Auscultation

Question 1

Upper left sternal edge

Normal

Answer 1

Splitting of S2 with INHALATION (A,P)
-drops pressure in chest so more blood to right heart, delaying pulmonary closure, some blood pools in lungs so less to left ventricle so aortic sound earlier

Diaphragm of stethoscope

Question 2

ASD effect on S2

Answer 2

Fixed split, never varies

Question 3

Delayed left side ejection

Answer 3

Paradoxic splitting

S2 split on EXPIRATION

Question 4

Abnormalities in loudness of S2 splitting

Answer 4

Normal: A louder than P
Increased in HTN
Decreased in valve immobility

Question 5

Lower left sternal edge

Normal

Answer 5

Splitting of S1
Asynchronous mitral then tricuspid closure

Both high frequency

Question 6

Pathological Wide S1 splitting

Answer 6

Delayed tricuspid closure seen in RBBB

Question 7

S3
At apex (L)
With Bell

Answer 7

Filling sound- low frequency with bell
Maybe left lateral decubitus position
Early diastolic
Augment with INSPIRATION

Normal in children
Patho: stiff LV

Question 8

S4

Apex with bell

Answer 8

Filling sound- low frequency
Atrial kick

Late diastole

Question 9

Differentiate split S1 from S4

Answer 9

Left lateral decubitus position
Bell at apex- low frequency S4
Diaphragm at apex- high frequency S1- closer together

Question 10

Mid systolic click

Answer 10

Apex with diaphragm
Mid systole
High frequency

Luptttdup
MVP- like parachute reaching full expansion

Question 11

Innocent murmurs

Upper left sternal edge diaphragm

Answer 11

Across pulmonary outflow tract of young person with vigorous circulation
Early in systole (due to turbulence alone)
Crescendo-decrescendo,short

Lubshhhhdub

Also normal S2 splitting (inhale)

Question 12

4 descriptors of murmurs

Answer 12

Location
Timing
Contour
Frequency

Question 13

Mitral regurg

Answer 13

Apex with diaphragm
High frequency- plateau shaped
Radiates to axilla
Throughout all of systole- holosystolic
Shhhhhhh

Question 14

MVP

Answer 14

Apex with diaphragm
Mid systolic click- crescendo high frequency murmur

Lubsquueeee

Question 15

Aortic stenosis

Answer 15

Systole, crescendo-decrescendo 
Slow rising carotid artery
Upper right sternal edge with diaphragm
Mid frequency, long murmur
Sustained apical impulse, may have thrill

Uurrrrgggg (groaning)

Question 16

Aortic regurg

Answer 16

Diastolic (between A2 and S1)
diaphragm high frequency
Lower left sternal edge
Decrescendo, long murmur

Lubcuuuu

Question 17

Mitral stenosis

Answer 17

Diastole
Rumbling, low frequency murmur
Apex with bell
Long murmur- worse stenosis
Impulse at parasternal edge

Rrrrrupiter

Question 18

Continuous murmur

Answer 18

Through S2, systolic and diastolic

Upper left sternal border

Patent ductus arteriosus

Question 19

Tricuspid regurg

Answer 19

Lower left sternal edge with diaphragm
Augmented during INSPIRATION
More blood to right heart during inspiration
Holosystolic, high frequency

Question 20

Pericardial rub

Answer 20

Between and apex Lower left sternal edge with diaphragm
Leaning forward
Chhh chhhh chhhh (scratchy)
Systole, late systolic, early diastole

Question 21

Upper right sternal edge

Normal

Answer 21

Single s1, s2

S2 louder than s1