Bates Flashcards
What makes up the physiologic splitting of S2?
A2 = aortic valve closure P2 = pulmonic valve closure
Which sound do you hear first in splitting of S2?
A2
When are you more likely to hear a split S2?
During inspiration when the right heart filling time is increased
During the splitting of S2, which sound is louder?
A2
Where should you listen to hear splitting of S2?
2nd and 3rd left left interspace close to the sternum
What causes S3?
A pathologic change in ventricular compliance; An abrupt deceleration of inflow across the mitral valve (dilated heart from too much volume)
What causes S4?
Increased left ventricular and diastolic stiffness that decreases compliance
What causes the “opening snap” of mitral valve stenosis?
The mitral valve leaflet motion is restricted, so when it opens you can hear it
S4 marks ____ contraction and comes right before S1
Atrial
Where would you hear a mitral regurgitation murmur?
At the apex
Where does a mitral regurgitation murmur radiant toe?
The left axilla
Does a mitral regurgitation murmur become louder with inspiration?
No!
Where do you listen to hear a tricuspid regurgitation murmur?
Lower left sternal border
Where does a tricuspid regurgitation murmur radiate to?
Right of the sternum, to the xiphoid area, and to the midclavicular line, but NOT into the axilla
Does the intensity of tricuspid regurgitation increase with inspiration?
Yes
Where will you hear a ventricular septal defect?
3rd, 4th, and 5th left ICS
Where will you hear an innocent/physiologic murmur?
2nd to 4th ICS between the left sternal border and the apex
Will an innocent/physiologic murmur radiate?
A little
What will cause an innocent murmur to disappear or decrease?
Sitting
Where would you hear aortic stenosis
Right 2nd ICS
Where does aortic stenosis radiate to?
Often to BOTH carotids, down the left sternal border and to the apex
What will help you to hear an aortic stenosis murmur better?
Have the patient sit and lean forward!
Where will you hear a pathologic murmur of hypertrophic cardiomyopathy?
3rd and 4th ICS
Where does a hypertrophic cardiomyopathy murmur radiate?
Down the left sternal border to the apex, possibly to the base, but NOT to the neck
What causes the pathologic murmur of hypertrophic cardiomyopathy to decrease?
Squatting!!***
What causes the pathologic murmur of hypertrophic cardiomyopathy to increase?
Straining down from Valsalva and standing
Where will you hear a pulmonic stenosis murmur?
2nd and 3rd left interspaces
Where will a pulmonic stenosis murmur radiate?
Toward the left shoulder and neck (if loud)
So if you haven’t noticed pulmonic stenosis and aortic stenosis sound VERY similar, so how do you tell the difference?
The areas where you listen
Pulmonic = Left 2nd and 3rd ICS
Aortic = Right 2nd ICS
The radiation
Pulmonic = left shoulder and neck
Aortic = Carotids and down left sternal border
Splitting of S2
Pulmonic will have a decreased P2 sound if split
Aortic will have a decreased A2 sound if split
And you are going to hear an aortic stenosis murmur better when the patient is SITTING FORWARD!
Where are you going to hear an aortic regurgitation murmur?
2nd and 4th ICS
Where is an aortic regurgitation murmur going to radiate?
To the apex and maybe right sternal border
What is the pitch of an aortic regurgitation murmur?
High … USE THE DIAPHRAGM
Blowing decrescendo; may be mistaken for breath sounds
Aortic regurgitation
How should the patient be positioned if you are listening for an aortic regurgitation murmur? What do you listen with?
Sitting and leaning forward with a breath held after exhalation
Listen with the diaphragm!
Where is the location of mitral stenosis usually limited to?
The apex
How should the patient be positioned to listen to a mitral stenosis murmur? What should you listen with?
Lateral decubitus - heard better w/ exhalation
Listen with the BELL!
If your patient reports having chest pain, what could be going on?
Angina
Myocardial infarction
Aortic dissection
Pulmonary embolus
An “irregularly irregular” heart palpitation could be?
Afib
If your patient says their heart beat “skips and flops” it could be?
Premature contractions
If your patient says their heart beat is regular and then speeds up and then slows down again, it could be?
PSVT
If your patients heart rate is regular and rapid, it could be?
Sinus tachycardia
When does “sudden” dyspnea occur?
Pulmonary embolus
Spontaneous pneumothorax
Anxiety
When does exertional dyspnea occur?
Heart failure and other cardiac and pulmonary problems
What disorders might your patient have if they are complaining of orthopnea, or dyspnea that occurs when they are lying down and gets better when they sit up?
LVH
Mitral stenosis
What is the type of dyspnea that will wake a patient up from sleeping 1-2 hours after going to bed, and what is it associated with?
Paroxysmal nocturnal dyspnea
LVH
Mitral stenosis
What is dependent edema, edema in the lowest body parts, typically caused by?
Heart failure
Ascites is usually caused by?
Liver failure
Pain or cramping in the legs during exertion that is relieved by rest within 10 minutes is called? what is it associated with?
Intermittent claudication
Atherosclerotic peripheral artery disease
What could cause abdominal, flank, or back pain?
An expanding hematoma from an abdominal aortic aneurysm
Coldness, numbness, or pallor in the legs with loss of hair over the anterior tibial surfaces could be?
Decreased ARTERIAL perfusion
Could get dry or brown-black ulcers from gangrene
What could be two causes of swelling in the calves, legs, or feet?
Pitting edema
Chronic venous insufficiency
How do you tell the difference between pitting edema and chronic venous insufficiency?
Chronic venous insufficiency will have “brawny changes” and skin thickening, especially near the ankle
Ulceration is common with chronic venous insufficiency; will have a brownish pigmentation
When the rhythm of the pulse remains regular, but the force of the arterial pulse alternates because of strong and weak ventricular contractions; alternately loud and soft Korotkoff sounds
Pulsus alterans
What does pulsus alterans usually indicate?
Severe left sided heart failure
An abnormally large drop in systolic pressure during inspiration. Should normally be 3-4mmHg, but when it is greater than a 10mmHg drop it is??
Paradoxical pulse
Paradoxical pulse should make you consider??
Pericardial tamponade
Constrictive pericarditis
Humming vibrations when you palpate the carotid artery
Thrills
A murmur like sound arising from turbulent arterial blood flow
Bruits
If your patient has a thrill on palpation or a bruit on auscultation, what does this mean?
They could likely have atherosclerotic narrowing of the carotid artery, but could also be from external carotid artery disease or aortic stenosis
Where will you hear a venous hum?
Above the medial third of the clavicles especially on the right
Where will a venous hum radiate to?
1st and 2nd ICS
What will help you hear a venous hum?
Auscultating with the BELL
Where is a pericardial friction rub best heard?
3rd ICS to the left of the sternum
What may increase the intensity of a pericardial friction rub?
When the patient leans forward, exhales, and holds their breath
What does a pericardial friction rub sound like? is it high or low pitched?
Scratchy, scraping sound that is high pitched
Pericardial friction rub is associated with??
Pericarditis!
Where will you hear patent ductus arteriosus best?
2nd left ICS
Produced from a congenital abnormality in which an open channel persists between the aorta and pulmonary artery
Patent ductus arteriosus
Benign sound produced by turbulence of blood in the jugular veins, common in children
Venous hum
What is the starting point for assessing JVP?
Head of bed at 30 degrees
What is an above normal JVP?
Greater than 3-4cm above the sternal angle OR 8-9cm above the right atrium
An above normal JVP is 98% specific for??
Increased left ventricular end diastolic pressure and low left ventricular ejection fraction
An above normal JVP increases a persons risk for?
Death from heart failure
What else is an elevated JVP associated with?
Acute and chronic right and left sided heart failure Tricuspid stenosis Chronic pulmonary HTN Cardiac tamponade Pericarditis
