2- auscultatory skills

Question 1

what is the first heart sound caused by?

Answer 1

caused by the closure of mitral & tricuspid = the beginning of systole

Question 2

what is the second heart sound caused by?

Answer 2

caused by the closure of aortic & pulmonary valves (beginning of diastole)

Question 3

do
a) systolic
OR
b) diastolic
murmurs coincide with the carotid pulse?

Answer 3

A = systolic murmurs coincide with the carotid pulse

Question 4

what is the physiological splitting of the 2nd heart sound?

Answer 4

due to inspiration - when inhaling 2 sounds are heard at pulmonary area (2nd intercostal space sternal right)

• inspiration causes drop in intrathoracic pressure resulting in increased venous return to right side of the heart
• this increased RV volume prolongs ventricular ejection time hence pulmonary component may be delayed a fraction of a second behind the aortic component during inspiration

Question 5

in physiological splitting of 2nd heart sound - what sound is loudest?

Answer 5

aortic (first sound) louder than pulmonary (second sound)

Question 6

what causes 3rd heart sound?

Answer 6

• EARLY diastolic flow frequency filling sound
• related to acceleration & deceleration of blood during early passive filling of the ventricles

occurs immediately after 2nd heart sound (sounds like bum budum)

Question 7

where are 3rd & 4th heart sounds best heard?

Answer 7

at the apex of heart with bell of the stethescope

Question 8

what is the significance of a 3rd heart sound in practice?

Answer 8

in otherwise healthy child or young adult with no evidence of cardiac disease = likely to be physiological & therefore a normal finding

in older patient with suspected or known cardiac disease = 3rd heart sound is likely pathological, commonly due to ventricular systolic dysfunction
- should be referred for echocardiography

Question 9

what causes of a 4th heart sound?

Answer 9

• LATE diastolic low frequency filling sound
• it’s due to atrial contraction causing rapid blood flow into a less compliant/stiff ventricle (common causes are MI, hypertension, aortic stenosis)
• sounds like budum bum

Question 10

what is significance of 4th heart sound in practice?

Answer 10

• 4th heart sound is almost always pathological (good indicator of severity of hypertension & aortic stenosis), should be referred for echocardiography

Question 11

what are cardiac murmurs caused by? and what should a description of murmur include?

Answer 11

turbulent blood flow in the heart

description should include:
- intensity
- character & pitch
- timing
- location
- radiation

Question 12

what causes an innocent cardiac murmur?

Answer 12

a systolic flow murmur usually caused by turbulence of blood in RV outflow tract
(it’s often loudest when the circulation is hyperdynamic e.g. fever, pregnancy, anaemia)

Question 13

what are characteristics of an innocent murmur?

Answer 13

1. soft mid systolic (diastolic murmur always pathological)
2. usually heard in pulmonary area
3. localized to one auscultatory area
4. no radiation
5. no other cardiac abnormalities

Question 14

what causes pathological cardiac murmurs?

Answer 14

caused by turbulence of blood resulting from a structural cardiac abnormality (can be systolic or diastolic)

Question 15

what are characteristics of pathological murmurs?

Answer 15

1. diastolic murmurs are always pathological
2. ejection systolic (LATE PEAKING and PAN SYSTOLIC murmurs are often pathological)
3. not localized: may be audible in more than one auscultatory areas
4. radiation: pathological murmurs may radiate
5. associated abnormalities

Question 16

what are the 4 auscultatory areas? and where do you listen to them?

Answer 16

1. aortic - 2nd intercostal space, sternal & right
2. pulmonary - 2nd intercostal space, sternal & left
3. tricuspid - 4th intercostal space, sternal & left
4. mitral - 5th intercostal space, mid-clavicular & left