Assessment of Heart Sounds and Cardiac murmurs

Question 1

what is significant of an enlarged PMI and when is the PMI not the most prominent precordial impulse

Answer 1

over > 2.5 cm means it is evident of left ventricular hyperotrophy from hypertension or aortic senosis

normal is 1-2.5cm

Not the most PMI in:
-COPD (usually in the xiphoid or epigastric area due to right ventricular hypertrophy)

Question 2

what does it mean if there is displacement of the PMI

Answer 2

displacement of the PMI lateral to the midclavicular line or >10cm lateral to the midsternal line occurs in LVH and also in ventricular dilation from myocardial infarction (MI) or heart failure

Question 3

what age is it when S3 and S4 sounds are patholigic

Answer 3

over the age of 40 years

Question 4

what does the S3 sound correspond with

Answer 4

Corresponds to an abrupt deceleration of inflow across the mitral valve
-usually due to an enlarged wall as part of the obstruction

Question 5

what does the S4 sound correspond with

Answer 5

Due to increased left ventricular end diastolic stiffness which decreases compliance
-increased resistance in openings

Question 6

Systole is the period of ventricular?

Diastole is the period of ventricular?

Answer 6

Systole: contraction
Diastole: relaxation

Question 7

what are the three main causes of a split-S2

Answer 7

Wide physiologic splitting of S2 refers to an increase in the usual splitting of S2 during inspiration that persists through the respiratory cycle
-delayed closure of the Pulmonic valve or early closure of the aortic valve

Fixed splitting refers to wide splitting that does not vary with respiration
-due to right ventricular systole, seen in atrial septal defects and in right ventricular failure

Paradoxical or reversed splitting refers to splitting that appears on expiration and disappears on inspiration
-closure of the aorta valve is abnormally delayed so that A2 follows P2 in expiration and in inspiration they happen at the same time (common in left bundle branch block

Question 8

what are the early systolic ejection sounds

Answer 8

occur shortly after the S1 coincident with sudden pathologic halting of the aortic and pulmonic valves as they open in early systole

• Aortic ejection sound at base and apex, associated with a dilated aorta, aortic valve disease from congenital stenosis or bicuspid valve
• Pumonic ejection sound best heard in 2nd/3rd left interspaces, intensity decreases with inspiration causes are dilation of pulonary artery, pulmonary hypertension, and pulmonic stenosis

Question 9

what are systolic clicks and when can they be heard?

Answer 9

usually caused by mitral valve prolapse, an abnormal systolic ballooning of part of the mitral valve into the left atrium related to leaflet redundancy and elongation of the chordae tendinae
-mid to late systole can hear the clicks

• clicks are normally single but can be more than one, at the medial to the apex but also at the lower sternal border
• often followed by murmur of mitral regurgitation that crescendos up to S2
• squatting will delay the click, due to increased venous return
• standing will move the click closer to the S1

Question 10

what is the opening snap?

Answer 10

very early diastolic sound caused by abrubt deceleration during opening of stenoic mitral valve

best heard medial to the apex along the lower left sternal border, heard with the diaphragm

occurs after S2 and its high pitch and snapping quality make it easy to distinguish from S2

Question 11

what are the causes of an S3

Answer 11

Ventricular gallup

arises from high left ventricular filling pressures and abrupt deceleration of inflow across the mitral valve at the end of the rapid filling phase of diastole

causes: decreased myocardial contractillity,
heart failure,
ventricular volume overload from aortic or mitral regurgitation,
and left to right shunts

sounds like Kentucky

Question 12

what are the causes of an S4

Answer 12

Atrial gallup, occurs before S1

dull and low pitched and is best heard with the bell
-due to ventricular hypertrophy or fibrosis causing stiffness and increased resistance or decreased compliance during ventricular filling following atrial contraction

Causes:

• Hypertensive heart disease
• aortic stenosis
• and ischemic and hypertrophic cardiomyopathy

sounds like Tennessee

Question 13

what is a summation gallop?

Answer 13

it is when a patient has an S3 and a S4

makes a quadruple rhythm

Question 14

List of all the causes of a Systolic murmur

Answer 14

• Aortic stenosis
• Aortic sclerosis (fibrosis of valve, pre-stenosis)
• Innocent benign murmur
• Hypertrophic cardiomyopathy
• Ventral septal defect
• Tricuspid regurgitation
• Mitral valve prolapse
• Mitral insufficiency

Question 15

During systole for mumurs, what can you hear at the right upper sternal border?

Answer 15

Carotid pulse is normal
-aortic sclerosis

Carotid pulse is reduced
-aortic stenosis

Question 16

During systole for murmurs, what can you hear at the left upper sternal border

Answer 16

via changes with squatting:
-no change = innocent benign flow murmur

-Decreases sound: Hypertrophic cardiomyopathy

Question 17

during systole for murmurs, what can you hear at the left lower sternal border

Answer 17

accenuates with inspiration?

• no = VSD
• yes= Tricuspid regurgitation

Question 18

during systole for murmurs, what can hear at the left midclavicular line (cardiac apex)

Answer 18

systolic click w/ or w/o murmur
-Mitral valve prolapse

Holosytolic murmur
-Mitral insufficiency (heard best with bell)

Question 19

What are the Diastolic murmurs

Answer 19

• Aortic insufficiency
• Pilmonic regurgitation
• Mitral stenosis
• Tricuspid stenosis

Question 20

during diasotle for murmurs, what can be heard at the right upper or left midsternal border

Answer 20

aortic insufficiency (heard best with bell)

Question 21

during diastole for murmur, what can be heard at the left upper midsternal border

Answer 21

Pulmonic regurgitation

Question 22

during diastole for murmurs, what can be heard that the right lower sternal border in left lateral decubitus position

Answer 22

Mitral stenosis

Question 23

During diastole for murmurs, what can best be heard at the left lower sternal border

Answer 23

Tricuspid stenosis

Question 24

Mid systolic murmur characterization of length of sound

Answer 24

begins after S1 and stops before S2

gaps are audible between the murmur and the heart sounds

Question 25

Pansystolic (holosystolic) murmur characterization of length of sound

Answer 25

starts with S1 and stops with S2 without a gap between murmur and heart sounds

Question 26

Late systolic murmur characterization of length of sound

Answer 26

usually starts in mid or late systole and persists up to S2

Question 27

characterization of an Early diastolic, middiastolic, and late diastolic murmur

Answer 27

Early diastolic: starts immediately after S2 then will fade before S1 Middiastolic: starts a short time after S2, it may fade away or merge into a late diastolic murmur Late diastolic murmur: starts late in diastole and typically continues up to S1

Question 28

what is a Continuous murmur

Answer 28

Begins in systole and extends into all or part of diastole (but is not necessarily uniform throughout)

Question 29

crescendo, decrescendo, plateu, and crescendo-decresecendo murmur

Answer 29

Crescendo murmur: grows louder Decrescendo murmur: growers softer Crescendo-decrescendo: first rises in intensity and then falls Plateu: has the same intensity throughout

Question 30

Radiation, Location, Intensity, Pitch, Quality, Maneuvers: Aortic stenosis

Answer 30

Decreased S2 Radiation: Often to the carotids, down the left sternal border, even to the apex, If severe, may reduce to left 2nd and 3rd interspaces Location: Right 2nd and 3rd interspaces Intensity: Sometimes soft, but often loud, with a thrill (4/6) Pitch: Medium, harsh; crescendo-decrescendo may be higher at the apex Quality: often harsh, may be more musical at the apex Maneuvers: Heard best with the patient sitting and leaning forward

Question 31

Radiation, Location, Intensity, Pitch, Quality, Maneuvers: Hypertropic cardiomyopathy

Answer 31

Radiation: down the left sternal border to the apex, possibly to the base, but not to the neck Location: Left 3rd and 4th interspaces Intensity: Variavle. see maeuvers Pitch: Medium Quality: Harsh Maneuvers: intensity decreases with squatting and valsava release phase, increases with standing and valsava strain phase

Question 32

Radiation, Location, Intensity, Pitch, Quality, Maneuvers: Pulmonic stenosis

Answer 32

Ejection 1 after S1 Split A2 and P2 Radiation: if loud, toward the left shoulder and neck Location: left 2nd and 3rd interspaces Intensity: soft to loud; if loud, associated with a thrill Pitch: Medium; crescendo-decrescendo Quality: often harsh Maneuvers: N/A

Question 33

Radiation, Location, Intensity, Pitch, Quality, Maneuvers: Mitral regurgitation

Answer 33

S3 heard Radiation: to the left axilla, less often to the left sternal border Location: Apex Intensity: soft to loud; if loud, associated with a apical thrill Pitch: Medium to high Quality: harsh, holosystolic Maneuvers: intensity does not change with inspiration

Question 34

Radiation, Location, Intensity, Pitch, Quality, Maneuvers: Tricuspid regurgitation

Answer 34

S3 heard Radiation: to the right of the sternum, to the xiphoid area, and at times to the left midclavicular line, but not into the axilla Location: Lower left sternal border, if right ventricular pressure is high and the eventricle is enlarged, the murmur may be loudest at the apex and confused with mitral regurgitation Intensity: Variable Pitch: Medium Quality: BLowing holocystolic Maneuvers: intensities increase with inspiration

Question 35

Radiation, Location, Intensity, Pitch, Quality, Maneuvers: Ventricular septal defect

Answer 35

Radiation: often wide, depending on the size of the defect Location: Left 3rd, 4th, and 5th interspaces Intensity: Often very loud, with a thrill. smaller defects have louder murmurs Pitch: High, holosystolic. smaller defects have murmurs with a higher pitch Quality: often harsh Maneuvers: N/A

Question 36

Radiation, Location, Intensity, Pitch, Quality, Maneuvers: Aortic regurgitation

Answer 36

Radiation: if loud, to the apex, perhaps to the right sternal border Location: Left 2nd to 4th interspaces Intensity: grade 1 to 3 Pitch: High, use diaphragm Quality: blowing decrescedno; may be mistaken for breath sounds Maneuvers: the murmur is heard best with the patient sitting and leaning forward, with breath held after exhalation

Question 37

Radiation, Location, Intensity, Pitch, Quality, Maneuvers: Mitral stenosis

Answer 37

Radiation: little or none Location: usually limited to the apex Intensity: grade 1 to 4 Pitch: High, use diaphragm Quality: decrescendo low pitched rumble with pre systolic accentuatuation, use the bell Maneuvers:placing the bell exactly on the apical impulse, turning the patient into a left lateral position and mild excercise like handgrips make the murmur adudible better heard in exhalatation

Question 38

What is the Cardiovascular effect, and effect on mitral vavle prolapse, hypertrophic cardiomyopathy, and aortic stenosis for: Squatting; Valsalva release phase

Answer 38

Cardiovascular effect: increased left ventricular volume from increase venous return to heart -increased vascular tone, increased BP, increased peripheral vascular resistance Mitral valve prolapse effect: decrease prolapse of mitral valve -delay of click and murmur shortens Hypertrophic cardiomyopathy effect: decrease outflow obstruction -decrease intensity of murmur Aortic stenosis effect: Increase in blood volume ejected into aorta -increased intensity of murmur

Question 39

What is the Cardiovascular effect, and effect on mitral vavle prolapse, hypertrophic cardiomyopathy, and aortic stenosis for: Standing Valsalva strain phase

Answer 39

Cardiovascular effect: decreased left ventricular volume from a decrease in venous return to heart -Decrease vascular tone from a decrease in arterial blood pressure Mitral valve prolapse effect: increase prolapse of mitral valve -click moves earlier in systole and murmur lengthens Hypertrophic cardiomyopathy effect: increase in outflow obstruction -increase intensity of murmur Aortic stenosis effect: decrease in blood volume ejected into aorta -decrease in intensity of murmur