Cardiac auscultation lab Flashcards
Name the 5 listening posts for the heart
Aortic Pulmonic Erb’s Point Tricuspid Mitral
The first heart sound (S1) represents?
Closure of the mitral and tricuspid valves Loudest at the apex of the heart
Second Heart Sound (S2) represents?
Closure of the aortic and pulmonic valves Loudest at the base of the heart
Splitting of S2 can be physiologic or pathologic. What causes physiologic splitting?
inspiration
A normal appearing 50 year old male in no apparent distress. Presents for yearly physical. No complaints. Hx of Hypertension.
Meds – Lisinopril 10 mg QD
BP = 120/80
Carotid and Peripheral pulses are normal.
PMI = 5th ICS MCL less than 2 cm, Neg. heaves or thrills
Lungs – Normal vesicular breath sounds
What is the Dx?
Normal examination with physiological splitting of S2
S3 heart sound represents?
Occurs after S2,early diastolic sound
Pathophysiology: occurs at the end of rapid ventricular filling as the ventricular wall reaches its limit of excursion.
Blood hitting a non-compliant ventricle.
Best heard at the apex with the patient lying on the left side
Cadence of “Kentucky”
S4 heart sound represents?
Late, dull, low pitched diastolic sound.
Pathophysiology: Caused by vibrations of the left ventricle, mitral valve and left ventricular outflow tract as a result of atrial contraction.
Occurs before the S1, late diastolic sound.
Cadence of “Tennessee”.
Most difficult heart sound to hear.
Listen at the apex with the patient in LLD position.
A 17 year old teenager with right shoulder and pectoral area pain. Very active and plays sports. No dyspnea or chest pain.
BP = 120/70
Meds - none
Carotid and peripheral pulses are normal in upstroke.
PMI – 5th ICS MCL , neg. heaves or thrills
Lungs – Normal vesicular breath sounds
Diagnosis?
Normal Examination, physiologic splitting of S2. S3 heard over mitral. Children and young adults often have physiologic S3 filling sounds.
48 year old obese white male. History of hypertension and hypercholesterolemia. History of chest pain and exertional dyspnea.
BP = 150/100
Meds: Propranolol SR 80 mg QD, Lipitor 20 mg QD
Carotid and peripheral pulses are normal in upstroke.
PMI – 5th ICS MCL, neg. heaves or thrills
Lungs – Normal vesicular breath sounds
Dx?
56 year old women with crushing chest pain, dyspnea and diaphoresis. History of ASHD and angina.
BP = 120/95
Meds: Propranolol SR 80 mg QD, SL NTG prn
PMI – 5th ICS MCL barely palpable, neg. heaves or thrills.
Carotid and peripheral pulses are decreased.
Lungs – lower posterior lobes = inspiratory crackles or rales B/L.
Dx?
Acute anterior wall myocardial infarction. There is as S3 and S4 (gallop rhythm). S3 indicates significant LV dysfunction. Crackles in the lungs reflect acute pulmonary congestion.
What are clicks? in reference to heart sounds.
Systolic click: Aortic Ejection Click
Heard at the onset of LV ejection
Systolic click: Pulmonic Ejection click
Heard at the onset of RV ejection
Midsystolic click: Mitral valve prolapse
Heard at the apex in mid or late systole
Sometimes associated with a late systolic murmur of MR
“Click-Murmur syndrome”
What is a pericardial friction rub, on heart ascultation?
Pathophysiology: rubbing together of two inflamed pericardial surfaces.
Have the patient sitting and leaning forward.
Sounds scratchy, grating, rasping or squeaky.
May have a triphasic component: systole and early and late diastole.
Causes: infectious pericarditis, MI, cardiac surgery, uremia, metastatic Ca, TB
A 38 year old male leaning forward to relieve his chest pain. Recent history of viral upper respiratory infection.
BP = 130/85
Meds: none
PMI – 5th ICS MCL, neg. heaves or thrills
Carotid and peripheral pulses are normal upstroke.
Lungs – pleural rub with inspiration, normal vesicular breath sounds
Dx?
Acute viral pericarditis. S1 and S2 are normal. Physiologic splitting of the S2. There is a three component pericardial friction rub and shows expiratory augmentation.
How are murmurs described?
Timing
Location
Radiation
Shape
Intensity
Pitch
Quality
How is the timing described for murmurs?
Systolic: between S1 and S2
Diastolic: between S2 and S1
What is the shape of murmurs? I thought they were sounds.
Crescendo
Decrescendo
Crescendo – Decrescendo
Plateau
How are murmurs graded?
What are the postitions for ascultating the heart?
Supine (30 degrees)
Left lateral decubitus
Upright
Leaning forward
What are some special maneuvers for systolic murmurs?
25 year old slender women with mild scoliosis. Complains of occasional episodes of palpitations that last a few minutes. No chest pain or dyspnea. IDDM x 20 years.
BP = 120/70
Meds – Humulin 70/30 20 units/daily
Carotid and peripheral pulses are normal upstroke.
PMI – 5th ICS MCL, no palpable thrill
Lungs – vesicular breath sounds
Dx?
Mitral valve prolapse (click murmur syndrome). Mid systolic click (c) and a high frequency grade 3/6 late systolic crescendo murmur.
Special maneuver – standing decrease venous return, reduces ventricular size, often making the click and the murmur louder.
An asymptomatic 32 year old women with a history of rheumatic fever in childhood. Hypothyroid x 10 years.
BP = 12O/70
Meds – Synthroid 50 mcg QD
Carotid and peripheral pulses are normal upstroke.
PMI – 5th ICS MCL, neg. heaves or thrills.
Lungs – normal vesicular breath sounds.
Dx?
Mild rheumatic mitral regurgitation.
High frequency grade 2/6, holosystolic murmur radiates to the axilla. S1 is obscured by the murmur.
Causes: Vegatations on valve leaflets, papillary muscle dysfunction, Dilated cardiomyopathy.
36 year old male c/o increasing exertional dyspnea for the past 6 months.
BP = 160/35
Meds – none
Carotid pulse – bisferiens with brisk upstroke and peripheral pulses are bounding.
PMI – 6th ICS and displaced lateral, neg. thrill or heaves.
Lungs – normal vesicular breath sounds.
Dx?
Severe congenital aortic regurgitation.
Aortic – 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 grade 2/6 d/t the aortic regurgitation.
Mitral – “Austin Flint murmur” d/t premature closure of the mitral valve.
A normal appearing 18 year old male presents for a pre-participation sports physical examination. He tells you recently on two occasions he almost “passed out” while exercising.
BP = 100/80
Meds - none
Carotid and peripheral pulses are hypokinetic.
PMI displaced infralaterally and + heave, neg. thrill.
Lungs – normal vesicular breath sounds
Dx?
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.
10 year old girl presents for routine back to school physical. No complaints, but is a little small in stature, 10th percentile.
BP= 100/60
Meds – Xopenex prn for asthma
Carotid and peripheral pulses are normal upstroke.
PMI – 5th ICS MCL, neg. thrills or heaves
Lungs – normal vesicular breath sounds
Dx?
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.
30 year old female with no complaints or evidence of cyanosis. Hx of depression.
BP = 150/50
Meds – Lexapro 20 mg QD
Carotid and peripheral pulses are bounding with large amplitude and upstroke.
PMI – 6th ICS in mid axillary line, neg. heaves and thrills.
Lungs – normal vesicular breath sounds
Dx?
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.
