Cardiac Auscultation

Question 1

S1

Answer 1

• closure of mitral and tricuspid valves produce S1

- left ventricle starts to contract so mitral valve snaps shut

Question 2

S2

Answer 2

• aortic and pulmonic valve closure produces S2
• end of systole
• ventricular pressure falls below aortic pressure so aortic valve shuts

Question 3

S2 Splitting

Answer 3

• right side events happen slightly later than left events
• first (A2) sound is from left side aortic valve closure
• second (P2) sound is from right side pulmonic valve closure
• at end of inspiration, A2 and P2 separate slightly
• during expiration, A2 and P2 fuse into single sound

Question 4

S3

Answer 4

• occurs just after S2
• usually heard best by the PMI
• Kentucky

Question 5

S4

Answer 5

• occurs just before S1
• usually heard best at PMI in left lateral decubitus position
• Tennessee

Question 6

Potential Causes of S3

Answer 6

• can be normal or physiologic in people under age 40 and is common in 3rd tri of pregnancy
• past 40, is almost always pathologic –> heart failure of volume overload

Question 7

Potential Causes of S4

Answer 7

• thought to be due to stiff myocardium w/ decreased compliance
• may be normal in athletes and elderly
• HTN
• coronary artery dz
• aortic stenosis
• cardiomyopathy

Question 8

When you are feeling the pulse, what are you hearing in the stethoscope simultaneously?

Answer 8

-feeling the pulse happens while you HEAR S1

Question 9

How are murmurs distinguished from heart sounds?

Answer 9

longer duration

Question 10

What are murmurs attributed to?

Answer 10

• turbulent blood flow

- may be innocent/physiologic or pathologic

Question 11

If you hear a murmur, what characteristics should be noted?

Answer 11

• timing, shape
• location of maximal intensity, radiation from this location
• intensity, pitch, quality

Question 12

Murmur Shape

Answer 12

-shape or configuration is determined by the murmur’s intensity over time

Question 13

Crescendo Murmur

Answer 13

gets louder over time

Question 14

Decrescendo Murmur

Answer 14

gets softer over time

Question 15

Crescendo-Decrescendo Murmur

Answer 15

first rises in intensity (volume) then falls

Question 16

Plateau Murmur

Answer 16

has same intensity throughout

Question 17

Midsystolic Murmur

Answer 17

-begins after S1 and stops before S2 WITH a gap between the murmur and heart sounds

Question 18

Pan/Holosystolic Murmur

Answer 18

-starts with S1 and stops at S2 w/o a gap between murmur and heart sounds

Question 19

Late Systolic Murmur

Answer 19

-starts in mid to late systole and persists to S2

Question 20

What is the most common kind of heart murmur?

Answer 20

midsystolic

Question 21

3 Types of Systolic Murmurs

Answer 21

1. innocent: w/o any detectable physiologic abnormality (grade 1-3)
2. physiologic: from physio changes in body metabolism (1-3)
3. pathologic: arising from a structural abnormality in heart or great vessels (grade 3-6)

Question 22

Usual Shape of Systolic Murmurs

Answer 22

crescendo-decrescendo

Question 23

What causes pan/holosystolic murmurs?

Answer 23

-arise from blood flowing from a chamber with high pressure to chamber with lower pressure, through a valve that should be closed

Question 24

3 Examples of Pan/Holosystolic Murmurs

Answer 24

• mitral valve regurgitation
• tricuspid valve regurgitation
• ventricular septal defect

Question 25

What usually causes systolic clicks?

Answer 25

mitral valve prolapse

Question 26

When do systolic clicks usually occur?

Answer 26

mid to late systole

Question 27

Where are systolic clicks best heard?

Answer 27

-with diaphragm between left lower sternal border and PMI

Question 28

How do squatting and standing affect the click?

Answer 28

- squatting delays the click closer to S2 | - standing moves it closer to S1

Question 29

What do diastolic murmurs indicate?

Answer 29

-almost always indicative of disease

Question 30

2 Main Types of Diastolic Murmurs

Answer 30

- aortic regurgitation: heard best @ base w/ pt sitting forward; suggests more severe dz if S3 or S4 present - mitral stenosis: low pitched and located near PMI; may be easier to hear in left lateral position

Question 31

Venous Hum

Answer 31

- benign - caused by turbulent flow in jugular veins - common in young kids - disappears w/ compression of jugular vein

Question 32

Patent Ductus Arteriosus

Answer 32

- congenital patent opening between aorta and pulmonary artery - often not heard until child 7-10 days old - may not show up until child is grown and could surface in a year or so

Question 33

Pericardial Friction Rubs

Answer 33

- usually heard best in second pulmonic area (Erb's point) - may be described as crunchy or squeaky - look for underlying causes: trauma, illness, tumor