Cardiac Auscultation

Question 1

what does splitting of s1 tell you?

Answer 1

RBBB or ASD without Eisenmenger’s physiology

Question 2

what causes reversed splitting?

Answer 2

LBBB or aortic stenosis

Question 3

where is splitting of S2 heard the best?

Answer 3

LUSB

Question 4

what causes normal splitting of S2 during inspiration?

Answer 4

increased systemic venous return, increased pulmonary vascular bed capacitance, decreased pulmonary venous impedence

Question 5

what causes wide physiological splitting during expiration

Answer 5

RBBB, pulmonic stenosis, pulmonic hypertension, ASD

Question 6

what causes narrow splitting?

Answer 6

tricuspid regurgitation - early P2
pulmonary hypertension - early P2
aortic stenosis - late A2
peripheral vascular shunt - late A2
PDA - late A2

Question 7

what does 24 suggest?

Answer 7

hypertensive heart disease, hypertrophic cardiomyopathy or acute MI

Question 8

what does the opening snap tell you?

Answer 8

rheumatic or congential valvular disease

mitral stenosis

Question 9

what abnormality does S3 suggest?

Answer 9

CHF with increased L heart pressure

AV valve regurgitation

Question 10

where do you hear aortic ejection sounds?

Answer 10

base –> apex

Question 11

what do you hear with mitral valve prolapse?

Answer 11

midsystolic click at apex or LLSB
occurs earlier with decreased preload (standing)
occurs later with increased preload (squatting)

Question 12

what causes valvular clicks?

Answer 12

congenitally deformed or bicuspid valves due to tensing of deformed valve leaflets

Question 13

what causes diastolic murmurs?

Answer 13

turbulent anterograde flow across mitral or tricuspid
retrograde across aortic or pulmonic valves
*pathologic

Question 14

what are symptoms of mitral stenosis?

Answer 14

first left then right sided heart failure

Question 15

what causes systolic ejection murmurs?

Answer 15

turbulent flow across aortic or pumonic tracts. they are separated from S1 by isovolumic contraction

Question 16

what is an austin flint murmur

Answer 16

physiologic impingement of mitral valve, diastolic excursion by severe aortic regurgitation

Question 17

physical findings of mitral stenosis?

Answer 17

loud s1, OS, diastolic rumble (left lateral decubitus position)

Question 18

what are symptoms of left sided heart failure?

Answer 18

exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea

Question 19

what causes continuous murmur?

Answer 19

PDA or benign cervical venous hum (children, pregnant women, ends with compressing of JVP) or mammary souffle (terminated by pressing diaphragm against chest wall)

Question 20

how do you diagnose hypertrophic obstructive cardiomyopathy?

Answer 20

thick septum causes abnormal motion of anterior mitral valve
late peaking SEM at LLSB
S4
pansystolic murmur regurgitation –> abnormal coaption

Question 21

what is a diastolic rumble?

Answer 21

anterograde flow across stenotic mitral or tricuspid valve best heard at LLSB and apex, beginning immediately after S2 until S1

Question 22

what are physical findings of mitral regurgitation?

Answer 22

holosystolic murmur at apex

accentuated murmur with fist clenching

Question 23

how do you diagnose an ASD?

Answer 23

L–>R flow increased anterograde flow across tricuspid and pulmonic valves, early peaking SEM at LUSB
diastolic flow murmur across tricuspid if shunt is large
wide fixed splitting of S2 –> increased forward SV across pulmonic valve and decreased impedence in pulmonary vascular bed
rule out pulmonary hypertension

Question 24

what are physical findings associated with aortic regurgitation?

Answer 24

wide pulse pressure
bounding pulses
early diastolic decrescendo murmur

Question 25

what are causes of aortic stenosis?

Answer 25

degenerative calcific
congenital
rheumatic

Question 26

what are causes of mitral regurgitation

Answer 26

acute: endocarditis, ruptured chordae, papillary muslce, dysfunction
chronic: rheumatic, mitral prolapse, calcified annulus, LV dilation

Question 27

what are causes of aortic regurgitation?

Answer 27

congenital, endocarditis, rheumatic, aortic root dilation

Question 28

what are physical findings associated with aortic stenosis?

Answer 28

SEM at RUSB
carotids: delayed upstroke and decreased volume
palpation: suprasternal thrill
soft A2

Question 29

what are symptoms of rights sided heart failure?

Answer 29

peripheral edema, abdominal bloating, right upper quadrant tenderness (hepatic enlargement)

Question 30

what are symptoms of mitral regurgitation?

Answer 30

acute: pulmonary edema
chronic: symptoms of left heart failure and low CO (fatigue)

Question 31

how do you diagnose an innocent murmur?

Answer 31

cresc-decres
grade <3
ends before S2 with normal splitting of S2
absence of systolic or diastolic ejection sounds
absence of conditions like anemia, thyrotoxicosis
exclude: aortic/pulmonic stenosis, high flow states like ASD

Question 32

what causes holo or pansystolic murmurs

Answer 32

mitral or tricuspid regurgitation
VSD
increased intensity with severity
described as blowing