Cardiac Auscultation Lab

Question 1

Lists the 5 Listening Posts with their location

Answer 1

1. aortic - 2nd ICS, RSB
2. pulmonic - 2nd ICS, LSB
3. Erb’s point - L, 3rd ICS
4. Tricuspid - 5th ICS, LSB
5. Mitral - 5th ICS, mid clavicular line

Question 2

First heart Sound (S1) represents what? Where is heard the loudest?

Answer 2

• Closure of the mitral and tricuspid valves

- Loudest at the apex of the heart

Question 3

Second heart sound (S2) represents what? Where is it heard the loudest?

Answer 3

• Closure of the aortic and pulmonic valves

- Loudest at the base of the heart

Question 4

S2 can spit into ______ during ______. Which closes first?

Answer 4

…a distinct A2 (aortic) and P2 (pulmonic) heart sound…inspiration
- aortic closes first

Question 5

Physiology of S2 spitting:

Answer 5

• 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

Question 6

S3 is a _____ sound that occurs after ___.

Answer 6

…early diastolic…..S2

Question 7

Pathophysiology of S3

Answer 7

• occurs at the end of rapid ventricular filling as the ventricular wall reaches its limit of excursion.
• Blood hitting a non-compliant ventricle.

Question 8

Where is S3 best heard? What word does it sound like?

Answer 8

• Best heard at the apex with the patient lying on the left side
• Cadence of “Kentucky”

Question 9

The most difficult heart sound to hear? Where is it best heard?

Answer 9

• S4

- Listen at the apex with the patient in LLD position

Question 10

When does S4 occur?

Answer 10

• Occurs before the S1, late diastolic sound.

Question 11

S4 Description? What word does it sound like?

Answer 11

• Late, dull, low pitched diastolic sound.

- Cadence of “Tennessee”.

Question 12

S4 Pathophysiology

Answer 12

Caused by vibrations of the left ventricle, mitral valve and left ventricular outflow tract as a result of atrial contraction.

Question 13

Children and young adults often have ______ sounds. Where is it heard?

Answer 13

• physiologic S3 filling sounds

- heard over the mitral valve

Question 14

Abnormal Auscultation findings for; ASHD with angina pectoris and left carotid bruit

Answer 14

• S4 over mitral valve reflects enhanced left atrial contraction into a ventricle with decreased compliance d/t ASHD.
• systolic bruit over upper left caroti

Question 15

Crackles in the lungs indicate:

Answer 15

pulmonary congestion

Question 16

Abnormal Auscultation findings for: Acute anterior wall myocardial infarction

Answer 16

• 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

Question 17

Two types of systolic clicks and when are they heard?

Answer 17

1. Aortic Ejection click - head at onset of LV ejection

2. Pulmonic Ejection - heard at the onset of RV ejection

Question 18

Midsystolic click represents what? Where is heard?

Answer 18

Mitral valve prolapse - Heard at the apex in mid or late systole

Question 19

“Click-Murmur syndrome”

Answer 19

When a Midsystolic click is associated with a late systolic murmur of MR

Question 20

Systolic and Diastolic Rubs: Pericardial Friction Rubs

Pathophysiology and causes

Answer 20

• rubbing together of two inflamed pericardial surfaces.

- Causes: infectious pericarditis, MI, cardiac surgery, uremia, metastatic Ca, TB

Question 21

Pericardial Friction Rubs: heard best? sounds like?

Answer 21

• Have the patient sitting and leaning forward.

- Sounds scratchy, grating, rasping or squeaky.

Question 22

Pericardial Friction Rubs triphasic component

Answer 22

systole and early and late diastole.

Question 23

Abnormal Auscultation findings for: Acute viral pericarditis; heard best?

Answer 23

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

Question 24

How to describe a heart murmur: (7)

Answer 24

• Timing
• Location
• Radiation
• Shape
• Intensity
• Pitch
• Quality

Question 25

Timing

Answer 25

- Systolic: between S1 and S2 | - Diastolic: between S2 and S1

Question 26

Location

Answer 26

- Site where the murmur originates | - Where you hear the murmur the best

Question 27

Radiation

Answer 27

- Does the murmur radiate – direction of blood flow

Question 28

Radiation of mitral Regurgitation

Answer 28

axilla

Question 29

Radiation of Aortic Stenosis

Answer 29

up the neck

Question 30

Shape

Answer 30

the shape of a murmur is determined by its intensity over time

Question 31

Crescendo

Answer 31

grows louder over time

Question 32

Decrescendo

Answer 32

grows softer over time

Question 33

Crescendo – Decrescendo

Answer 33

first rises in intensity then falls

Question 34

Plateau

Answer 34

same intensity throughout

Question 35

Intensity

Answer 35

Graded on a 6 point scale and expressed as a fraction.

Question 36

Intensity: Grade 1

Answer 36

very faint, heard only after the listener has "tuned in", may not be heard in all positions

Question 37

Intensity: Grade 2

Answer 37

Quiet, but heard immediately after placing the stethoscope on the chest

Question 38

Intensity: Grade 3

Answer 38

Moderately loud

Question 39

Intensity: Grade 4

Answer 39

Loud, with palpable thrill

Question 40

Intensity: Grade 5

Answer 40

Very loud with thrill, may be heard when the stethoscope is partly off the cest

Question 41

Intensity: grade 6

Answer 41

Very loud with thrill, may be heard when the stethoscope is entirely off the chest

Question 42

Ptich

Answer 42

high, medium or low

Question 43

Quality

Answer 43

Described in terms of blowing, harsh, rumbling, or musical

Question 44

Other useful Murmur characteristics

Answer 44

- Changes with respiration - Changes with position: Lying down, leaning forward, LLD - Other maneuvers Valsalva, squatting

Question 45

Positions for Auscultation

Answer 45

- Supine (30 degrees) - Left lateral decubitus - Upright - Leaning forward

Question 46

Standing/strain phase of Valsalva: CV effect

Answer 46

- Decreased LV volume dt dec venous return to heart | - dec vascular tone: dec arterial BP

Question 47

Standing/strain phase of Valsalva: Effects on systolic sounds/murmurs of mitral prolapse

Answer 47

- increased prolapse of mitral valve - click moves earlier in systole and murmur lengthens - click and murmur gets louder

Question 48

Standing/strain phase of Valsalva: Effects on systolic sounds/murmurs of hypertrophic cardiomyopathy

Answer 48

- increased outflow obstruction | - increased intensity of the murmur

Question 49

Standing/strain phase of Valsalva: Effects on systolic sounds/murmurs of Aortic Stenosis

Answer 49

- dec blood vol ejected into the aorta | - dec intensity of murmur

Question 50

Squatting/Release of Valsalva: CV effects

Answer 50

- increased LV volume dt increased venous return to the heart - increased vascular tone: increased arterial BP; increased peripheral vascular resistance

Question 51

Squatting/Release of Valsalva: Effects on systolic sounds/murmurs of Mitral valve prolapse

Answer 51

- dec prolapse of mitral valve | - delay of click and murmur shortens

Question 52

Squatting/Release of Valsalva: Effects on systolic sounds/murmurs of Hypertrophic cardiomyopathy

Answer 52

- dec outflow obstructions | - dec intensity of murmur

Question 53

Squatting/Release of Valsalva: Effects on systolic sounds/murmurs of aortic stenosis

Answer 53

- increased blood volume ejection into the aorta | - increased intensity of murmur

Question 54

The supine position is used to evaluate:

Answer 54

- S1 & S2 in all areas | - Systolic murmurs or sounds in all areas

Question 55

The LLD position is used to evaluate:

Answer 55

- diastolic events at the apex with bell of stethoscope

Question 56

The upright position is used to evaluate:

Answer 56

- S1 & S2 in all areas - systolic murmurs or sounds in all areas - diastolic murmurs or sounds in all areas

Question 57

The upright, Leaning forward is used to evaluate:

Answer 57

- diastolic events at base with diaphragm of stethoscope

Question 58

Abnormal Auscultation findings for: Mitral prolapse (click - murmur syndrome). Where is is heard?

Answer 58

- Mid systolic click (c) and a high frequency grade 3/6 late systolic crescendo murmur. - Loudest over mitral, but heard over tricuspid too

Question 59

Abnormal Auscultation findings for: Mild rheumatic mitral regurgitation. Where is is heard best?

Answer 59

- 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)

Question 60

Causes of Mitral Regurgitation

Answer 60

Vegatations on valve leaflets, papillary muscle dysfunction, Dilated cardiomyopathy, RF

Question 61

Abnormal Auscultation findings for: Severe congenital aortic regurgitation at the aortic valve

Answer 61

- 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)

Question 62

Abnormal Auscultation findings for: Severe congenital aortic regurgitation at the mitral valve

Answer 62

“Austin Flint murmur” d/t premature closure of the mitral valve.

Question 63

Abnormal Auscultation findings for: Severe aortic stenosis d/t congenital bicuspid valve

Answer 63

- 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.

Question 64

Abnormal Auscultation findings for: Ventricular septal defect

Answer 64

- 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.

Question 65

Abnormal Auscultation findings for: : Large patent ductus arteriosus

Answer 65

- 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.