15 - Heart Sounds Flashcards
When listening to the heart, where would you listen to the aortic area?
upper right sternal edge (AS)
When listening to the heart, where would you listen to the pulmonary area?
upper left sternal edge (PS,PR, ASD, OS of MS)
When listening to the heart, where would you listen to the tricuspid area?
lower left sternal edge (AR, PR, TS, VSD)
When listening to the heart, where would you listen to the mitral area?
apex (1st, 3rd, 4th heart sounds, MS, AR)
When listening to the heart, where would you listen to mitral radiation?
posterolateral to apex
When listening to the heart, where would you listen to aortic or pulmonary radiation?
upper chest
Where else is a a place where we listen to the heart?
Carotids
Describe the sequence of S1, S2, S3 and S4… What do they mean?
S1 ________ S2 __*_____**_ S1
S1-->S2 = systole S2-->S1 = diastole * = S3 will occur here if present (pathologic) ** = S4 will occur here if present (pathologic)
What is physiological splitting?
Physiological splitting
This happens when someone takes a deep breath
This is normal
What is pathological splitting?
Pathological splitting
This happens when there is a atrial septal defect
A fourth heart sound is almost always abnormal
Common to hear S3 in an MI or with some heart failure going on
What is the scale for murmur intensity?
1 - very faint
2 - quiet, usually not heard immediately
3 - moderately loud (NO THRILL)
4 - loud with a thrill (THRILL)
5 - very loud with a thrill (barely touch chest with stethoscope and hear it)
6 - no stethoscope is need to hear (with a thrill)
How do you describe a murmur?
- Pitch – high or low
- Quality – blowing, harsh, musical
- Timing - systolic or diastolic, continuous vs. cresendo-decresendo
- Where it is best heart (aortic, apex)
- Radiation (axilla = ventricular hypertrophy)
What is S1 related to?
- Mitral and tricuspid valve closure
When does S1 occur?
S1 occurs just before the upstroke of the carotid pulse
Can you hear S1 better with the diaphragm or the bell?
Diaphragm
Where is S1 usually louder?
Usually louder over the apex and along lower left sternal border
When will you hear decreased S1 sounds?
Decreased conduction of sounds with COPD, pulmonary disease and pericardial effusion
When would a wide split of S1 occur?
A widely split occurs in complete right bundle branch block
What can an S1 split be confused with?
A relatively loud S4 preceding S1 may sometimes be confused with a split S1
What does it mean when S1 varies from beat to beat in intensity?
Variation in the intensity of S1
- This means it varies from beat to beat
- Common feature of atrial fibrillation
- The first thing you should think of when someone older
- They will have SOB, they get tired, they feel palpitations
- They can go in and out of atrial fib and can’t feel it if they’re older
What is S2?
The sound of aortic and pulmonary valve closure
A2 = aortic valve closing P2 = pulmonic valve closing
Is S2 best heard with the diaphragm or the bell?
Diaphragm
Where is S2 best heard?
Location – left second interspace close to the sternal border
Describe S2 splitting
Physiologically normal
- S2 is usually single during expiration
- Separation of A2 and P2 occurs during inspiration
What does it mean when there is an increased intensity in A2?
Increased intensity of A2 often occurs in systemic hypertension, coarctation of the aorta, and a ascending aortic aneurysm
What does it mean when there is an increased intensity in P2?
Increased P2 intensity is pulmonary arterial hypertension
What is S3?
- Low frequency diastolic sounds that appear to originate in the ventricles
- Ventricular filling sounds
Is S3 best heard with the diaphragm or the bell?
Bell
When will we see S3?
- Can be heard in healthy young adults (thyrotoxicosis, pregnancy)
- Usually abnormal in patients over 40, suggests an enlarged ventricular chamber
- S3 is the ventricular gallop (chronic mitral regurgitation)
- Important and common early finding in heart failure(diastolic)
What is the pitch of S3?
S3 and S4 are lower pitched sounds than S1 and S2
When will we hear S4?
- Can be heard in many healthy older adults without any cardiac abnormality due to decreased ventricular compliance
- With age, the ventricles are tired, worn out and stiff
- Instead of the ventricle taking in all the blood easily and expanding accordingly, the blood is hitting the ventricular wall and the blood is moving around a bit
- Common in hypertensive heart disease, Aortic stenosis, hypertrophic cardiomyopathy
- Heard in the majority of patients during acute case of MI
What population is S4 abnormal in?
Usually abnormal in children and young adults
Is S4 a high or low pitched sound?
Lower pitched sound
There are two types of aortic pathology to know… What are they?
- Aortic stenosis
- Aortic regurgitation
What is aortic stenosis?
In Aortic Stenosis blood encounters an obstruction while exiting the left ventricle
Classic case is the little old lady who stands up too quickly and falls over
What is aortic regurgitation?
In Aortic Regurgitation a diastolic murmur may be heard over the aortic area and you may hear an associated diastolic murmur at the apex
Describe a aortic stenosis
- Heard best in the top two regions (Aortic and Pulmonic areas)
- Pitch is usually medium
- Described as harsh
- Graded at a 4-6
- Heard during systole
- Ejection sound or S4 sound
- Apical heave
NARROW pulse pressure
Describe aortic regurgitation
- Heard best in the bottom of the heart - tricuspid region
- Heard in diastole (S2-S1)
- Indicative of left ventricular hypertrophy so PMI may shift to axilla
- Bounding carotid pulse is present
WIDE pulse pressure
Describe mitral stenosis
- Heard best when laying on the left side
- Heard best with the bell
- Low pitched, rumbling sound
- Graded at 1-4
- Indicative of right ventricular hypertrophy
- Seen with weak pulses
NARROW pulse pressure
Describe mitral regurgitation
- Heard best in the mitral area ***
- Heard best with the diaphragm
- High pitched “blowing” sound
- Systolic and mid-systolic rumble
- Radiates to the axilla
- S3 can be heard
- S4 is seen in acute, but not usually in chronic mitral valve regurgitation
WIDE pulse pressure
If you have a murmur present during systole (S1-S2), what are the two possibilities?
- Mitral regurgitation
- Aortic stenosis
If you have a murmur present during diastole (S2-S1) what are the two possibilities?
- Aortic stenosis
- Mitral stenosis
If you have a wide pulse pressure, what are the two possibilities?
- Aortic regurgitation
- Mitral regurgitation
