Block 3 - Pd: Cardiac Auscultation

Front 1

What do heart sounds represent?

Back 1

The closing of valves

Front 2

The closure of AV valves (tricuspid & mitral) produce which heart sound?

Back 2

The first heart sound S1

Front 3

The closure of semilunar valves (aortic & pulmonic) produce which heart sound?

Back 3

The second heart sound S2

Front 4

During which is the pressure higher - systole or diastole?

Back 4

Systole

Front 5

The extra heart sound S3 represents what and is caused by what?

Back 5

Ventricular filling and is caused by volume overload (Kentucky)

Front 6

The extra heart sound S4 represents what and is caused by what?

Back 6

Atrial contraction and is caused by a stiff left ventricle (Tennessee)

Front 7

Why is the presence of S3 or S4 called a gallop rhythm?

What does a summation gallop signify?

Back 7

Presence of an S3 or S4 creates a cadence similar to the gallop of a horse.

A summation gallop signifies an S3 and S4.

Front 8

Physilogic splitting of S2 can be heard where?

Back 8

Detected in 2nd or 3rd L interspace

Front 9

Physiologic splitting is accentuated with (inspiration/expiration), disappears with (inspiration/expiration).

Why?

Back 9

Inspiration, expiration

When you inhale, the aortic and pulmonic split out. This happens, because when you take a breath, you are decreasing pressure in the chest (negative pressure breathing). This negative force causes an increase return of blood to the heart when you inhale, more blood in right side, so the right ventricle takes just a little longer to fill (beats just a split second after the aortic).

Front 10

T/F

Physiologic splitting of S2 is a normal heart sound.

Back 10

True!

It's actually pretty common

Front 11

In physiologic splitting of S1, which valve is louder?

Back 11

Mitral component is louder than the tricuspid component

Front 12

How do you distinguish splitting of S1 from an S4?

Back 12

Virtually indistinguishable other than the tone.

Front 13

Where is physiologic splitting of S1 heard best at?

Back 13

At tricuspid listening point

Front 14

Does physiologic splitting of S1 vary with respiration?

Is it pathological?

Back 14

NO, does not vary with respiration

NO, is not pathological

Front 15

Listen at all auscultatory points with the (diaphragm/bell) of the stethoscope. Use the (diaphragm/bell) only at the tricuspid and mitral spots.

Back 15

Diaphragm, bell

Front 16

Which heart ausculatory points mar vary

Back 16

Pulmonic and tricuspid

Front 17

Which valve may be heard across the precordium?

Back 17

Aortic

Front 18

What is the opening sound of the aortic or pulmonic valve due to pathology called? It is a high pitched sound heard best with the diaphragm in early systole.

Back 18

Ejection sound (click)

Front 19

What is the midsystolic click due to mitral valve prolapse called? It is a high pitched sound heard with the diaphragm at LLSB, frequently followed by an ejection murmur.

Back 19

Systolic click

Front 20

What is the opening sound of mitral valve (rarely tricuspid) indicating pathology called? It is a high pitched sound heard best with the diaphragm in early diastole.

Back 20

Opening snap

Front 21

Describe a midsystolic murmur.

Back 21

Hear S1, then murmur, then S2.

Front 22

Describe a holocystolic murmur.

Back 22

Goes all the way from S1 to S2. Don't necessarily even hear S2.

Front 23

How can you tell S1 from S2?

Back 23

Feel the pulse. Pulse is during systole, so the sound before the pulse is S1, sound after is S2.

Front 24

Describe a late cystolic murmur.

Back 24

Well after S1 but through S2.

Front 25

Describe a crescendo murmur.

Back 25

Starts soft and gets louder into S2.

Front 26

Describe a decrescendo murmur.

Back 26

It starts loud and gets softer.

Front 27

Describe a crescendo-decrescendo murmur.

Back 27

It first grows louder, then softer.

Front 28

Describe a plateau murmur.

Back 28

It has the same intensity throughout.

Front 29

What is it called when a murmur sounds like air rushing out of a balloon?

Back 29

Blowing

Front 30

What is it called when a murmur sounds like sandpaper over wood?

Back 30

Harsh

Front 31

What is it called when a murmur sounds like large tires over cut strips in a highway?

Back 31

Rumble

Front 32

Which murmurs can radiate to carotids or even the apex if loud?

Back 32

Aortic

Front 33

Which murmurs can radiate to the left axilla?

Back 33

Mitral

Front 34

Which murmurs can radiate to the right lower sternal border?

Back 34

Tricuspid

Front 35

What can radiate to the left neck or shoulder if loud?

Back 35

Pulmonic stenosis

Front 36

Which grade is very faint, heard after listener has “tuned in”, not heard in all positions?

Back 36

Grade 1

Front 37

Which grade is quiet, but readily heard, not necessarily in all positions?

Back 37

Grade 2

Front 38

Which grade is moderately loud, heard in all positions to varying extent (no thrill)?

Back 38

Grade 3

Front 39

Which grade is loud with a palpable thrill (feels like cat purring)?

Back 39

Grade 4

Front 40

Which grade is very loud, with thrill, heard with stethoscope in partial contact with chest?

Back 40

Grade 5

Front 41

Which grade is very loud, with thrill, and can be heard with stethoscope off the chest or with the naked ear?

Back 41

Grade 6

Often patients have trouble sleeping because of the noise

Front 42

How can you position someone for aortic murmurs?

Back 42

Exhale and lean forward

Front 43

How can you position someone for mitral murmurs?

Back 43

Left lateral decubitus position

Front 44

Why would you have someone stand/squat?

Back 44

Squatting increases venous return to the heart. More blood in the heart, and depending on the murmur, will get louder or softer. Most get louder.

Front 45

T/F

Murmurs are generally stenotic or regurgitant.

Back 45

True!

Stenotic - narrowing

Front 46

What is the valsalva maneuver?

Back 46

Take a deep breath and bend down. Ups arterial pressure, decreases venous return, etc...

Front 47

Name the pulse.

The pulse pressure is approximately 30-40 mmHg. The pulse contour is smooth and rounded. (the notch on the descending slope of the pulse wave is not palpable)

Back 47

Normal pulse

Front 48

Name the pulse.

The pulse pressure is diminished, and the pulse feels weak and small. The upstroke may feel slowed, the peak prolonged. Causes include (1) decreased stroke volume, as in heart failure, hypovolemia, and severe aortic stenosis, and (2) increased peripheral resistance, as in exposure to cold and severe congestive heart failure.

Back 48

Small, weak pulses

Front 49

Name the pulse.

The pulse pressure is increased, and the pulse feels strong. The rise and fall may feel rapid, the peak brief. Causes include (1) increased stroke volume, decreased peripheral resistance, or both, as in fever, anemia, hyperthyroidism, aortic regurgitation, ateriovenous fistulas, and patent ductus arteriosus; (2) increased stroke volume because of slow heart rates, as in bradycardia and complete heart block; and (3) decreased compliance (increased stiffness) of the aortic walls, as in aging or atherosclerosis.

Back 49

Large, bounding pulses

Front 50

Name the pulse.

Increased arterial pulse with a double systolic peak. Causes include pure aortic regurgitation, combined aortic stenosis and regurgitation, and, though less commonly palpable, hypertrophic cardiomyopathy.

Back 50

Bisferiens pulse

Front 51

Name the pulse.

The pulse changes in amplitude from beat to beat even though the rhythym is basically regular (and must be for you to make this judgment). When the difference between the stronger and weaker beats is slight, it can be detected only by sphygmomanometry. It indicates left ventricular failure and is usually accompanied by a left-sided S3.

Back 51

Pulsus Alternans

Front 52

Name the pulse.

This disorder of rhythym may mimic pulsus alternans. It is caused by a normal beat alternating with a premature contraction. The stroke volume of the premature beat is diminished in relation to that of the normal beats, and the pulse varies in amplitude accordingly.

Back 52

Bigeminal Pulse

Front 53

Name the pulse.

It may be detected by a palpable decrease in the pulse's amplitude on quiet inspiration. If the sign is less pronounced, a blood pressure cuff is needed. Systolic pressure decreases by more than 10 mm Hg during inspiration. It is found in pericardial tamponade, constrictive pericarditis (though less commonly), and obstructive lung disease.

Back 53

Paradoxical pulse

Front 54

Name the murmur types that are pathologic, arising from blood flow from a chamber with high pressure to one of lower pressure, through a valve or other structure that should be closed. The murmur begins immediately with S1 and continues up to S2.

Back 54

Pansystolic (holosystolic)

Front 55

Name the pansystolic (holocystolic) murmur and why it occurs.

It is located at the apex, but can radiate to the left axilla, and sometimes to the left sternal border (less often). It is soft to loud - if loud, it's associated with an apical thrill. The pitch is medium to high, and the quality is harsh. It does NOT become louder in inspiration.
S1 is usually normal. An apical S3 reflects volume ocerload of the left ventricle. The apical impulse is increased in amplitude (diffuse), laterally displaced, and may be sustained.

Back 55

Mitral regurgitation

When the mitral valve fails to close fully in systole

Front 56

Name the pansystolic (holocystolic) murmur and why it occurs.

It is located in the lower left sternal border, but can radiate to the right of the sternum, to the xiphoid area, and perhaps to the left midclavicular line, but not into the axilla. The intensity is variable, pitch is medium, and quality is blowing. Intensity may increase slightly with inspiration.
The right ventricular impulse is increased in amplitude and may be sustained. An S3 may be audible along the lower left sternal border. JVP is often elevated.

Back 56

Tricuspid regurgitation

When the tricuspid valve fails to close fully in systole

Front 57

Name the pansystolic (holosystolic) murmur and why it occurs.

It is located in the 3rd, 4th, and 5th left interspaces, but it's radiation is often wide. The intensity is often very loud, with a thrill. The pitch is high and quality is often harsh.
S2 may be obscured by the loud murmur. Findings vary with severity of defected and with associated lesions.

Back 57

Ventricular septal defect

Congenital abnormality in which blood flows from the relatively high-pressure left ventricle into the low-pressure right ventricle through a hole.

Front 58

Name the midsystolic murmur and why it occurs.

It is located at the 2nd to 4th interspaces b/w the left sternal border and the apex and radiates little. It's intensity is grade 1 to 2, possibly 3, and the quality is variable. It usually decreases or disappears when sitting.
There are no associated findings.

Back 58

Innocent murmurs

Result from turbulent blood flow

Front 59

Name the midsystolic murmur and why it occurs.

It is similar to innocent murmurs, but has possible signs of a likely cause. (?)

Back 59

Physiologic murmurs

Turbulence due to a temporary increase in blood flow in predisposing conditions such as anemia, pregnancy, fever, and hyperthyroidism.

Front 60

Name the midsystolic murmur and what causes it.

It is located in the right 2nd interspace, but often radiates to the carotids, down the left sternal border, even to the apex. The intensity is sometimes soft but often loud, with a thrill. The pitch is medium, and the crescendo-decrescendo may be higher at the apex. The quality is often harsh, but may be more musical at the apex. It is heard best with the patient sitting and leaning forward.
A2 may be delayed and merge with P2 -> single S2 on expiration or paradoxical S2 split. Carotid upstroke may be delayed, with slow rise and small amplitude.

Back 60

Aortic valve stenosis (pathologic)

Impairs blood flow across the valve, causing turbulence, and increasing left ventricular afterload. Causes are congenital, rheumatic and degenerative.

Front 61

Name the midsystolic murmur and what causes it.

It is located in the 3rd and 4th interspaces, but it radiates down the left sternal border to the apex, possibly to the base, but not to the neck. The intensity is variable, pitch is medium, and quality is harsh. It decreases with squatting, increases with straining down from Valsalva and standing.
S3 may be present. An S4 is often present at apex. Apical impulse may be sustained and have 2 palpable components. The carotid pulse rises quickly.

Back 61

Hypertrophic cardiomyopathy

Associated with unusually rapid ejection of blood from the left ventricle during systole. Outflow tract obstruction of flow may coexist. Accompanying distortion of the mitral valve may cause mitral regurgitation.

Front 62

Name the midsystolic murmur and what causes it.

It is located in the 2nd and 3rd left interspaces, and if loud it radiates toward the left shoulder and neck. The intensity is soft to loud - if loud, associated with a thrill. The pitch is medium and quality is often harsh.
When severe, S2 is widely split, and P2 is diminished or inaudible. An early pulmonic ejection sound is common. May hear a right-sided S4. Right ventricular impulse often increased in amplitude and sustained.

Back 62

Pulmonic stenosis

Impairs flow across the valve, increasing right ventricular afterload. Congenital and usually found in children.

Front 63

What conditions mimic aortic stenosis without obstructive flow?

Back 63

Aortic sclerosis, a bicuspid aortic valve (congenital condition that may not be recognized until adulthood), a dilated aorta (as in arteriosclerosis, syphilis, or Marfan's), or pathologically increased flow across the the aortic valve.

Front 64

What condition can mimic pulmonic valve stenosis?

Back 64

Atrial septal defect (from pathologically increased flow across pulmonic valve.

Front 65

Name the diastolic murmur and what causes it.

It is located in the 2nd and 4th left interspaces, and if loud it radiates to the apex, perhaps to the right sternal border. The intensity is grade 1 to 3. The pitch is high (use diaphragm), and the quality is blowing decrescendo. Murmur is heard best when patient is sitting, leaning forward, with breath held after exhalation.
An ejection sound may be present. An S3 or S4, if present, means it's severe. Progressive changes in the apical impulse include increased amplitude, displacement laterally and downward, widened diameter, and increased duration. The pulse pressure increases, and arterial pulses are often large and bounding.

Back 65

Aortic regurgitation

Leaflets of the aortic valve fail to close completely during diastole, and blood regurgitates from the aorta back into the left ventricle, causing volume overload.

Front 66

Name the diastolic murmur.

It is usully limited to the apex. The intensity is grade 1 to 4, and pitch is decrescendo low-pitched rumble (use bell). Bell on apical impulse, patient in left lateral position, and mild exercise all help make the murmur audible. Heard better in exhalation.

Back 66

Mitral stenosis

Leaflets of the mitral valve thicken, stiffen, and become distorted from the effects of rheumatic fever, and the mitral valve fails to open sufficiently in diastole.

Front 67

Mitral regurgitation, tricuspid regurgitation, and ventricular septal defect are what type of murmurs?

Back 67

Pansystolic (holosystolic) murmurs

Front 68

Innocent murmurs, physiologic murmurs, aortic stenosis, hypertrophic cadiomyopathy, and pulmonic stenosis are what type of murmurs?

Back 68

Midsystolic murmurs

Front 69

Aortic regurgitation and mitral stenosis are what type of murmurs?

Back 69

Diastolic murmurs