastolic rumble (the regurgitant jet strikes the anterior mitral leaflet and partly closes it), with no opening snap and no loud S1, which separates it from mitral stenosis; S1 may be soft (premature mitral closure).","An Austin Flint murmur indicates severe regurgitation and supports valve replacement; it should disappear after surgery."],pulmonic:["\u6742\u97F3\u8F83\u5F31\uFF1BP2 \u6B63\u5E38\uFF1BS2 \u591A\u4E3A\u5355\u4E00\uFF08A2 \u5EF6\u540E\uFF0C\u4E0E P2 \u91CD\u5408\uFF09\u3002","\u65E0\u7279\u6B8A\u5916\u79D1\u610F\u4E49\u3002","The murmur is faint; P2 is normal; S2 is usually single (the delayed A2 coincides with P2).","No specific surgical implication."],aortic:["\u8212\u5F20\u65E9\u671F\u9012\u51CF\u6742\u97F3\u5728\u8FD9\u91CC\u4E5F\u6E05\u695A\uFF0C\u8FD8\u5E38\u6709\u6536\u7F29\u671F\u55B7\u5C04\u6027\u6742\u97F3\uFF08\u5927\u91CF\u524D\u5411\u8840\u6D41\u901A\u8FC7\u74E3\u53E3\uFF0C\u4E0D\u4E00\u5B9A\u5408\u5E76\u72ED\u7A84\uFF09\u3002","\u4E3B\u52A8\u8109\u6839\u90E8\u6269\u5F20\uFF08\u9A6C\u65B9\u7EFC\u5408\u5F81\u3001\u4E3B\u52A8\u8109\u5939\u5C42\uFF09\u5F15\u8D77\u7684\u53CD\u6D41\u6742\u97F3\u5728\u80F8\u9AA8\u53F3\u7F18\u6BD4\u5DE6\u7F18\u66F4\u54CD\uFF0C\u63D0\u793A\u9700\u540C\u65F6\u5904\u7406\u4E3B\u52A8\u8109\u6839\u90E8\uFF08Bentall \u6216\u4FDD\u7559\u74E3\u819C\u7684\u6839\u90E8\u7F6E\u6362\uFF09\u3002","The early diastolic decrescendo murmur is also clear here, often with a systolic ejection murmur (large forward flow across the valve, not necessarily stenosis).","Regurgitation from aortic root dilatation (Marfan syndrome, dissection) is louder at the right than the left sternal border and points to root surgery (Bentall or valve-sparing root replacement) as well."],erb:["\u8212\u5F20\u65E9\u671F\u9AD8\u8C03\u9012\u51CF\u6027\u53F9\u6C14\u6837\u6742\u97F3\u5728\u8FD9\u91CC\u6700\u54CD\uFF0C\u7D27\u63A5 A2 \u5F00\u59CB\uFF1B\u5750\u4F4D\u524D\u503E\u3001\u547C\u6C14\u672B\u5C4F\u6C14\u3001\u819C\u578B\u91CD\u538B\u6700\u6E05\u695A\u3002S2 \u591A\u4E3A\u5355\u4E00\uFF08A2 \u5EF6\u540E\uFF09\u3002","\u6742\u97F3\u5360\u8212\u5F20\u671F\u7684\u6BD4\u4F8B\u8D8A\u5927\u53CD\u6D41\u8D8A\u91CD\uFF1B\u51FA\u73B0 Austin Flint \u6742\u97F3\u3001\u5DE6\u5BA4\u6269\u5927\u6216\u5FC3\u529F\u80FD\u4E0B\u964D\u63D0\u793A\u9700\u6362\u74E3\u3002","A high-pitched early diastolic decrescendo (sighing) murmur is loudest here, starting right after A2; clearest with the patient sitting, leaning forward, breath held in expiration, diaphragm pressed firmly. S2 is usually single (delayed A2).","The larger the fraction of diastole the murmur occupies, the more severe the regurgitation; an Austin Flint murmur, LV dilatation or falling LV function indicates valve replacement."],tricuspid:["\u6742\u97F3\u4F20\u5230\u80F8\u9AA8\u5DE6\u4E0B\u7F18\u4ECD\u4E3A\u9AD8\u8C03\u9012\u51CF\uFF0C\u6BD4 Erb \u533A\u5F31\u3002","\u65E0\u7279\u6B8A\u5916\u79D1\u610F\u4E49\u3002","The murmur reaches the lower left sternal border as a fainter high-pitched decrescendo.","No specific surgical implication."]},hfpef:{mitral:['S4 \u5728\u5FC3\u5C16\u6700\u6E05\u695A\uFF1A\u8212\u5F20\u672B\u671F\u5FC3\u623F\u6536\u7F29\u628A\u8840\u6324\u8FDB\u50F5\u786C\u7684\u5DE6\u5BA4\uFF0C\u4F4E\u8C03\u3001\u7D27\u8D34\u5728 S1 \u4E4B\u524D\uFF08"Ten-nes-see" \u7684 Ten\uFF09\uFF1B\u949F\u578B\u8F7B\u653E\u3001\u5DE6\u4FA7\u5367\u4F4D\u3002S1\u3001S2 \u6B63\u5E38\uFF0C\u6CA1\u6709\u6742\u97F3\u3002\u5C04\u8840\u5206\u6570\u6B63\u5E38\u4E0D\u7B49\u4E8E\u6CA1\u6709\u5FC3\u8870\u3002','\u50F5\u786C\u7684\u5FC3\u5BA4\u5BF9\u5BB9\u91CF\u5F88\u654F\u611F\uFF1A\u56F4\u672F\u671F\u8865\u6DB2\u8FC7\u5FEB\u5C31\u80BA\u6C34\u80BF\u3001\u8FC7\u5C11\u5C31\u4F4E\u8840\u538B\uFF1B\u672F\u524D\u628A\u8840\u538B\u63A7\u5236\u597D\uFF0C\u672F\u4E2D\u7EF4\u6301\u7AA6\u5F8B\uFF08\u623F\u98A4\u4F1A\u4E22\u6389\u8FD9\u4E00\u4E0B"\u5FC3\u623F\u8E22"\uFF09\u3002','S4 is clearest at the apex: end-diastolic atrial contraction forcing blood into a stiff LV, low-pitched and tight against S1 (the "Ten" of "Ten-nes-see"); bell lightly applied, left lateral position. S1 and S2 are normal and there is no murmur. A normal EF does not mean no heart failure.',"A stiff ventricle is volume-sensitive: too much fluid in the perioperative period means pulmonary oedema, too little means hypotension; control the blood pressure before surgery and keep sinus rhythm during it (atrial fibrillation loses the atrial kick)."],pulmonic:["S2 \u6B63\u5E38\u6216 P2 \u8F7B\u5EA6\u4EA2\u8FDB\uFF08\u5347\u9AD8\u7684\u5145\u76C8\u538B\u4F20\u56DE\u80BA\u5FAA\u73AF\uFF09\uFF1BS4 \u4F20\u4E0D\u5230\u8FD9\u91CC\u3002","\u5DE6\u623F\u538B\u957F\u671F\u5347\u9AD8\u53EF\u7EE7\u53D1\u80BA\u52A8\u8109\u9AD8\u538B\uFF0C\u62AC\u9AD8\u4EFB\u4F55\u5927\u624B\u672F\u7684\u98CE\u9669\u3002","S2 is normal or P2 is slightly loud (the raised filling pressure is passed back to the lungs); S4 does not reach here.","Chronically raised LA pressure can cause secondary pulmonary hypertension, which raises the risk of any major operation."],aortic:["A2 \u4EA2\u8FDB\uFF08\u4E3B\u52A8\u8109\u538B\u9AD8\uFF0C\u74E3\u819C\u5173\u5F97\u54CD\u800C\u8106\uFF09\uFF1B\u53EF\u6709\u4E3B\u52A8\u8109\u74E3\u786C\u5316\u7684\u8F7B\u67D4\u55B7\u5C04\u6027\u6742\u97F3\uFF0C\u4E0D\u5411\u9888\u90E8\u4F20\u5BFC\u3002","\u9AD8\u8840\u538B\u60A3\u8005\u672F\u524D\u8981\u6392\u9664\u4E3B\u52A8\u8109\u74E3\u72ED\u7A84\uFF1A\u786C\u5316\u662F\u6742\u97F3\u67D4\u548C\u3001A2 \u54CD\u4EAE\uFF1B\u72ED\u7A84\u662F\u6742\u97F3\u7C97\u7CD9\u3001A2 \u51CF\u5F31\u3002","A2 is loud (high aortic pressure closes the valve sharply); a soft ejection murmur of aortic sclerosis may be present and does not radiate to the neck.","Before surgery a hypertensive patient needs aortic stenosis excluded: sclerosis gives a soft murmur with a loud A2, stenosis a harsh murmur with a soft A2."],erb:["A2 \u54CD\u4EAE\u3001\u8212\u5F20\u671F\u5B89\u9759\uFF1B\u9AD8\u8840\u538B\u628A\u4E3B\u52A8\u8109\u6839\u90E8\u6491\u5927\u65F6\uFF0C\u8FD9\u91CC\u53EF\u51FA\u73B0\u4E3B\u52A8\u8109\u74E3\u5173\u95ED\u4E0D\u5168\u7684\u9012\u51CF\u6742\u97F3\u3002","\u65B0\u51FA\u73B0\u7684\u8212\u5F20\u671F\u9012\u51CF\u6742\u97F3\u63D0\u793A\u6839\u90E8\u6269\u5F20\u6216\u5173\u95ED\u4E0D\u5168\uFF0C\u8981\u505A\u8D85\u58F0\u5E76\u8003\u8651\u540C\u671F\u5904\u7406\u3002","Loud A2 and a silent diastole; if hypertension dilates the aortic root, a decrescendo murmur of aortic regurgitation can appear here.","A new diastolic decrescendo murmur suggests root dilatation or regurgitation and calls for echocardiography and possibly combined treatment."],tricuspid:["\u53F3\u5FC3\u4E00\u822C\u6B63\u5E38\uFF1BS4 \u5076\u53EF\u4F20\u5230\u80F8\u9AA8\u5DE6\u4E0B\u7F18\uFF0C\u5438\u6C14\u65F6\u4E0D\u589E\u5F3A\uFF08\u6765\u81EA\u5DE6\u5BA4\uFF09\u3002","\u56F4\u672F\u671F\u7684\u5BB9\u91CF\u7BA1\u7406\uFF0C\u770B\u9888\u9759\u8109\u538B\u4E0E\u53F3\u5FC3\u4F53\u5F81\u6BD4\u770B\u8840\u538B\u66F4\u65E9\u3001\u66F4\u51C6\u3002","The right heart is usually normal; S4 occasionally reaches the lower left sternal border and does not increase on inspiration (LV origin).","Perioperative volume management is read earlier and better from the jugular venous pressure and right-heart signs than from the blood pressure."]},mi:{mitral:["S1 \u51CF\u5F31\uFF08\u6536\u7F29\u529B\u4E0B\u964D\u3001\u4E8C\u5C16\u74E3\u5173\u95ED\u53D8\u6162\uFF09\uFF0CS4 \u51E0\u4E4E\u5FC5\u6709\uFF08\u7F3A\u8840\u7684\u5FC3\u5BA4\u50F5\u786C\uFF09\uFF1B\u51FA\u73B0 S3 \u63D0\u793A\u5DE6\u5BA4\u529F\u80FD\u4E25\u91CD\u53D7\u635F\u3002\u65B0\u51FA\u73B0\u7684\u5FC3\u5C16\u5168\u6536\u7F29\u671F\u6742\u97F3 = \u4E73\u5934\u808C\u529F\u80FD\u4E0D\u5168\u6216\u65AD\u88C2\u5BFC\u81F4\u7684\u6025\u6027\u4E8C\u5C16\u74E3\u53CD\u6D41\u3002","\u65B0\u53D1\u5FC3\u5C16\u6742\u97F3\u4F34\u8840\u538B\u9AA4\u964D\u662F\u5916\u79D1\u6025\u75C7\uFF1A\u4E73\u5934\u808C\u65AD\u88C2\u8981\u6025\u8BCA\u4FEE\u590D\u6216\u6362\u74E3\u3002\u5FC3\u6897\u672C\u8EAB\u7684\u8840\u8FD0\u91CD\u5EFA\u9996\u9009\u6025\u8BCA\u4ECB\u5165\uFF0C\u591A\u652F\u75C5\u53D8\u8003\u8651\u642D\u6865\u3002","S1 is soft (reduced contractility, slower mitral closure) and an S4 is almost always present (stiff ischaemic ventricle); an S3 signals severe LV dysfunction. A new apical holosystolic murmur means acute mitral regurgitation from papillary muscle dysfunction or rupture.","A new apical murmur with sudden hypotension is a surgical emergency: papillary muscle rupture needs urgent repair or replacement. Revascularisation of the infarct itself is usually by emergency PCI, with bypass surgery for multivessel disease."],pulmonic:["S2 \u6B63\u5E38\uFF1B\u5E76\u53D1\u5DE6\u5FC3\u8870\u7AED\u65F6 P2 \u4EA2\u8FDB\u3002","\u76D1\u62A4\u4E2D P2 \u7531\u5F31\u53D8\u54CD\uFF0C\u63D0\u793A\u80BA\u6DE4\u8840\u52A0\u91CD\uFF0C\u8981\u91CD\u65B0\u8BC4\u4F30\u5BB9\u91CF\u4E0E\u5FC3\u529F\u80FD\u3002","S2 is normal; P2 becomes loud if left heart failure develops.","A P2 that grows louder during monitoring signals worsening pulmonary congestion and prompts reassessment of volume and cardiac function."],aortic:["S2 \u6B63\u5E38\u3001\u6CA1\u6709\u6742\u97F3\u3002\u5FC3\u6897\u540E 2\u20133 \u5929\u53EF\u51FA\u73B0\u5FC3\u5305\u6469\u64E6\u97F3\uFF0C\u80F8\u9AA8\u5DE6\u7F18\u66F4\u6E05\u695A\u3002","\u4E3B\u52A8\u8109\u74E3\u533A\u5B89\u9759\u6709\u52A9\u6392\u9664\u4E3B\u52A8\u8109\u74E3\u72ED\u7A84\u5F15\u8D77\u7684\u80F8\u75DB\uFF1B\u642D\u6865\u672F\u524D\u8981\u8BC4\u4F30\u5347\u4E3B\u52A8\u8109\u80FD\u4E0D\u80FD\u4E0A\u963B\u65AD\u94B3\u3002","S2 is normal and there is no murmur. A pericardial friction rub may appear 2\u20133 days after infarction, clearer at the left sternal border.","A quiet aortic area helps exclude aortic stenosis as the cause of the chest pain; before bypass surgery the ascending aorta is assessed for clamping."],erb:["\u5FC3\u5305\u6469\u64E6\u97F3\uFF08\u6897\u6B7B\u540E\u5FC3\u5305\u708E\uFF09\u5728\u80F8\u9AA8\u5DE6\u7F18\u6700\u6E05\u695A\uFF1A\u4E09\u76F8\u3001\u4E0E\u547C\u5438\u65E0\u5173\u3001\u50CF\u6413\u76AE\u9769\uFF1B\u8212\u5F20\u671F\u6CA1\u6709\u6742\u97F3\u3002","\u5FC3\u6897\u540E\u6570\u5929\u7684\u6469\u64E6\u97F3\u662F\u53CD\u5E94\u6027\u5FC3\u5305\u708E\uFF1B\u672F\u540E\u51FA\u73B0\u5219\u8981\u6392\u9664\u5FC3\u5305\u79EF\u8840\u4E0E\u586B\u585E\u3002","A pericardial friction rub (post-infarction pericarditis) is clearest at the left sternal border: triphasic, independent of breathing, like creaking leather; there is no diastolic murmur.","A rub a few days after infarction is reactive pericarditis; after surgery it must be distinguished from haemopericardium and tamponade."],tricuspid:["\u80F8\u9AA8\u5DE6\u7F18\u7B2C 4\u20135 \u808B\u95F4\u65B0\u51FA\u73B0\u7C97\u7CD9\u7684\u5168\u6536\u7F29\u671F\u6742\u97F3\u4F34\u9707\u98A4 = \u5BA4\u95F4\u9694\u7A7F\u5B54\uFF08\u5FC3\u6897\u540E 3\u20135 \u5929\uFF09\uFF1B\u53F3\u5BA4\u6897\u6B7B\u65F6\u53EF\u6709\u53F3\u5BA4 S3\u3001\u9888\u9759\u8109\u6012\u5F20\u3002","\u5BA4\u95F4\u9694\u7A7F\u5B54\u662F\u5916\u79D1\u6025\u75C7\uFF1A\u4E3B\u52A8\u8109\u5185\u7403\u56CA\u53CD\u640F\u7A33\u5B9A\u540E\u624B\u672F\u4FEE\u8865\uFF1B\u53F3\u5BA4\u6897\u6B7B\u8981\u8865\u6DB2\u800C\u4E0D\u662F\u5229\u5C3F\u3002","A new harsh holosystolic murmur with a thrill at the 4th\u20135th left interspace means ventricular septal rupture (3\u20135 days after infarction); RV infarction can add an RV S3 and distended neck veins.","Septal rupture is a surgical emergency: stabilise with an intra-aortic balloon pump, then repair; RV infarction needs fluids, not diuretics."]},exercise:{mitral:["S1 \u589E\u5F3A\uFF08\u4EA4\u611F\u5174\u594B\uFF0C\u5FC3\u7387\u5FEB\u65F6\u4E8C\u5C16\u74E3\u4ECE\u66F4\u5F00\u7684\u4F4D\u7F6E\u88AB\u66F4\u5FEB\u5173\u4E0A\uFF09\uFF0CS2 \u4E5F\u589E\u5F3A\uFF1B\u8212\u5F20\u671F\u660E\u663E\u7F29\u77ED\uFF0CS1 \u4E0E S2 \u51E0\u4E4E\u7B49\u8DDD\u3002\u5065\u5EB7\u4EBA\u8FD0\u52A8\u65F6\u5FC3\u5C16\u6CA1\u6709\u6742\u97F3\u3002","\u672F\u524D\u5FC3\u80BA\u8FD0\u52A8\u8BD5\u9A8C\uFF08\u5FC3\u8F93\u51FA\u91CF\u80FD\u4E0D\u80FD\u5347\u5230\u9759\u606F\u7684\u4E09\u500D\uFF09\u662F\u5927\u624B\u672F\u98CE\u9669\u8BC4\u4F30\u7684\u4E00\u90E8\u5206\uFF1B\u80FD\u4E00\u53E3\u6C14\u722C\u4E24\u5C42\u697C\uFF08\u2265 4 METs\uFF09\u662F\u5E38\u7528\u7684\u5E8A\u8FB9\u95E8\u69DB\u3002","S1 is louder (sympathetic drive; at a fast rate the mitral valve is shut faster from a wider open position) and so is S2; diastole shortens markedly, so S1 and S2 become almost evenly spaced. A healthy heart has no apical murmur during exercise.","Cardiopulmonary exercise testing (can the cardiac output rise to three times the resting value?) is part of risk assessment before major surgery; climbing two flights of stairs (\u2265 4 METs) is the usual bedside threshold."],pulmonic:["\u9AD8\u6D41\u91CF\u51B2\u8FC7\u6B63\u5E38\u7684\u80BA\u52A8\u8109\u74E3 \u2192 \u67D4\u548C\u3001\u77ED\u4FC3\u7684\u6536\u7F29\u4E2D\u671F\u529F\u80FD\u6027\uFF08\u751F\u7406\u6027\uFF09\u6742\u97F3\uFF0C\u8FD9\u91CC\u6700\u6E05\u695A\uFF0C\u4F11\u606F\u540E\u6D88\u5931\uFF1BS2 \u5206\u88C2\u968F\u547C\u5438\u6B63\u5E38\u53D8\u5316\u3002","\u529F\u80FD\u6027\u6742\u97F3\u4E0D\u662F\u624B\u672F\u7981\u5FCC\uFF0C\u4E5F\u4E0D\u9700\u8981\u8FDB\u4E00\u6B65\u68C0\u67E5\uFF1B\u672F\u524D\u542C\u5230\u7684\u6742\u97F3\u5148\u5206\u6E05\u529F\u80FD\u6027\u8FD8\u662F\u5668\u8D28\u6027\u3002","High flow across a normal pulmonary valve produces a soft, short mid-systolic functional (innocent) murmur, clearest here and gone after rest; S2 splitting varies normally with breathing.","An innocent murmur is no contraindication to surgery and needs no further work-up; a murmur heard before surgery is first sorted into innocent versus structural."],aortic:["\u540C\u6837\u53EF\u6709\u67D4\u548C\u7684\u529F\u80FD\u6027\u55B7\u5C04\u6027\u6742\u97F3\uFF1BA2 \u6E05\u8106\u3002\u4E0E\u4E3B\u52A8\u8109\u74E3\u72ED\u7A84\u7684\u533A\u522B\uFF1A\u6742\u97F3\u67D4\u548C\u3001\u4E0D\u5411\u9888\u90E8\u4F20\u3001A2 \u6B63\u5E38\u3002","\u8FD0\u52A8\u4E2D\u51FA\u73B0\u7C97\u7CD9\u6742\u97F3\u6216\u6655\u53A5\u8981\u505C\u4E0B\u6765\u67E5\u4E3B\u52A8\u8109\u74E3\u72ED\u7A84\u548C\u80A5\u539A\u578B\u5FC3\u808C\u75C5\u3002","A soft functional ejection murmur may be heard here too; A2 is crisp. Unlike aortic stenosis the murmur is soft, does not radiate to the neck and A2 is normal.","A harsh murmur or syncope during exercise means stop and look for aortic stenosis or hypertrophic cardiomyopathy."],erb:["\u529F\u80FD\u6027\u6742\u97F3\u53EF\u4EE5\u4F20\u5230\u8FD9\u91CC\uFF0C\u4ECD\u7136\u67D4\u548C\uFF1B\u8212\u5F20\u671F\u5B89\u9759\uFF0C\u6CA1\u6709\u9012\u51CF\u6742\u97F3\u3002","\u6CA1\u6709\u7279\u6B8A\u7684\u5916\u79D1\u610F\u4E49\uFF1B\u8212\u5F20\u671F\u6742\u97F3\u5728\u8FD0\u52A8\u4E2D\u4E0D\u4F1A\u662F\u529F\u80FD\u6027\u7684\u3002","The functional murmur may be heard here and stays soft; diastole is silent, with no decrescendo murmur.","No specific surgical implication; a diastolic murmur during exercise is never innocent."],tricuspid:["\u53F3\u5FC3\u6D41\u91CF\u540C\u6837\u589E\u52A0\uFF0C\u80F8\u9AA8\u5DE6\u4E0B\u7F18\u53EF\u6709\u67D4\u548C\u7684\u529F\u80FD\u6027\u6742\u97F3\uFF0C\u5438\u6C14\u65F6\u589E\u5F3A\u3002","\u6CA1\u6709\u7279\u6B8A\u7684\u5916\u79D1\u610F\u4E49\uFF1B\u53F3\u5FC3\u7684\u529F\u80FD\u6027\u6742\u97F3\u540C\u6837\u968F\u4F11\u606F\u6D88\u5931\u3002","Right-heart flow increases too, so a soft functional murmur may be heard at the lower left sternal border, louder on inspiration.","No specific surgical implication; the right-sided functional murmur also disappears with rest."]},shock:{mitral:["S1\u3001S2 \u90FD\u51CF\u5F31\uFF08\u6BCF\u640F\u91CF\u5C0F\u3001\u5916\u5468\u8840\u7BA1\u6536\u7F29\uFF09\uFF0C\u5FC3\u7387\u5FEB\u5230 120\uFF0C\u5FC3\u5C16\u640F\u52A8\u5F31\uFF1B\u6CA1\u6709\u6742\u97F3\u3001\u6CA1\u6709\u5954\u9A6C\u5F8B\uFF1A\u5FC3\u810F\u672C\u8EAB\u662F\u6B63\u5E38\u7684\uFF0C\u53EA\u662F\u6CA1\u8840\u53EF\u6CF5\u3002","\u5931\u8840\u6027\u4F11\u514B\u662F\u5916\u79D1\u6025\u75C7\uFF1A\u5148\u6B62\u8840\uFF08\u635F\u4F24\u63A7\u5236\uFF09\uFF0C\u518D\u590D\u82CF\u3002\u5FC3\u97F3\u5F31 + \u8109\u538B\u7A84 + \u5FC3\u7387\u5FEB\uFF0C\u5728\u8840\u538B\u4E0B\u964D\u4E4B\u524D\u5C31\u63D0\u793A\u5931\u8840\u5DF2\u5230 30%\u3002","Both S1 and S2 are soft (small stroke volume, peripheral vasoconstriction), the rate is up to 120 and the apex beat is weak; no murmur and no gallop: the heart itself is normal, it simply has little blood to pump.","Haemorrhagic shock is a surgical emergency: stop the bleeding first (damage control), then resuscitate. Soft sounds, a narrow pulse pressure and tachycardia point to a 30% blood loss before the blood pressure falls."],pulmonic:["S2 \u5F31\u3001P2 \u4E0D\u4EA2\u8FDB\uFF08\u80BA\u52A8\u8109\u538B\u4F4E\uFF09\uFF1B\u5FC3\u7387\u5FEB\uFF0CS1 \u4E0E S2 \u6324\u5728\u4E00\u8D77\u3002","\u590D\u82CF\u8FC7\u7A0B\u4E2D P2 \u91CD\u65B0\u6E05\u695A\u3001\u53D8\u54CD\uFF0C\u662F\u5BB9\u91CF\u56DE\u6765\u7684\u58F0\u97F3\u4E4B\u4E00\u3002","S2 is soft and P2 is not accentuated (low pulmonary artery pressure); with the fast rate S1 and S2 crowd together.","During resuscitation a P2 that becomes clear and louder again is one of the sounds of volume coming back."],aortic:["A2 \u5F31\uFF08\u4E3B\u52A8\u8109\u538B\u4F4E\uFF09\uFF1B\u6CA1\u6709\u6742\u97F3\u3002","\u8840\u538B\u662F\u9760\u5916\u5468\u8840\u7BA1\u6536\u7F29\u6491\u7740\u7684\uFF0C\u9EBB\u9189\u8BF1\u5BFC\u4E00\u6269\u8840\u7BA1\u5C31\u4F1A\u57AE\uFF1A\u5148\u8865\u5BB9\u91CF\u518D\u8BF1\u5BFC\u3002","A2 is soft (low aortic pressure); there is no murmur.","The blood pressure is held up by vasoconstriction; anaesthetic induction dilates the vessels and can collapse it, so restore volume before inducing."],erb:["\u5FC3\u97F3\u6574\u4F53\u51CF\u5F31\uFF0C\u8212\u5F20\u671F\u5B89\u9759\uFF1B\u6CA1\u6709\u6742\u97F3\uFF0C\u4E5F\u6CA1\u6709\u5954\u9A6C\u5F8B\u3002","\u6CA1\u6709\u7279\u6B8A\u7684\u5916\u79D1\u610F\u4E49\uFF1B\u590D\u82CF\u540E\u5728\u6B64\u590D\u542C\u5FC3\u97F3\u6709\u6CA1\u6709\u6062\u590D\u3002","All sounds are soft and diastole is silent; there is no murmur and no gallop.","No specific surgical implication; after resuscitation listen here again for the sounds to recover."],tricuspid:["\u53F3\u5FC3\u5145\u76C8\u5DEE\uFF0C\u9888\u9759\u8109\u584C\u9677\uFF0C\u5FC3\u97F3\u5F31\u3002","\u9888\u9759\u8109\u584C\u9677 + \u5FC3\u97F3\u5F31 = \u5BB9\u91CF\u4E0D\u8DB3\uFF1B\u9888\u9759\u8109\u6012\u5F20 + \u5FC3\u97F3\u5F31\u5219\u60F3\u5230\u5FC3\u5305\u586B\u585E\uFF0C\u521B\u4F24\u60A3\u8005\u7684\u53E6\u4E00\u79CD\u4F11\u514B\u3002","Right-heart filling is poor, the neck veins are collapsed and the sounds are soft.","Collapsed neck veins with soft sounds mean hypovolaemia; distended neck veins with soft sounds point to cardiac tamponade, the other shock of the trauma patient."]},athlete:{mitral:["\u5FC3\u7387 48\uFF0C\u8212\u5F20\u671F\u5F88\u957F\uFF1B\u5FC3\u5C16\u53EF\u6709\u751F\u7406\u6027 S3\uFF08\u5927\u91CF\u5FEB\u901F\u5145\u76C8\u649E\u51FB\u987A\u5E94\u6027\u597D\u7684\u5FC3\u5BA4\uFF09\uFF0C\u58F0\u97F3\u4E0E\u75C5\u7406\u6027 S3 \u4E00\u6837\uFF0C\u533A\u522B\u5728\u5E74\u9F84\u3001\u80CC\u666F\u548C\u6CA1\u6709\u75C7\u72B6\u3002S1\u3001S2 \u6B63\u5E38\u3002","\u672F\u524D\u5FC3\u7535\u56FE\u7684\u9AD8\u7535\u538B\u3001\u65E9\u671F\u590D\u6781\u3001\u7AA6\u6027\u5FC3\u52A8\u8FC7\u7F13\u5728\u8FD0\u52A8\u5458\u662F\u6B63\u5E38\u53D8\u5F02\uFF0C\u4E0D\u8981\u5F53\u6210\u75C5\u53D8\uFF1B\u9EBB\u9189\u4E2D\u7684\u5FC3\u52A8\u8FC7\u7F13\u4E00\u822C\u4E0D\u7528\u5904\u7406\u3002","Rate 48 with a long diastole; a physiological S3 may be heard at the apex (rapid filling of a large, compliant ventricle), identical in sound to a pathological S3, the difference being age, context and the absence of symptoms. S1 and S2 are normal.","Tall voltages, early repolarisation and sinus bradycardia on a pre-operative ECG are normal variants in athletes and must not be read as disease; bradycardia under anaesthesia usually needs no treatment."],pulmonic:["S2 \u5206\u88C2\u968F\u547C\u5438\u6B63\u5E38\u53D8\u5316\uFF1B\u6BCF\u640F\u91CF\u5927\uFF0C\u53EF\u6709\u67D4\u548C\u7684\u529F\u80FD\u6027\u6536\u7F29\u671F\u6742\u97F3\u3002","\u6CA1\u6709\u7279\u6B8A\u7684\u5916\u79D1\u610F\u4E49\uFF1B\u529F\u80FD\u6027\u6742\u97F3\u4E0D\u9700\u8981\u8FDB\u4E00\u6B65\u68C0\u67E5\u3002","S2 splitting varies normally with breathing; with the large stroke volume a soft functional systolic murmur may be present.","No specific surgical implication; an innocent murmur needs no further work-up."],aortic:["A2 \u6B63\u5E38\uFF1B\u6BCF\u640F\u91CF\u5927\u65F6\u53EF\u6709\u67D4\u548C\u7684\u55B7\u5C04\u6027\u6742\u97F3\uFF0C\u4E0D\u5411\u9888\u90E8\u4F20\u3002","\u8981\u4E0E\u80A5\u539A\u578B\u5FC3\u808C\u75C5\u9274\u522B\uFF08\u8FD0\u52A8\u5458\u731D\u6B7B\u7684\u9996\u8981\u539F\u56E0\uFF09\uFF1A\u8FD0\u52A8\u5458\u5FC3\u810F\u7684\u6742\u97F3\u67D4\u548C\u3001Valsalva \u65F6\u4E0D\u589E\u5F3A\u3002","A2 is normal; a soft ejection murmur may accompany the large stroke volume and does not radiate to the neck.","Distinguish from hypertrophic cardiomyopathy (the leading cause of sudden death in athletes): the athlete's murmur is soft and does not get louder with Valsalva."],erb:["\u4E3B\u52A8\u8109\u74E3\u7B2C\u4E8C\u542C\u8BCA\u533A\u8212\u5F20\u671F\u5B89\u9759\uFF0C\u6CA1\u6709\u4E3B\u52A8\u8109\u74E3\u5173\u95ED\u4E0D\u5168\u7684\u9012\u51CF\u6742\u97F3\uFF1BS1\u3001S2 \u5F3A\u5EA6\u63A5\u8FD1\u3002","\u6CA1\u6709\u7279\u6B8A\u7684\u5916\u79D1\u610F\u4E49\u3002","Diastole is silent at Erb's point, with no decrescendo murmur of aortic regurgitation; S1 and S2 are about equal.","No specific surgical implication."],tricuspid:["\u53F3\u5FC3\u540C\u6837\u589E\u5927\uFF0C\u80F8\u9AA8\u5DE6\u4E0B\u7F18\u53EF\u6709\u751F\u7406\u6027 S3\uFF0C\u5438\u6C14\u65F6\u589E\u5F3A\u3002","\u6CA1\u6709\u7279\u6B8A\u7684\u5916\u79D1\u610F\u4E49\u3002","The right heart is enlarged too; a physiological S3 may be heard at the lower left sternal border, louder on inspiration.","No specific surgical implication."]}};function AuscChest({site:e,onPick:s,lang:t}){const i=(r,c)=>t==="en"?c:r,a="rgba(34,49,63,0.5)",o="rgba(34,49,63,0.3)",n=[58,80,102,124,146];return React.createElement("div",{className:"ausc-chest"},React.createElement("svg",{viewBox:"0 0 300 170",xmlns:"http://www.w3.org/2000/svg","aria-hidden":"true"},React.createElement("path",{d:"M150 70 C 126 76 116 108 138 128 C 158 146 194 152 216 140 C 234 130 228 108 212 94 C 196 80 172 64 150 70 Z",fill:"rgba(162,59,54,0.09)",stroke:"rgba(162,59,54,0.35)",strokeWidth:"1"}),React.createElement("path",{d:"M52 40 C 85 32 115 40 138 46",fill:"none",stroke:a,strokeWidth:"2.2",strokeLinecap:"round"}),React.createElement("path",{d:"M248 40 C 215 32 185 40 162 46",fill:"none",stroke:a,strokeWidth:"2.2",strokeLinecap:"round"}),n.map((r,c)=>React.createElement("g",{key:c},React.createElement("path",{d:`M137 ${r} C 100 ${r-1} 70 ${r-9} 40 ${r-20}`,fill:"none",stroke:o,strokeWidth:"1.6",strokeLinecap:"round"}),React.createElement("path",{d:`M163 ${r} C 200 ${r-1} 230 ${r-9} 260 ${r-20}`,fill:"none",stroke:o,strokeWidth:"1.6",strokeLinecap:"round"}))),React.createElement("rect",{x:"137",y:"44",width:"26",height:"108",rx:"6",fill:"rgba(34,49,63,0.06)",stroke:a,strokeWidth:"1.2"}),React.createElement("line",{x1:"137",y1:"58",x2:"163",y2:"58",stroke:a,strokeWidth:"1.2"}),React.createElement("text",{x:"133",y:"54",fontSize:"7.5",fill:a,textAnchor:"end"},i("\u80F8\u9AA8\u89D2","sternal angle")),React.createElement("text",{x:"283",y:"48",fontSize:"7",fill:o,textAnchor:"middle"},i("\u808B\u95F4","ICS")),[2,3,4,5].map((r,c)=>React.createElement("text",{key:r,x:"283",y:n[c]+14,fontSize:"8",fill:a,textAnchor:"middle",fontFamily:"'JetBrains Mono',ui-monospace,'SF Mono',Menlo,Consolas,'Liberation Mono',monospace"},r)),React.createElement("line",{x1:"225",y1:"30",x2:"225",y2:"158",stroke:o,strokeWidth:"1",strokeDasharray:"3 3"}),React.createElement("text",{x:"225",y:"167",fontSize:"7",fill:o,textAnchor:"middle"},i("\u9501\u9AA8\u4E2D\u7EBF","midclavicular line")),AUSC_SITES.map(r=>{const c=AUSC_VALVE_PROJ[r.id];return React.createElement("line",{key:r.id,x1:c[0],y1:c[1],x2:r.x,y2:r.y,stroke:"rgba(30,58,95,0.32)",strokeWidth:"1",strokeDasharray:"2 2"})}),[["P","pulmonic"],["A","aortic"],["M","mitral"],["T","tricuspid"]].map(([r,c])=>{const[u,h]=AUSC_VALVE_PROJ[c];return React.createElement("g",{key:r},React.createElement("circle",{cx:u,cy:h,r:"4.2",fill:"rgba(255,255,255,0.9)",stroke:"rgba(30,58,95,0.85)",strokeWidth:"1"}),React.createElement("text",{x:u,y:h+2.3,fontSize:"6",fill:"rgba(30,58,95,1)",textAnchor:"middle",fontWeight:"700"},r))}),React.createElement("text",{x:"6",y:"12",fontSize:"7.5",fill:o},i("\u60A3\u8005\u53F3","patient's right")),React.createElement("text",{x:"294",y:"12",fontSize:"7.5",fill:o,textAnchor:"end"},i("\u60A3\u8005\u5DE6","patient's left"))),AUSC_SITES.map(r=>React.createElement("button",{key:r.id,type:"button",className:"ausc-site"+(r.id===e?" on":""),"data-site":r.id,style:{left:r.x/3+"%",top:r.y/1.7+"%"},title:`${AUSC_CIRCLED[r.n]} ${i(r.zh,r.en)} \xB7 ${i(r.locZh,r.locEn)}`,onClick:()=>s(r.id)},r.n)))}function AuscPanel({stateId:e,site:s,onPick:t,lang:i,canvasRef:a,audioOn:o,onToggleAudio:n}){const r=(h,d)=>i==="en"?d:h,c=auscSiteById(s),u=AUSC_INFO[e]&&AUSC_INFO[e][s];return React.createElement("div",{className:"ausc-panel glass"},React.createElement("div",{className:"wig-head",style:{alignItems:"center"}},React.createElement("div",{className:"t"},r("\u5FC3\u810F\u542C\u8BCA","Auscultation")),React.createElement("div",{className:"s",style:{display:"flex",alignItems:"center",gap:8,whiteSpace:"nowrap"}},r("\u4E94\u4E2A\u542C\u8BCA\u533A \xB7 \u540C\u6B65","five areas \xB7 live"),n&&React.createElement("button",{type:"button",className:"btn tiny "+(o?"primary":"ghost"),onClick:n,title:"L",style:{whiteSpace:"nowrap"}},o?"\u{1F50A}":"\u{1F508}"," ",r("\u542C\u8BCA","Listen")))),React.createElement(AuscChest,{site:s,onPick:t,lang:i}),React.createElement("canvas",{ref:a,className:"ausc-canvas"}),React.createElement("div",{className:"ausc-site-head"},React.createElement("b",null,AUSC_CIRCLED[c.n]," ",r(c.zh,c.en))," \xB7 ",r(c.locZh,c.locEn),React.createElement("div",{className:"dim"},r(c.tipZh,c.tipEn))),React.createElement("div",{className:"ausc-explain"},u?React.createElement(React.Fragment,null,r(u[0],u[2]),React.createElement("div",{className:"sx"},React.createElement("b",null,r("\u5916\u79D1","Surgery")),r(u[1],u[3]))):null),React.createElement("div",{className:"ausc-foot"},r("\u5FC3\u97F3\u56FE\u4E3A\u793A\u610F\u6CE2\u5F62\uFF0C\u951A\u70B9\u4E0E\u5FC3\u7535\u56FE\u3001\u5FC3\u97F3\u540C\u6B65\uFF08S1 = \u623F\u5BA4\u74E3\u5173\uFF0CS2 = \u534A\u6708\u74E3\u5173\uFF09\u3002\u300C\u542C\u8BCA\u300D\u7684\u5F55\u97F3\u6309\u672C\u72B6\u6001\u6700\u4F73\u542C\u8BCA\u533A\u64AD\u653E\uFF0C\u5176\u4ED6\u533A\u6309\u4F20\u5BFC\u8870\u51CF\u5E76\u52A0\u4F4E\u901A\uFF08\u793A\u610F\uFF09\u3002\u7A7A\u5FC3\u5708 = \u74E3\u819C\u4F53\u8868\u6295\u5F71\u3002","Schematic phonocardiogram anchored to the ECG and the heart sounds (S1 = AV closure, S2 = semilunar closure). 'Listen' plays the recording as heard at this state's best area; other areas are attenuated and low-passed (illustrative). Hollow circles = surface projections of the valves.")))}Object.assign(window,{AUSC_SITES,AUSC_INFO,auscModel,auscSliceGain,auscSynthGain,auscWave,drawAuscMonitor,AuscPanel});