Nur 731 Murmurs & Hs

Front 1

Systole?

Back 1

Contraction of the heart

S1 to S2

Front 2

Diastole?

Back 2

Resting of the heart
S2 to the next S1

Front 3

S1 represents closure of which valves?

Back 3

Mitral and tricuspid valves

Front 4

S2 represents closure of which valves?

Back 4

Aortic and Pulmonic valves

Front 5

Which side of the heart do the valves close first?

Back 5

Left side

Front 6

Where is theMitral valve?

Back 6

Usually the 5 th ICS MCL
can be pushed more over to the left if pt has cardiomegaly

Front 7

Where is the Pulmonic valve?

Back 7

2 nd L ICS

Front 8

Where is the Tricuspid valve?

Back 8

4-5th L ICS

Front 9

Where is Erbs point?

Back 9

3 rd L ICS
Intesity of S1 should = S2

Front 10

Where is the Aortic valve?

Back 10

2nd Rt ICS

Front 11

Where do you listen for mitral regurg or MS?

Back 11

At the Apex, not the PMI, because that can be displaced
in the epigartrim with rt heart cardiomegaly
Mitral Area= Apex

Front 12

Where is the RA?

Back 12

5 cm below the sternal angle

Front 13

Where is the RV?

Back 13

Under the body of the sternum

Front 14

What are the AV valves?

Back 14

Mitral and tricuspid
atrioventricular

Front 15

What are the Semilunar valves?

Back 15

pulmonic and aortic

Front 16

Murmurs are caused by?

Back 16

Turbulent bloodflow

Front 17

What sound does stenosis make?

Back 17

Not opening
Rumbling

Front 18

What sound does regurg make?

Back 18

Blowing
Not closing
Incompetent

Front 19

Diaphragm?

Back 19

High
Press Hard
H&H

Front 20

Bell?

Back 20

Low
Press lightly
If you press hard it will function as a diaphragm
L&L

Front 21

Which murmurs are diastolic?

Back 21

MS ARD
Mitral Stenosis and
Aortic Regurg

Front 22

Which murmurs are systolic?

Back 22

MR ASS
Mitral Regurg and
Aortic Stenosis

Front 23

Which HS is louder at the base of the heart S1 or S2?

Back 23

S2
If S1 is louder at the base of the heart (2nd ICS), it may be from Pulmonary HTN

Front 24

Which HS is louder at the apex of the heart S1 or S2?

Back 24

S1

Front 25

Which murmurs = pathology?

Back 25

Diastolic and Holosystolic Murmurs
Systolic Murmurs are usually benign

Front 26

What is the PMI?

Back 26

area on the chest wall where you can best feel the beating of the heart. It is usually just left of the breast

Front 27

Which HS are high pitched?

Back 27

Listen with diaphragm
S1 & S2
Split S1
Split S2
Murmurs can be low or high pitched sounds

Front 28

Which HS are low pitched?

Back 28

Listen with bell
S3 & S4
Murmurs can be high or low pitched sounds

Front 29

Where is the best place to hear a split S2?

Back 29

Pulmonic area
2nd Lt ICS

Front 30

Where is the best place to hear a split S1?

Back 30

Aortic area
2nd Rt ICS

Front 31

Best place to hear a Split S 1?

Back 31

4-5th L ICS
next to the sternum
Tricuspid area

Front 32

Fixed Split?
What would you look for when you hear a fixed split?

Back 32

Constant split & timing
1-2-2
Pathopneumonic for an atrial septal defect

Front 33

Widely split?

Back 33

Stays as 2 different sounds
Splits more on inhalation

Front 34

Paradoxical Split?

Back 34

Opposite of physiologic split
HEAR IT ON EXHALATION, disappears on inhalation
Present with LBBB
Can't diagnose an MI in presence of LBB with just and EKG

Front 35

Physiological Split?

Back 35

Pulmonic is best place ot hear S2 split
2nd ICS Lt side, sometimes radiates into the 3 rd IC
Audible on INHALATION, not exhalation

Front 36

S3?

Back 36

Sloshing in
Kentucky
CHF (3 words)
late diastole
ventricular gallop
really is the 3rd heart sound
Bell
rapid ventricular filling into a dilated ventricle
Turn pt to left side
first marker for CHF

Front 37

4 types of S2 splits?

Back 37

1 Physiological Split
2 Paradoxical Split
3 Widely Split
4 Fixed Split

Front 38

S4?

Back 38

A----stiff-wall
Tenessee
HTN
early diastole
Bell
Marker for HTN
Turn pt to left lateral side
Atrial contraction when ventricles resist filling
can find in kids
=pathology when >40 yrs

Front 39

Opening snap?

Back 39

A sharp, high-pitched sound heard in early diastole, associated with the opening of the abnormal valve in cases of mitral stenosis
happens right after S1
usually lt sided

Front 40

Ejection Click?

Back 40

associated with high pulmonary resistance and hypertension, they are common and of no clinical significance in pregnant women and in many other healthy people.
if mital valve
right after S2

Front 41

How do you classify a murmur?

Back 41

1 Pitch (high/ low)
2 Quality (rumbling/ blowing)
3 Shape (crescendo/ decrescendo)
4 Timing
5 Intensity (grade 1-6 as a fraction)
6 Location
7 Radiation

Front 42

Earliest presenting symptom of AR?
Progressive sympts?

Back 42

palpitations.
Progresses from palpitations to DOE, easy fatiguability. Later to LVH, failure and angina at rest.

Front 43

AR occurs most often secondary to?

Back 43

1 rheumatic fever
2 2nd to untreated syphilis
3 bacterial endocarditis
4 connective tissue disease (Reiter’s syndrome, anklyosing spondilitis).

Front 44

AR, occurs when aortic valve is supposed to be?
Describe the murmur of AR?

Back 44

closed, leads to backflow
and audible diastolic murmur, high pitched, blowing. Best heard with pt sitting up, leaning forward, exhales and holds breath.

Front 45

AR is best heard with pt in what position?

Back 45

sitting up, leaning forward, exhales and holds breath.

Front 46

AR is loudest in what location?

Back 46

aortic area, radiates to 3rd and 4th ICS.

Front 47

Long term AR produces?

Back 47

loud early diastolic murmur that extends past mid-diastole, with S3, bounding pulse and wide pulse pressure.

Front 48

How do you diagnose AR?

Back 48

via echo with Doppler

Front 49

Management of AR?

Back 49

cardiology consult immediately

Front 50

What s/s would cause you to consult with cardiology immediately?

Back 50

1 evidence worsening dyspnea
2 signs LVH and strain
3 increased cardiomegaly on CXR
4 falling ejection fraction and increased LV end systolic
dimension.

Front 51

Meds for AR?

Back 51

Often begin dig and HCTZ with onset dyspnea climbing one flight of stairs without evidence LVH.

Front 52

S/Sx of MS?

Back 52

include DOE, often acute with disease progression

Front 53

MS corresponds to?

Back 53

increased LA pressure and pulmonary venous congestion

Front 54

MS often has a symptom interval of?

Back 54

10 years

Front 55

MS=?

Back 55

narrowing of mitral valve

Front 56

MS is what kind of murmur?

Back 56

diastolic murmur that doesn’t radiate: only heard at apex

Front 57

Which position is best to hear MS in?

Back 57

especially in LL decubitus position.

Front 58

What may increase murmur intensity?

Back 58

Exertion may increase murmur intensity.

Front 59

Heard after pause after which HS?

Back 59

S2, low pitch, rumbling, maybe with increased intensity S1.

Front 60

With MS, which HS may be heard louder at the base of the heart?

Back 60

S1 may > S2 at base

Front 61

MS may produce a click or a snap?

Back 61

maybe with OS (follows S2)
Not Opening

Front 62

MS can be complicated by?

Back 62

a fib and preceded by PACs and PAF

Front 63

On CXR, MS may present as?

Back 63

lateral view,dilation of LA, pulmonary HTN (increased right pulmonary artery, RVH)

Front 64

On EKG, MS may present as?

Back 64

QRS shift > 60 degrees. With pulmonary artery pressure increase, induces RVH

Front 65

Caution with MS with ?

Back 65

in pregnancy or with extreme exertion.

Front 66

MR's often the result of ?
MR's associated with?

Back 66

rheumatic fever, or S/P MI.
MR's associated with MVP (which indicates a need for endocarditis prophylaxis)

Front 67

On Hx, with MR you may find pt has?

Back 67

DOE, easy fatiguability.

Front 68

S/Sx with MR?

Back 68

LVH, displaced PMI, apical pansystolic murmur, S3, mid-diastolic rumble and sometimes wide split S2.

Front 69

MR On EKG?

Back 69

right and left atrial enlargement

Front 70

Diet for MR?

Back 70

No added salt diet (2 gm), HCTZ

Front 71

Rx for MR?

Back 71

valve replacement. Endocarditis prophylaxis.

Front 72

AS is what kind of murmur?

Back 72

systolic murmur, which occurs as blood passes through a narrowed aortic valve while the ventricles contract.

Front 73

AS is loudest in?

Back 73

aortic area, often crescendo-decrescendo

Front 74

AS can radiate?

Back 74

to carotid

Front 75

AS is often associated with a click or snap?

Back 75

ejection click (opening sound from aortic valve) secondary to calcium deposition on valve

Front 76

AS is easier to hear if pt is in what position?

Back 76

sits, leans forward and breathes out

Front 77

At what age does AS occur?

Back 77

some aortic valve calcification occurs with aging

Front 78

50% of pts with AS die of ?

Back 78

CHF

Front 79

Since LV has increased ability to hypertrophy and compensate for a pressure load, watch this pt cardfully for?

Back 79

onset angina or effort syncope: with development of CHF, ominous since LV can’t compensate any further.

Front 80

With AS on PE, check for?

Back 80

SEM, delay in carotid upstroke, delayed 2nd heart sound

Front 81

With AS, S2 may be?

Back 81

single or paradoxically split, as with calcification and valve rigidity, the aortic valve closure becomes quieter. Note increased force of PMI secondary to LVH

Front 82

AS on EKG?

Back 82

1 evidence of LVH
2 LA enlargement (biphasic P)
3 strain pattern with severe LVH
4 ST segment depression
5 T wave inversion with asymmetric wave with abrupt
upstroke.

Front 83

Cardiomegaly may be noted with which murmurs on CXR?

Back 83

AS & MR

Front 84

Diagnose AS via?

Back 84

echo.

Front 85

Management of AS?

Back 85

in young pt, no competitive sports

Front 86

With elderly, what mandates evaluation?

Back 86

effort syncope, CHF development mandates cardiology evaluation.

Front 87

With coexisting CHF & AS?

Back 87

give dig, Lasix, referral

Front 88

MS is heard best in which position?

Back 88

at apex especially in the LL decubitus position

Front 89

Management for MS includes?

Back 89

salt restriction, mild HCTZ and cardiology referral.

Front 90

MR On CXR?

Back 90

cardiomegaly

Front 91

When do you consult cardiology for MR?

Back 91

with increased dyspnea.

Front 92

Murmurs can be classified by what characteristics?

Back 92

1 timing
2 shape
3 location
4 radiation
5 intensity
6 pitch and
7 quality

Front 93

Timing of a murmur, refers to?

Back 93

whether the murmur is a systolic or diastolic murmur.

Front 94

Shape of a murmur refers to?

Back 94

the intensity over time

Front 95

Location of a murmur refers to?

Back 95

where the heart murmur is auscultated best. There are 6 places on the anterior chest to listen for heart murmurs

Front 96

Locations of the heart are?
(correspond to a different part of the heart.)

Back 96

The locations are:
2nd Rt intercostal space (Aortic)
2nd Lt ICS (Pulmonic)
3rd Lt ICS (Erbs Point)
4-5 th Lt ICS (Tricuspid Area)
MCL 5th ICS (Mitral Area)

Front 97

Radiation of a murmur refers to?

Back 97

where the sound of the murmur radiates. The general rule of thumb is that the sound radiates in the direction of the blood flow.

Front 98

Intensity of a murmur refers to?

Back 98

the loudness of the murmur, and is graded on a scale from 0-6/6.

Front 99

The pitch of a murmur is?

Back 99

low, medium or high and is determined by whether it can be auscultated best with the bell or diaphragm of a stethoscope.

Front 100

Some examples of the quality of a murmur are?

Back 100

blowing, harsh, rumbling and musical Continuous murmurs