Auscultation: Just the Words

Question 1

• Systolic, from S1 to S2
• Loudest at the Apex
• Holosystolic, high-pitched “blowing murmur” of constant intensity from S1 to S2
• Enhanced by Hand grip and squating - manuevers that increase vascular resistance
• A/w Ischemic Heart Disease, MVP, Rheumatic fever, infective endocarditis, or LV dilation

Answer 1

Mitral Regurgitation

Question 2

• Systolic - from S1 to S2
• Loudest at the 4th Left intercostal space
• Pansystolic sound radiates toward the Left upper sternal border
• Enhanced by Inspiration; manuevers that increase Right Atrial (RA) return
• A/w RV dilation, Rheumatic fever heart disease, Infective Endocarditis, and Ebstein’s anomoly

Answer 2

Tricuspid Regurgitation

Ebstein’s Anomoly

Question 3

• Systolic
• Loudest at the 2nd Right intercostal space w/ the pt. sitting up and leaning forward
• Crescendo-decresendo systolic ejection murmur, diamond peaking between S1 and S2
• *Decreases *with Hand grip manuever or Valsalva
• Sound radiates to carotids “Pulsus parvus et tardus”
• P/w Syncope, Angina, Dyspnea
• A/w Age-related calcification stenosis, bicuspid vavles

Answer 3

Aortic Stenosis

Question 4

• Systolic
• Loudest at the 4th Left intercostal space
• Harsh holosystolic sounding murmur from S1 to S2
• Enhanced by Hand grip manuevers

Answer 4

Ventricular Septal Defect

Question 5

• Systolic
• Loudest at the Apex
• Late systolic crescendo murmur that begins with a midsystolic click and gets louder toward S2
• The click can be heard throughout the precordium
• Shifting from Standing to Squating, Hand grip, or Valsalve causes the midsystolic click to move later during systole

Answer 5

Mitral Valve Prolapse

Question 6

• Diastolic
• Loudest at the Left Sternal boarder or 2nd Left Intercostal space with the pt. leaning forward
• High-pitched “blowing” murmur following S2 w/ early diastolic decrescendo
• Enhanced during Hand grip manuever
• P/w Bounding pulses, head bobbing
• A/w Aortic root dilation, Bicuspid aortic valve, Endocarditis, or Rheumatic fever

Answer 6

Aortic Regurgitation

Question 7

• Diastolic
• Loudest at the Apex w/ the pt. in the lateral decubitus position
• Low-pitched decresendo delayed rumbling murmur with a possible Opening Snap after S2
• Enhanced by expiration or manuevers that increase LA return
• The longer it is delayed after S2 the more serious
• A/w Rheumatic fever, LA dilation

Answer 7

Mitral Stenosis

Question 8

• Systolic and Dyastolic (continuous)
• Loudest at the 2nd Left intercostal space
• A continuous “machine-like’ murmur that gets louder at S2 and decresendos, after S1 it cresendos up to S2
• A/w Congenital Rubella or Prematurity

Answer 8

Patent Ductus Arteriosus (PDA)

Question 9

• Systolic
• Loudest at the 2nd Left and 2nd Right intercostal space
• High frequency vibrations between S1 and S2 of Aortic or Pulmonic origin, sounds like turbulence
• A/w aging and if heard at the 2nd Right intercostal space an Aortic Aneurysm should be suspected

Answer 9

Innocent Systolic Murmur

Question 10

• Diastolic (late)
• Loudest at the Apex with the pt. in the lateral decubitus position w/ the Bell of the stethoscope and also sitting
• Sounds like a double beat at S1 or “atrial-kick”
• A/w a stiff ventricle, Ventricular Hypertophy, High Atrial Pressure

Answer 10

4th Heart Sound

Question 11

• Diastolic
• Loudest at the Apex with the pt. in the lateral decubitus position w/ the Bell of the stethoscope and also sitting
• Sounds like a double beat at S2, and may be palapable at the Apex
• A/w increased filling pressures such as Mitral regurgitation, CHF, Dilated Ventricles, is considered normal in children and prenant women

Answer 11

3rd Heart Sound

Question 12

• Diastolic
• Loudest at the Apex with the pt. in the lateral decubitus position w/ the Bell of the stethoscope and also sitting
• Quadruple rhythm at S1 and S2 at HR < 90 BPM
• May sound like 3 beats at HR > 90 BPM
• Palpate the carotid pulse to determine systole
• A/w Dilated cardiomyopathy, Ischemic cardiomyopathy, Left Ventricular aneurysm

Answer 12

Quadruple Rhythm

3rd and 4th Heart Sounds

Question 13

• Systolic
• Loudest at the Apex and across the precordium
• Sounds like a High-pitched click following S1 and may have increased Aortic regurgitation
• A/w Aortic stenosis of the bicuspid valve and age related calcification, wear and tear in pt. 40 - 70 y.o.

Answer 13

Bicuspid Aortic Valve

Question 14

• Systolic
• Loudest at the 4th Left Intercostal space but radiates across the precordium
• Harsh blowing sound between S1 and S2
• Decreases with Hand grip and Valsalva manuevers or manuevers that increase Afterload
• A/w Autosomal Dominant, Thickening of the Septum, Obstruction of Mitral valve, Syncope, and Sudden Cardiac Death

Answer 14

Hypertrophic Cardiomyopathy

Question 15

• Systolic flow murmur with a Split 2nd Diastolic sound
• Loudest at the 2nd Left intercostal space w/ the pt. sitting
• The sound is heard moving across the atria witha Wide splitting second heart sound due to delayed right ventricular ejection
• A/w Right heart failure
• T/w Percutaneous closure of the defect

Answer 15

Atrial Septal Defect (ASD)

Question 16

• Systolic and Diastolic (continous)
• Loudest at 2nd Left intercostal space with the pt. sitting up and leaning forward
• Sounds like a two component continous wish-washing sound
• Inflammed surfaces rubbing together the heart sounds may sound distant or muffled
• A/w Viral pericarditis, Endocarditis, SLE

Answer 16

Pericardial Friction Rub

Question 17

• Systolic
• Loudest at the 3rd or 4th Left intercostal space
• Sounds like a mild turbulence between S1 and S2 or a long wooshing S1 sound
• A/w Cyanosis, Blue-baby, Sudden Cardiac Death
• Tx: Surgical repair

Answer 17

Tetrology of Fallot