Abnormal Heart Sounds Flashcards
Cardiac auscultation listening posts
Aortic valve = right 2nd ICS at SB
Pulmonic valve = left 2nd ICS at SB
Tricuspid valve = left 4th ICS at SB
Mitral valve = left 5th ICS at MCL
Grading of heart murmurs
Grade 1 = very faint
Grade 2 = quiet, soft, easily heard with stethoscope
Grade 3 = moderately loud
Grade 4 = loud with palpable thrill
Grade 5 = very loud with thrill; can hear with stethoscope
Grade 6 = heard without stethoscope
Systolic murmurs occur between ___ and ____
Diastolic murmurs occur between ___ and ____
S1; S2
S2; S1
What does S1 represent?
Closure of tricuspid valve and mitral valve
What does S2 represent?
Closure of aortic valve and pulmonic valve — may split with inspiration
Describe S3 heard in some pts
Dull, low pitch; best heard with bell (Kent-Tuck-y)
Physiologic in children, young adults
Pathologic in older adults = heart failure
Ventricular gallop
Describe S4 heard in some pts
Dull, low pitch; best heard with bell (Ten-Nes-See)
Forceful atrial contraction against stiffened low compliant ventricle
Atrial gallop
What are the systolic murmurs?
Mitral regurg (MVP) Tricuspid regurg Aortic stenosis Pulmonic stenosis VSD Aortopulmonary shunts
What are the diastolic murmurs?
Aortic regurg Pulmonic regurg Mitral stenosis Tricuspid stenosis Atrial myxoma
What are the continuous murmurs?
PDA — machine-like
AV fistula
ASD with high LA pressure
Coarctation
What are the most common valvular heart diseases encountered today?
Degenerative (senile calcification)
Myxomatous degeneration (MVP)
Congenital (bicuspid aortic valve)
[decline in incidence of rheumatic valvular disease]
Chronic vs. acute etiologies of mitral regurg
Chronic:
MVP — Most common etiology
Mitral annular calcification
Acute: Rupture of chordae tendinae Rupture of papillary muscle Ischemic Papillary muscle dysfunction (CAD/MI — next MCC of MR) Infective endocarditis Valve perforation
Symptoms of MR
Asymptomatic years —> fatigue, DOE, palpitations
Acute; volume overload/orthopnea, PND, RHF/LHF
PE findings with MR
Systolic murmur — blowing, prominent at apex; radiates into left axilla
Loudness of murmur correlates with severity
Decreased S1 or normal; may have systolic click
Sx of mitral stenosis
Arise in 4th decade
DOE, cough, orthopnea, PND, pulmonary edema, hemoptysis, arterial emboli, A.fib
Ortner syndrome: hoarseness d/t compression of left recurrent laryngeal n
mitral stenosis findings on PE
Malar flush — ruddy cheeks, blue facies
Increase S1; opening snap (OS) after S2
Rumbling, diastolic murmur — low pitched; best heard at apex. Use bell
Etiologies of aortic stenosis
Degenerative (calcific, senile, fibrosis, or sclerosis)
Congenital bicuspid aortic valve (BAV) - 1% of population
Rheumatic or postinflammatory scarring
[normal AoV area is 4.0 cm]
Symptoms of aortic stenosis
Arise in 6th decade
Exertional dyspnea, angina, syncope, heart failure
Without tx, prognosis is poor — most die w/i 3 years of developing syncope and w/i 2 years of onset of HF
Pathophysiology of aortic stenosis
Obstruction leads to pressure overload; LVH, increase LVED pressure
Gradient across valve
[severe AS if AoV <1 cm]
Aortic stenosis on PE
Narrow pulse pressure; decreased SV and systolic pressure
Delayed pulses - Parvis (weak-small)/Tardus (late)
Systolic murmur, harsh, 2nd ICS RSB; radiates into suprasternal notch/carotids
What is the Gallavardin phenomenon?
AS murmur radiates to apex (like MR)
Causes of acute vs. chronic aortic regurg
Acute: IE, aortic dissection, BAV
Chronic: Syphilis, ankylosing spondylitis
PE findings with aortic regurg
Diastolic decrescendo murmur, 3rd ICS LSB
Systolic murmur usually present, soft
Wide pulse pressure; bisferious pulse
De Musset sign, Corrigan’s pulse, Quincke’s pulse, Traube’s sign, Durozrey’s sign, Hill’s sign
Austin Flint murmur — can mimic mitral stenosis
Conditions associated with tricuspid regurg
Pulmonary HTN, inferior MI/RV infarct
What murmur is associated with prominent V wave in JVP?
Tricuspid regurg
PE findings with tricuspid regurg
Blowing systolic murmur LSB; increase with inspiration (Carvallo’s sign)
Murmur associated with mitral stenosis, tricuspid regurg, and RHD
Tricuspid stenosis
Tricuspid stenosis is associated with prominent ____ wave in JVP, ascites, and potentially pulsatile hepatomegalia
A
PE findings with tricuspid stenosis
Diastolic murmur LSB; increase with inspiration (Carvallo’s sign) and decrease with expiration and valsalva
Most cases of pulmonic regurg are due to ________
Pulmonary HTN
Pulmonic regurg on PE
Diastolic, blowing murmur 2nd ICS LSB (Graham Steel)
Pulmonic stenosis can cause _____ and ____
Angina; syncope
PE findings with pulmonic stenosis
2nd-3rd ICS, LSB — radiates toward left shoulder and increases on inspiration/RVH
Which of the following presents with crescendo-decrescendo systolic murmur, often with systolic thrill, typically loudest at second right ICS?
A. Mitral stenosis B. Mitral regurgitation C. Mitral valve prolapse D. Aortic stenosis E. Aortic regurgitation F. Tricuspid regurgitation
D. Aortic Stenosis
Which of the following presents with mid or late systolic click(s) followed by late systolic murmur at apex; exaggerated by valsalva maneuver and reduced by squatting?
A. Mitral stenosis B. Mitral regurgitation C. Mitral valve prolapse D. Aortic stenosis E. Aortic regurgitation F. Tricuspid regurgitation
C. Mitral Valve Prolapse
Which of the following presents with severe RV failure with edema, hepatomegaly, and prominent v waves in jugular venous pulse with rapid y descent, as well as a systolic murmur heard along lower left sternal edge that increases with inspiration?
A. Mitral stenosis B. Mitral regurgitation C. Mitral valve prolapse D. Aortic stenosis E. Aortic regurgitation F. Tricuspid regurgitation
F. Tricuspid regurgitation
Which of the following presents with fatigue, weakness, and exertional dyspnea as well as loud holosystolic murmur at apex, possibly with brief early-mid-diastolic murmur?
A. Mitral stenosis B. Mitral regurgitation C. Mitral valve prolapse D. Aortic stenosis E. Aortic regurgitation F. Tricuspid regurgitation
B. Mitral regurgitation
Which of the following presents with exertional dyspnea and awareness of forceful heartbeat, angina pectoris, and signs of LV failure with blowing decrescendo diastolic murmur along the left sternal border?
A. Mitral stenosis B. Mitral regurgitation C. Mitral valve prolapse D. Aortic stenosis E. Aortic regurgitation F. Tricuspid regurgitation
E. Aortic regurgitation
Which of the following presents with opening snap followed by diastolic rumbling murmur with presystolic accentuation when in sinus rhythm?
A. Mitral stenosis B. Mitral regurgitation C. Mitral valve prolapse D. Aortic stenosis E. Aortic regurgitation F. Tricuspid regurgitation
A. Mitral stenosis
What is ortner syndrome and what valvular dz is it associated with?
Hoarseness d/t compression of left recurrent laryngeal n.; associated with mitral stenosis when left atrium enlarges and compresses on that nerve
Acute ____ ____ can present with cardiogenic shock
Mitral regurgitation
