Auscultation / Murmurs Flashcards
What murmur is heard in the aortic area / base of heart?
aortic stenosis
What type of murmur is aortic stenosis?
systolic murmur
Which murmurs are found in the pulmonic area?
ASD and pulmonic stenosis
What type of murmur is ASD?
systolic murmur
What diastolic murmurs are found at left sternal border?
aortic regurgitation
pulmonic regurgitation
What systolic murmurs are found at left sternal border?
HCM
What holosystolic murmurs are found in tricuspid area?
tricuspid regurgitation
VSD
What diastolic murmur is found in tricuspid area?
tricuspid stenosis
What holosystolic murmur is found at apex?
mitral regurgitation
sometimes this is just described as systolic
What systolic murmur is found at apex?
MVP
What diastolic murmur is found at apex?
mitral stenosis
Which murmur is crescendo-decrescendo?
aortic stenosis
What happens to heart sounds as aortic stenosis worsens?
crescendo-decrescendo moves later in systole
S2 heart sound becomes inaudible
Why does the crescendo-decrescendo move later in systole in worsening AS?
because as aortic stenosis worsens, it takes longer for blood to push out and lengthens time
Which murmur has an opening click followed by late systole murmur?
MVP
What moves the MVP murmur earlier?
decreased preload = earlier MVP
What moves the MVP murmur later?
increased preload = later MVP
Difference between S3 and S4
S3 = early diastole and due to rapid ventricular filling. Indicates increased LAP
S4 = late diastole and due to blood hitting a stiff LV wall. Can be due to longstanding HTN or HCM
Which heart sound S3 or S4 can healthy people have?
S3
“Young female, otherwise healthy” indicates what condition? What murmur should you check for? Where should you listen?
MVP
opening click with late systolic murmur
listen at apex
“Healthy young athlete with syncope” indicates what condition? What murmur should you check for? Where should you listen?
HCM
systolic murmur
listen at left sternal border
“Immigrant or pregnant” indicates what condition? What murmur should you check for? Where should you listen?
mitral stenosis
diastolic murmur with opening snap
listen at apex
“IV drug abuser” indicates what condition? What murmur should you check for? Where should you listen?
Tricuspid regurgitation
holosystolic murmur
listen at tricuspid area
What two conditions cause holocystolic murmur?
tricuspid regurgitation and mitral regurgitation
(also VSD)
What does increased inspiration cause in regard to heart sounds?
increased negative pressure, so increased venous return
more preload on R side = greater intensity of R sided heart sounds
also causes physiological splitting of S2 as more blood makes PV close after AV
What does hand grip do in general?
increases afterload
What does hand grip do to heart sounds?
increased afterload = more regurgitation, so increases sound of MR, AR and VSD
What does hand grip do to MVP?
increased afterload = later click of MVP
What does hang grip do to HCM?
increase afterload = transient increase in preload, so this will temporarily relieve HCM and decrease murmur
What does hand grip due to aortic stenosis?
increase afterload = decrease aortic stenosis murmur
What do valsava manuevers and standing up do in general?
they decrease preload which decreases intensity of most murmurs
Which murmurs worsen with valsava / standing ?
HCM
decrease preload = less expansion = worse for HCM
What does rapid squatting do in general?
increase preload by squeezing blood from veins to heart
When does rapid squatting increase murmur?
increases most murmurs since there is more preload
When does rapid squatting decrease murmur?
increased preload = better for HCM, decreases murmur
What does rapid squatting due to MVP?
increased preload = later click of MVP
What is another term for persistent splitting?
wide splitting
What is physiological splitting?
on inspiration there is increased R venous return
this increase in blood means PV closes after AV
Persistent / wide S2 splitting
S2 splitting occurs during expiration but is wider during expiration
this indicates a problem with anything that causes delayed conduction down right side (RBBB or pulmonary stenosis)
Fixed S2 splitting
equally large split on inspiration and expiration
caused by ASD
ASD = always have venous return to right side due to the hole in the septum
Paradoxical S2 splitting
during exhalation, AV is delayed in closing
reverse of physiologic splitting
caused by left sided delayed (LBBB, pacemaker, aortic stenosis, HCM)
What does amyl nitrate do in general?
decreases afterload = increased contractility = decreased ESV / preload
Which murmurs are louder with increased afterload?
backwards murmurs: AR, MR and VSD
Which murmurs after lessened by increased preload?
HCM and MVP
What does amyl nitrate do to HCM?
worsens murmur since there is less preload
(through afterload decreasing)
Laplace’s law and when it occurs
states that increased pressure = increased wall thickness
this occurs in AS, since to overcome increased afterload you need increased pressure. This increase in pressure will lead to increased wall thickening
What is the same as a S4 but with palpation?
presystolic heave
What can AS predispose you to?
aortic aneurysm
(monitor the symptoms: syncope, angina, DOE)
When do patients with undiagnosed MS often present?
normally during pregnancy due to increased blood volume and cardiac output
mitral valve cannot keep up with the increase in pressure and CO will not compensate, leads to SOB and pulmonary edema
What relationship is often flawed to cause pathologic results?
CO = HR * SV
(if you can’t keep up, you’re going to have problems)
What does mitral stenosis sound like?
opening snap followed by descendo diastolic murmur
What sound indicates worse mitral stenosis?
less time between A2 and opening click
less time = greater left atrial pressure
Where can you hear systolic murmur at LLSB?
ASD
When does VSD murmur get more high pitched?
smaller hole = more high pitches
What does hand grip do to VSD?
increased afterload = increased strength of murmur
What is associated with ASD in terms of auscultation?
systolic murmur at LLSB
diastolic rumble
tricuspid valve closes harder = increased S1 sound
What is associated with mitral regurgitation in terms of auscultation?
systolic murmur at apex
S3 gallop (if in heart failure with it)
What causes an S3 gallop?
often due to heart failure
indicates increased LAP / rapid ventricular filling
Effects of squatting on mitral regurgitation
squatting causes increased afterload
increased afterload pushes more fluid through regurg
also increased preload = more regurg.
What 2 conditions can cause A2 to come quicker than P2 leading to wide splitting on expiration?
VSD and mitral regurgitation
causes persistent splitting
What 2 conditions can lead to paradoxical split?
anything that causes A2 to consistently come after P2
would occur in: aortic stenosis, LBBB or HCM
What else can cause persistent splitting besides mitral regurg / VSD?
something that persistently causes the P2 sound to come later
this would include: LBBB, pulmonary HTN or pulmonic stenosis
What would an ionotropic agent do to MVP?
ionotropic = increased contractility= decreased ESV
decreased volume = earlier click of MVP
What does amyl nitrite do?
it dilates arteries, so it is primarily concerned with decreasing afterload
however you can think that there is less volume for your OWN understanding … in reality this is not as true
Where is the tricuspid area physiologically?
at the left middle / lower sternal border
What happens to pulse pressure in aortic regurgitation?
decreased pulse pressure in aortic regurg!
Opening click at the beginning of systole that does not move with maneuvers
Bicuspid aortic valve
