Abnormal Heart Sounds Flashcards
Which valves are AV vales and which are Semilunar valves?
AV valves: mitral and tricuspid valves
Semilunar valves: aortic and pulmonic valves
Closure of which valve produces S1? What phase of cardiac cycle do you hear it?
Mitral valve closure during start of systole
Closure of which valve produces S2? What phase of cardiac cycle do you hear it?
Aortic valve closure during start of diastole
S3 heart sound
Sound of rapid ventricular filling of a compliant LV at end of S2; can be normal or abnormal
S4 heart sound
Sound of atria contracting forcefully in an effort to overcome an abnormally stiff or hypertrophic ventricle; right before the “lub-dub”
Where and d/t what condition would you hear A2 with increased intensity?
What if A2 is decreased or absent?
A2 (aortic valve closure) increased intensity:
- 2nd right ICS
- systemic HTN; aortic root dilation
A2 decreased/absent:
– calcific stenosis d/t valve immobility
When do you heart P2? If it’s equal or louder than A2 what does that mean?
Under what conditions is P2 decreased/absent?
P2 (pulmonic valve closure) increased intensity;
- if equal to/louder than A2 = pulmonary HTn
- other causes of P2 = dilated pulmonary artery and ASD
P2 decreased/absesnt:
- d/t increased AP diameter or chest assoc. w/aging
- d/t pulmonic stenosis
Spitting of S2 - what is it, what causes it, is it greater on inspiration or expiration
Caused by delayed closer of pulmonic valve (d/t pulmonic stenosis or RBBB)
- or early closure of the aortic valve (d/t mitral regurg.)
- greater during inspiration (more delayed closure of valve; more split P2)
When does paradoxical/reversed S2 splitting occur?
During expiration; disappears during inspiration
– occurs in any setting that delays closure of arotic valve (i.e aortic stenosis; HOCM)
What is the most common cause of paradoxical/reversed S2 splitting?
LBBB
What are the two main kinds of extra heart sounds in systole?
- Early ejection sounds
2. Clicks (mid-and late systole)
Early Ejection Sounds
- when do they occur
- characterization of sound
- heard best with bell or diaphragm/
- indicates what disease in general
- occurs shortly after S1
- high pitch; sharp clicking
- heard w/ diaphragm
- indicates CVD
Pulmonic Ejection sound
- location
- characterization
- indicates what dzs
- 2nd and 3rd left ICS; S1 here is loud in this area (normally quiet)
- intensity decreases with inspiration
- d/t dilation of pulmonary artery, pulmonary HTN, and pulmonic stenosis
Systolic Clicks
- when/where do they occur
- d/t what abnormality
- characterization
- head best with bell or diaphragm
- affect of squatting and standing
- occur mid or late systole; medial to apex and lower left sternal border
- usually caused by MITRAL VALVE PROLAPSE
- high pitched
- heard best with diaphragm
- Squatting = delays the click/murmur d/t increased venous return
- Standing = click occurs sooner (closer to S1)
Opening Snap
- when/ where does it occur
- d/t what abnormality
- characterization
- heard best with bell or diaphragm
- occurs during early diastole; just medial to apex along lower let sternal border; if loud = radiates to apex and pulmonic area
- assoc with MITRAL STENOSIS
- High pitch
- best heard with diaphragm
S3
- physiologic in what group
- pathologic in what group
- when/ where does it occur
- characterization
- heard best with bell or diaphragm
- d/t what conditions
- physiologic (normal) in children and young adults to ages 35-40; normal during last trimester of pregnancy
- pathologic (abnormal) in adults >40 yo
- dull and low in pitch
- heard best at apex in left lateral decubitus position
- use BELL OF STETHOSCOPE
- causes: dec miocardial contractility, heart failure, ventricular volume overload from aortic or mitral regurg, and left to right shunts
S4
- physiologic in what group
- when/ where does it occur
- characterization
- heard best with bell or diaphragm
- d/t what conditions
- occasionally normal in trained athletes and older age groups
- heard just before S1; at apex
- dull, low pitch
- use BELL OF STETHOSCOPE
- causes: ventricular hypertrophy or fibrosis causing stiffness and inc. resistance (dec. compliance)
Grading of murmurs
Grade 1: very faint, really have to listen to hear; may not be heard in all positions
Grade 2: quiet, but heard immediately after placing stethoscope on chest
Grade 3: moderately loud
Grade 4: Loud + palpable thrill
Grade 5: VERY LOUD; thrill; may be heard when stethoscope is PARTLY OFF THE CHEST
Grade 6: VERY LOUD, thrill, heard with stethoscope ENTIRELY OFF THE CHEST
Systolic murmurs decrease in intensity with what movements?
Movements that reduce left ventricular volume - standing, sitting up, valsalva
Crescendo-decrescendo murmur; when is it best heard
Aortic stenosis - best heard with pt sitting and learning forward
Hypertropic Cardiomyopathy
- Location
- Radiation
- Pitch
- Quality
- Maneuvers
Location - left 3rd and 4th ICS
Radiation - down left sternal border to apex; NOT to neck
Pitch - medium
Quality - harsh
Maneuvers - DEC w/ squatting (d/t inc venous return); INC w/standing (d/t dec left vent volume)
Pulmonic stenosis
- Location
- Radiation
- Intensity
- Pitch
- Quality
- Maneuvers
Location - left 2nd and 3rd ICS
Radiation - if loud, toward left shoulder and neck
Intensity - soft to loud; if loud assoc w/thrill
Pitch - medium; crescendo-decrescendo
Quality - harsh
List the three pansystolic (holosystolic) murmurs
- Mitral regurg
- Tricuspid regurg
- VSD
Mitral Regurg.
- Location
- Radiation
- Intensity
- Pitch
- Quality
- Maneuvers
Location - apex
Radiation - left axilla
Intensity - soft to loud; if loud = assoc with apical thrill
Pitch - medium to high
Quality - harsh; holosystolic
Maneuvers - intensity dose NOT change with inspiration (same throughout)
Tircuspid Regurg.
- Location
- Radiation
- Intensity
- Pitch
- Quality
- Maneuvers
Location - lower left sternal border
Radiation - to the right of sternum, to xiphoid area, sometimes to left midclavicular line (NOT AXILLA)
Intensity - variable
Pitch - medium
Quality - blowing, holosystolic
Maneuvers - intensity INC with INspiration; (opp. of mitral regurg.)
VSD (ventricular septal defect)
- Location
- Radiation
- Intensity
- Pitch
- Quality
Location - left 3rd, 4th, and 5th ICS
Radiation - wide, depending on size of defect
Intensity - very loud + thrill; SMALLER defect = LOUDER murmur
Pitch - high, holosystolic; SMALLER = HIGHER pitch
Quality - harsh
What are the two basic types of diastolic murmurs in adults?
- Early decrescendo - signify regurg flow through an incompetent semilunar valve (arotic usually)
- Rumbling murmurs in mid or late diastole - stenosis of AV valve (mitral usually)
* diastolic murmurs are less common than systolic, harder to hear
Aortic Regurg
- Location
- Radiation
- Intensity
- Pitch
- Quality
- Maneuvers
Location - left 2nd - 4th ICS
Radiation - if loud = to apex
Intensity - grade 1-3
Pitch - high; use diaphragm
Quality - blowing decrescendo
Maneuvers - best heard with patient sitting, leaning forward w/ breath held after exhalation
Mitral Stenosis
- Location
- Radiation
- Intensity
- Pitch
- Quality
- Maneuvers
Location - limited to apex
Radiation - little to none
Intensity - grade 1-4
Pitch - decrescendo, low-pitched rumble followed by opening snap; use BELL
Maneuvers - place bell exactly on apical impulse, turn pt into left lateral position, and have them do a mild exercise like handgrip; better heard in exhalation
What is an atrial myxoma and how does it cause a murmur; how can it be distinguished by sound?
atrial myxoma = noncancerous tumor in the upper left or right side of the heart; grows on the wall that separates the two sides of the heart (atrial septum)
- May cause obstruction of AV valves
- left atrial myxoma –> auscultatory findings similar to mitral stenosis
- presystolic and crescendo murmur
- murmur occurs at start of ventricular systole when tumor is moved toward left atrium through mitral orifice
- unique sound = TUMOR PLOP
Effect of squatting on mitral valve prolapse, hypertrophic cardiomyopathy, and aortic stenosis murmurs
MVP: dec
HCM: dec
AS: INC (b/c more blood volume ejected into aorta)
Effect of standing on mitral valve prolapse, hypertrophic cardiomyopathy, and aortic stenosis murmur intensities
MVP: inc
HCM: inc
AS: DEC
Most common structural heart dz in children with murmurs
Ventricular septal defect (VSD)
What kinds of murmurs are present in the first 6 hours of life (neonates/infants)?
Valve problems = triscupid or mitral regurg; or aortic or pulmonary stenosis
What kinds of murmurs are present after 6 hours of life (neonates/infants)?
Murmurs d/t valve problems or shunt lesiosn = atrial and ventricular septal defects (ASDs and VSDs), patent ducts arteriosis (PDA), peripheral pulmonary stenosis
Murmur of PDA
- location
- characterization
Location to hear PDA: upper left sternal border
Character: crescendo-decrescendo; rough MACHINE-LIKE murmur
In infants with large left-to-right shunt what type of murmur might present and where might you hear it?
- Murmur that is like a mitral stenosis
- will present as diastolic rumble at apex
- caused by increased volume transversing mitral valve
In children, how is S2 affected by a persistent, large PDA and elevated pulmonary artery pressure?
S2 is LOUD and SINGLE and there might not be any audible murmur
What type of murmur is this:
- in a newborn with low Apgar score
- transient papillary muscle dysfunction d/t birth asphyxia
- also assoc with pulmonary atresia and Ebstein’s anomaly
Tricuspid regurg
- best heard at left lower stenral border; holosystolic; blowing
- Ebstein’s anomaly: rare heart defect in which the tricuspid valve doesn’t work properly
Compare characterization of small, muscular VSD to membranous, malalignment, or moderate/large muscular VSD
Small muscular = high frequency, short systolic murmur
Membranous/large VSD = holosystolic harsh murmur
