Approach to Cardiac Murmurs and Sounds

Question 1

Which heart sounds are pathological in adults?

Answer 1

S3 & S4

Question 2

What does S3 correspond to?

Answer 2

abrupt deceleration of inflow across mitral valve

Question 3

What does S4 correspond to?

Answer 3

due to increased left ventricular end diastolic stiffness which decreases compliance

Question 4

What is systole?

Answer 4

period of ventricular contraction

Question 5

What is diastole?

Answer 5

period of ventricular relaxation

Question 6

What does S1 correspond to?

Answer 6

closure of mitral valve

Question 7

What does S2 correspond to?

Answer 7

aortic valve closure (when another diastole begins)

Question 8

What causes wide physiologic splitting of S2?

Answer 8

delayed closure of pulmonic valve (pulmonic stenosis or R bundle branch blockk) or early closure of aortic valve (mitral regurgitation)

Question 9

What causes fixed splitting of S2?

Answer 9

prolonged RV systole seen in atrial septal defect & RV failure

Question 10

What causes paradoxical or reversed splitting?

Answer 10

closure of aortic valve is abnormally delayed so that A2 follows P2 in expiration

due to L bundle branch block

Question 11

Early systolic ejection sounds

Answer 11

after S1 w/ pathologic halting of aortic & pulmonic valves as open in early systole

Question 12

Where will S2 be louder than S1?

Answer 12

@ L upper sternal border

Question 13

Where will S1 be louder than S2?

Answer 13

apex of heart (point of maximal impulse)

Question 14

PMI

Answer 14

diameter should be 1 to 2.5 cm

Question 15

What does an abnormal PMI indicate?

Answer 15

PMI is >2.5 cm evidence of LV hypertrophy from hypertension or aortic stenosis

Question 16

Why may PMI not be @ apex of LV?

Answer 16

COPD

Question 17

What does displacement of PMI lateral to midclavicular line indicate?

Answer 17

LV hypertrophy, ventricular dilation from MI or heart failure

Question 18

What is systolic heart failure?

Answer 18

lack of ventricular contraction

Question 19

What is diastolic heart failure?

Answer 19

lack of ventricular relaxation (increased resistance)

Question 20

Early sounds in diastole

Answer 20

S3, S4 or opening snap

note location, timing, intensity & pitch

Question 21

Systolic & diastolic murmurs

Answer 21

murmurs are differentiated from SI, S2 & extra sounds by longer duration

Question 22

Systolic murmurs

Answer 22

aortic stenosis
aortic sclerosis
innocent murmur
hypertrophic cardiomyopathy
VSD
tricuspid regurgitation
mitral valve prolapse
mitral insufficiency

Question 23

Diastolic murmurs

Answer 23

aortic insufficiency
pulmonic regurgitation
mitral stenosis
tricuspid stenosis

Question 24

Where would you hear tricuspid stenosis?

Answer 24

left lower sternal border

Question 25

Where would you hear mitral stenosis?

Answer 25

right lower sternal border

Question 26

Where would you hear pulmonic regurgitation?

Answer 26

left upper sternal border

Question 27

Where would you hear aortic insufficiency?

Answer 27

right upper or left midsternal border

Question 28

Systolic clicks

Answer 28

caused by mitral valve prolapse

mid or late systole

Question 29

What positions do you use to assess a systolic click?

Answer 29

when squatting-click is single @ lower L sternal border (moves extra click closer to S2)

when standing-moves extra click closer to S1

Question 30

When does an opening snap occur?

Answer 30

right after S2 (early diastolic sound caused by abrupt deceleration during opening of a stenotic mitral valve)

Question 31

Where is an opening snap best heart?

Answer 31

medial to apex & along lower L sternal border

Question 32

When does S3 sound occur?

Where do you listen for S3?

Answer 32

occurs after S2

Left sided S3 heard @ apex & R sided S3 heard along lower left sternal border

Question 33

When does S4 sound occur?

Where do you listen for S4?

Answer 33

S4 occurs right before S1

listen @ lower L sternal border for R ventricular S4

listen @ apex for L ventricular S4

Question 34

Why does changing pt position affect mid-systolic murmurs?

Answer 34

decrease intensity b/c reduce LV volume

Question 35

Midsystolic murmur

Answer 35

begins after S1 & stops before S2

Question 36

Pansystolic murmur

Answer 36

starts w/ S1 & stops @ S2 (no gap btween murmur & heart sounds)

Question 37

Late systolic murmur

Answer 37

starts in mid systole & persists up to S2

Question 38

Early diastolic murmur

Answer 38

starts right after S2 & fades into silence before next S1

Question 39

Mid-diastolic murmur

Answer 39

starts after S2 & fades out

Question 40

Late diastolic murmur

Answer 40

starts late in diastole & typically continues up to S1

Question 41

Aortic Stenosis

Answer 41

heard in 2nd-3rd intercostal spaces

assoc w/ reduced carotid pulse

Question 42

Aortic sclerosis

Answer 42

heard in 2nd-3rd intercostal spaces (R upper sternal border)

normal carotid pulse

Question 43

Hypertrophic cardiomyopathy

Answer 43

L upper sternal border

sound decreases w/ squatting (increases venous return)

Question 44

Pulmonic stenosis

Answer 44

heard in 2nd-3rd L intercostal spaces

medium & crescendo pitch

Question 45

Tricuspid regurgitation

Answer 45

heard along L lower sternal border & increase intensity in inspiration

Question 46

Mitral Valve prolapse

Answer 46

heard @ L midclavicular line

systolic click present (right before S1)

Question 47

Mitral valve insufficiency

Answer 47

Holosystolic murmur (same intensity from S1 to S2)

heard @ L midclavicular line