3-1: 8/24: Introduction To Auscultation Of The Heart

Front 1

______ brings out high frequencies and should be pressed _________.

Back 1

Diaphragm: high frequencies, press firmly

Front 2

______ brings out low frequencies and should be pressed _______.

Back 2

Bell: low frequencies, press lightly

Front 3

S1 represents the closure of the ______.

Back 3

Mitral valve

Front 4

What factors would increase S1?

Back 4

Any condition that would increase the rapidity of mitral valve closure, such as:

Mitral stenosis (increased mitral gradient and LA pressure)

Increased trans-mitral flow (left-to-right shunts such as Atrial Septal Defect, VSD)

Short PR interval causing early closure of the mitral valve

Front 5

What factors would decrease S1?

Back 5

Any condition that would cause the mitral leaflets not to come together properly, including fibrosis:

Low cardiac output states (dilated cardiomyopathy)
Rheumatic mitral regurg
Severe, acute aortic regurg (may have premature closure of mitral valve)
LONG PR interval (causes delay in mitral valve closure)

Front 6

S2 represents the closure of the _____ before the _______.

Back 6

Aortic valve before the pulmonic valve (splitting)

Front 7

What is wide splitting and what is it indicative of?

Back 7

Wide splitting occurs when S2 is wider both with expiration and inspiration.

Due to RBBB (delayed contraction of RB)

Front 8

What is wide, fixed splitting and what is it indicative of?

Back 8

No change in splitting with inspiration

Occurs when large atrial septal defect with left-to-right shunting, i.e., large Atrial Septal Defect

Front 9

What is reverse or paradoxical splitting and what is it indicative of?

Back 9

Due to delay of aortic valve closure leading to P2 occurring before A2, leads to LESS splitting with inspiration.

Due to LBBB

Front 10

What is an opening snap?

Back 10

Opening snap of mitral valve occurs when mitral valve is stenotic and is caused by sudden cessation of mitral valve opening due to RHEUMATIC DEFORMITY

Front 11

What is the S3 gallop?

Back 11

normal finding in children and young adults, but considered abnormal in anyone above age of 40.

Heard when there's dilated, hypocontractile LV (CHF due to systolic dysfn)

Front 12

What is the S4 gallop?

Back 12

Much more common finding than S2; due to dec'd LV compliance and coincides with atrial systole

Causes:
Hypertensive heart dz (concentric LVH, normal LV systolic fn)
Hypertrophic cardiomyopathy
Aortic Stenosis

Front 13

What is a mid-systolic click indicative of?

Back 13

Prolapse of mitral valve

Can be heard earlier if patient is standing or taking amyl nitrate

Can occur later when increasing LVEDV such as by squatting down or hand-grip maneuver

Front 14

Describe each grade of the murmur intensity scale.

Back 14

Grade I: audible w/stethoscope in quiet room
Grade II: quiet but readily audible with stethoscope
Grade III: easily heard with stethoscope
Grade IV: very loud, palpable thrill
Grade V: very loud, heard elsewhere in body; thrill present
Grade VI: heard without stethoscope, thrill present

Front 15

Crescendo vs Decrescendo Murmur

Back 15

Crescendo murmur increases in intensity

Decrescendo decreases in intensity

Front 16

Plateau murmur

Back 16

Murmur unchanging in intensity

Front 17

Holosytolic Murmur

Back 17

Occurs throughout systole

Front 18

Aortic stenosis:
Auscultatory Findings

Back 18

(easy to hear during systole when aortic valve is open)

Radiates from second right intercostal space (aortic area) upwards to carotid arteries, sometimes with thrill

As severity of aortic stenosis progresses, diminishment of carotid pulses, leading to delayed and reduced carotid upstrokes

Therefore:
Late-peaking, harsh SYSTOLIC murmur heart at base, RADIATING to CAROTIDS, with WEAK CARORTID UPSTROKES = carotid stenosis

Front 19

What is pulsus parvus et tardus?

Back 19

Diminishment of carotid pulses leading to delayed and reduced carotid upstrokes

Indicative of aortic stenosis

Front 20

Aortic insufficiency:
Auscultatory Findings

Back 20

Diastolic decrescendo blowing murmur at left sternal border

Leads to increase in volume of blood ejected from LV during systole, almost always assocd w/systolic ejection murmur due to inc'd flow through LV outflow tract

Front 21

Mitral Stenosis:
Auscultatory Findings

Back 21

Low-pitched diastolic rumbling at apex in lateral left decubitus position

Early in mitral stenosis: opening snap followed by short rumble

End stage: flow across MV reduced, murmur may become softer or "silent"

Front 22

Mitral Insufficiency:
Auscultatory Findings

Back 22

AKA mitral regurgitation

If chronic: high-picthed, holosytolic apical murmur heard in left lateral decubitus position

May radiate laterally to axillary region or posteriorly to left scapular area

Front 23

Tricuspid Insufficiency:
Auscultatory Findings

Back 23

Soft, holosystolic, high-pitched murmur increasing with inspiration

Due to rheumatic heart dz or sig pulm HTN from late-stage valvular heart dz