Cardiac Auscultation Lab Flashcards
Lists the 5 Listening Posts with their location
- aortic - 2nd ICS, RSB
- pulmonic - 2nd ICS, LSB
- Erb’s point - L, 3rd ICS
- Tricuspid - 5th ICS, LSB
- Mitral - 5th ICS, mid clavicular line
First heart Sound (S1) represents what? Where is heard the loudest?
- Closure of the mitral and tricuspid valves
- Loudest at the apex of the heart
Second heart sound (S2) represents what? Where is it heard the loudest?
- Closure of the aortic and pulmonic valves
- Loudest at the base of the heart
S2 can spit into ______ during ______. Which closes first?
…a distinct A2 (aortic) and P2 (pulmonic) heart sound…inspiration
- aortic closes first
Physiology of S2 spitting:
- D/T increased blood volume to the right ventricle.
- Negative intrathoracic pressure during inspiration also causes increased venous return to the right side of the heart
S3 is a _____ sound that occurs after ___.
…early diastolic…..S2
Pathophysiology of S3
- occurs at the end of rapid ventricular filling as the ventricular wall reaches its limit of excursion.
- Blood hitting a non-compliant ventricle.
Where is S3 best heard? What word does it sound like?
- Best heard at the apex with the patient lying on the left side
- Cadence of “Kentucky”
The most difficult heart sound to hear? Where is it best heard?
- S4
- Listen at the apex with the patient in LLD position
When does S4 occur?
- Occurs before the S1, late diastolic sound.
S4 Description? What word does it sound like?
- Late, dull, low pitched diastolic sound.
- Cadence of “Tennessee”.
S4 Pathophysiology
Caused by vibrations of the left ventricle, mitral valve and left ventricular outflow tract as a result of atrial contraction.
Children and young adults often have ______ sounds. Where is it heard?
- physiologic S3 filling sounds
- heard over the mitral valve
Abnormal Auscultation findings for; ASHD with angina pectoris and left carotid bruit
- S4 over mitral valve reflects enhanced left atrial contraction into a ventricle with decreased compliance d/t ASHD.
- systolic bruit over upper left caroti
Crackles in the lungs indicate:
pulmonary congestion
Abnormal Auscultation findings for: Acute anterior wall myocardial infarction
- There is as S3 and S4 (gallop rhythm). S3 indicates significant LV dysfunction
- S3, S4 heard over the
mitral valve - Pulmonary valve: S2 split during inspiration and expiration
Two types of systolic clicks and when are they heard?
- Aortic Ejection click - head at onset of LV ejection
2. Pulmonic Ejection - heard at the onset of RV ejection
Midsystolic click represents what? Where is heard?
Mitral valve prolapse - Heard at the apex in mid or late systole
“Click-Murmur syndrome”
When a Midsystolic click is associated with a late systolic murmur of MR
Systolic and Diastolic Rubs: Pericardial Friction Rubs
Pathophysiology and causes
- rubbing together of two inflamed pericardial surfaces.
- Causes: infectious pericarditis, MI, cardiac surgery, uremia, metastatic Ca, TB
Pericardial Friction Rubs: heard best? sounds like?
- Have the patient sitting and leaning forward.
- Sounds scratchy, grating, rasping or squeaky.
Pericardial Friction Rubs triphasic component
systole and early and late diastole.
Abnormal Auscultation findings for: Acute viral pericarditis; heard best?
S1 and S2 are normal. Physiologic splitting of the S2. There is a three component pericardial friction rub and shows expiratory augmentation.
- heard best over tricuspid valve; faintly over pulmonary, sometimes over mitral
How to describe a heart murmur: (7)
- Timing
- Location
- Radiation
- Shape
- Intensity
- Pitch
- Quality
Timing
- Systolic: between S1 and S2
- Diastolic: between S2 and S1
Location
- Site where the murmur originates
- Where you hear the murmur the best
Radiation
- Does the murmur radiate – direction of blood flow
Radiation of mitral Regurgitation
axilla
Radiation of Aortic Stenosis
up the neck
Shape
the shape of a murmur is determined by its intensity over time
Crescendo
grows louder over time
Decrescendo
grows softer over time
Crescendo – Decrescendo
first rises in intensity then falls
Plateau
same intensity throughout
Intensity
Graded on a 6 point scale and expressed as a fraction.
Intensity: Grade 1
very faint, heard only after the listener has “tuned in”, may not be heard in all positions
Intensity: Grade 2
Quiet, but heard immediately after placing the stethoscope on the chest
Intensity: Grade 3
Moderately loud
Intensity: Grade 4
Loud, with palpable thrill
Intensity: Grade 5
Very loud with thrill, may be heard when the stethoscope is partly off the cest
Intensity: grade 6
Very loud with thrill, may be heard when the stethoscope is entirely off the chest
Ptich
high, medium or low
Quality
Described in terms of blowing, harsh, rumbling, or musical
Other useful Murmur characteristics
- Changes with respiration
- Changes with position: Lying down, leaning forward, LLD
- Other maneuvers
Valsalva, squatting
Positions for Auscultation
- Supine (30 degrees)
- Left lateral decubitus
- Upright
- Leaning forward
Standing/strain phase of Valsalva: CV effect
- Decreased LV volume dt dec venous return to heart
- dec vascular tone: dec arterial BP
Standing/strain phase of Valsalva: Effects on systolic sounds/murmurs of mitral prolapse
- increased prolapse of mitral valve
- click moves earlier in systole and murmur lengthens
- click and murmur gets louder
Standing/strain phase of Valsalva: Effects on systolic sounds/murmurs of hypertrophic cardiomyopathy
- increased outflow obstruction
- increased intensity of the murmur
Standing/strain phase of Valsalva: Effects on systolic sounds/murmurs of Aortic Stenosis
- dec blood vol ejected into the aorta
- dec intensity of murmur
Squatting/Release of Valsalva: CV effects
- increased LV volume dt increased venous return to the heart
- increased vascular tone: increased arterial BP; increased peripheral vascular resistance
Squatting/Release of Valsalva: Effects on systolic sounds/murmurs of Mitral valve prolapse
- dec prolapse of mitral valve
- delay of click and murmur shortens
Squatting/Release of Valsalva: Effects on systolic sounds/murmurs of Hypertrophic cardiomyopathy
- dec outflow obstructions
- dec intensity of murmur
Squatting/Release of Valsalva: Effects on systolic sounds/murmurs of aortic stenosis
- increased blood volume ejection into the aorta
- increased intensity of murmur
The supine position is used to evaluate:
- S1 & S2 in all areas
- Systolic murmurs or sounds in all areas
The LLD position is used to evaluate:
- diastolic events at the apex with bell of stethoscope
The upright position is used to evaluate:
- S1 & S2 in all areas
- systolic murmurs or sounds in all areas
- diastolic murmurs or sounds in all areas
The upright, Leaning forward is used to evaluate:
- diastolic events at base with diaphragm of stethoscope
Abnormal Auscultation findings for: Mitral prolapse (click - murmur syndrome). Where is is heard?
- Mid systolic click (c) and a high frequency grade 3/6 late systolic crescendo murmur.
- Loudest over mitral, but heard over tricuspid too
Abnormal Auscultation findings for: Mild rheumatic mitral regurgitation.
Where is is heard best?
- High frequency grade 2/6, holosystolic murmur radiates to the axilla. S1 is obscured by the murmur.
- Heard over mitral valve
- (small S1 split is heard over the tricuspid valve but no murmur heard here)
Causes of Mitral Regurgitation
Vegatations on valve leaflets, papillary muscle dysfunction, Dilated cardiomyopathy, RF
Abnormal Auscultation findings for: Severe congenital aortic regurgitation at the aortic valve
- normal S1 followed by an ejection sound (ES) d/t upward movement of congenital abnormal valve.
- Short grade 2/6 early systolic murmur.
- At S2, high frequency murmur grade 2/6 d/t the aortic regurgitation. (this one is also heard on the pulmonic and tricuspid valves)
Abnormal Auscultation findings for: Severe congenital aortic regurgitation at the mitral valve
“Austin Flint murmur” d/t premature closure of the mitral valve.
Abnormal Auscultation findings for: Severe aortic stenosis d/t congenital bicuspid valve
- Aortic: Normal S1 followed by ejection sound (ES). Grade 3/6 systolic murmur and ends before S2.
- Mitral: Prominent S4 d/t atrial contraction against a thicken poorly compliant LV. The S4 indicates the AS obstruction is severe. Also a 1/6 mitral regurgitation.
Abnormal Auscultation findings for: Ventricular septal defect
- Pulmonary: Physiologic S2 splitting. Grade 1/6 early systolic murmur d/t normal turbulence.
- Tricuspid: Grade 3/6 high frequency holosystolic murmur.
- Mitral: Same grade 2/6 murmur transmitted from the tricuspid side.
Abnormal Auscultation findings for: : Large patent ductus arteriosus
- Pulmonary: High frequency grade 3/6 continuous systolic and diastolic murmur that peaks at S2. “Machine” or “to-and-fro” murmur.
- Mitral: S3 followed by a short grade 2/6 mid diastolic murmur related to the increased flow across the mitral valve.
