BATES

Question 1

How is S3 associated with heart failure in adults over age 40?

Answer 1

S3 corresponds to an abrupt deceleration of inflow across the mitral valve

Question 2

How is S4 associated with heart failure in adults over age 40?

Answer 2

S4 corresponds to increased left ventricular and diastolic stiffness which decreases compliance

Question 3

When does the aortic valve shut?

Answer 3

when LV pressure drops below aortic pressure

Question 4

What happens during inspiration to the heart and how does it affect S2?

Answer 4

The right heart filling time is increased- increases the duration of right ventricular ejection compared to the left ventricle. This delays the closure of the pulmonic valve, splitting S2
Distensibility of venous system from the pulmonary vascular bed contribute to the hangout time of P2.

Question 5

Of the 2 components of S2, which is louder?

Answer 5

Aortic valve (A2)

Question 6

Where is S1 in a EKG?

Answer 6

R of QRS wave

Question 7

Where is S2 in a EKG?

Answer 7

End of T wave

Question 8

Where is S3 in a EKG?

Answer 8

Between the T and P waves

Question 9

Where is S4 in a EKG?

Answer 9

Q or QRS

Question 10

Preload

Answer 10

The load the stretches the cardiac muscle before contraction. The volume of blood in the RV at the end of diastole constitutes its preload for the next beat.

Increased by increasing venous return to the right heart

Question 11

Causes of decreased preload

Answer 11

• Exhalation
• Decreased LV output
• Pooling of blood in the capillary bed or the venous sytem

Question 12

myocardial contractility

Answer 12

The ability of the cardiac muscle, when given a load, to shorten

Question 13

Afterload

Answer 13

The degree of vascular resistance to ventricular contraction

Question 14

Sources of resistance to LV contraction

Answer 14

• Tone in the walls of the aorta
• Large arteries
• Peripheral vascular tree (small arteries and arterioles)
• Volume of blood already in the aorta

Question 15

Why is the term heart failure now preferred over congestive heart failure?

Answer 15

Not all pts have volume overload on initial presentation

Question 16

How to correctly identify S1 and S2

Answer 16

keep fingers on the right carotid artery.
S1 is just before the carotid upstroke
S2 is after the carotid upstroke

Question 17

What is the diaphragm better at listening for?

Answer 17

High pitched sounds

• S1 and S2, murmurs of aortic and mtiral regurg
• Pericardial friction rubs

Question 18

What is the bell better at listening for?

Answer 18

Low pitched sounds

• S3 and S4
• Mitral stenosis

Question 19

What position accentuate S3, S4, and mitral stenosis?

Answer 19

Left lateral decubitus

Question 20

What position accenuates aortic murmurs?

Answer 20

When the pt sits up, leans forward, exhales completely, and stop breathing in exhalation

Question 21

When is S1 louder?

Answer 21

At more rapid heart beats

Question 22

When is S2 persistently single?

Answer 22

When either A2 or P2 is absent

Question 23

What causes persistent splitting?

Answer 23

Delayed closure of the pulmonic valve or early closure of the aortic valve

Question 24

What does a loud P2 suggest?

Answer 24

Pulmonary HTN

Question 25

Murmurs during pregnancy

Answer 25

Should promptly be evaluated for possible risk to the pregnancy and the need for termination, especially from aortic stenosis and pulmonary HTN

Question 26

When do midsystolic murmurs typically arise?

Answer 26

From blood flow across the semilunar (aortic and pulmonic) valves

Question 27

When do pansystolic murmurs occur?

Answer 27

With regurgitant flow across the atrioventricular valves

Question 28

Late systolic murmur

Answer 28

Mitral valve prolapse

Question 29

What murmurs reflect turbulent flow across the AV vales?

Answer 29

middiastolic and presystolic murmurs

Question 30

What produces continuous murmurs?

Answer 30

PDA and AV fistulas, common in dialysis pts.
Neither is valvular in origin

Venous hums and and friction rubs also have systolic and diastolic components

Question 31

Functional murmurs

Answer 31

Short, early, midsystolic murmurs that decrease in intensity with maneuvers that reduce LV volume, such as standing, sitting up.

Often heard in healthy pts and not pathologic

Question 32

Procedure of valsalva identifying heart failure and pulmonary htn

Answer 32

Inflate the blood pressure cuff 15 mm Hg greater than the systolic BP and have pt Valsalva for 10 sec, then resume normal breathing. Keep cuff locked.
Listen for Korotkoff sounds over the brachial artery throughout

In pts with severe heart failure, Korotkoff sounds are heard during phase 2 strain phase, but not during the phase 4 release- the square root response
This response is highly correlated with volume overload and elevated left ventricular end diastolic pressure and pulmonary capillary wedge pressure

Question 33

Where is S1 softer than S2?

Answer 33

At the base

Question 34

When is S1 louder than S2?

Answer 34

At the apex

Question 35

Diminished S1

Answer 35

• First degree heart block
• When the mitral valve is calcified and immobile
• When LV contractility is reduced

Question 36

Varying S1

Answer 36

• Complete heart block

- Irregular rhythm

Question 37

Wide splitting of S2

Answer 37

Delayed closure of the pulmonic valve- pulmonic stenosis or RBBB

Question 38

Fixed splitting

Answer 38

Wide splitting that doesn’t vary with respiration

• Atrial septal defect
• RV failure

Question 39

Paradoxical or reversed splitting

Answer 39

Splitting that occurs on expiration. Closure of the aortic valve is abnormally delayed so that A2 follows P2

Question 40

Increased intensity of A2 in the right 2nd ICS

Answer 40

Systemic htn

Aortic root dilation

Question 41

Decreased or absent A2

Answer 41

calcific aortic stenosis

Question 42

Increased intensity of P2

Answer 42

Pulmonary HTN
Dilated pulmonary artery
ASD

Question 43

Decreased or absent P2

Answer 43

Increased anterioposterior diameter of the chest associated with aging
- Pulmonic stenosis