Cardio Exam Module

Question 1

What are the “big 12” heart sounds?

Answer 1

2nd sound splitting; 3rd sound; 4th sound; systolic click; innocent murmur; mitral regurgitation; aortic stenosis; aortic regurgitation; mitral stenosis; continuous murmur; tricuspid regurgitation; pericardial rub

Question 2

What are the most important heard sounds?

Answer 2

3rd sound and 4th sound, since they represent ventricular functions (they’re called “filling sounds”)

Question 3

What are the 5 fingers of the “5 finger approach”?

Answer 3

1. the appearance of the patient; 2. assessing the carotid arterial pulse; 3. the venous pulse; 4. chest wall movement (precordial movement); 5. auscultation

Question 4

What does S1 represent?

Answer 4

When the pressure in the left ventricle rises above the pressure in the left atrium and mitral valve closes; sounds occurs at the beginning of the carotid impulse

Question 5

Where is S1 loudest?

Answer 5

at the apex

Question 6

What does S2 represent?

Answer 6

When the pressure in the left ventricle falls below that of the aorta and the aortic valve closes; sound occurs at the end of the carotid impulse

Question 7

Where is S2 loudest?

Answer 7

at the base

Question 8

What do you hear on heart auscultation?

Answer 8

valves closing - valves opening typically doesn’t make an audible sound!

Question 9

What should the bell of the stethoscope be used for?

Answer 9

Low frequency sounds

Question 10

What can an abnormally loud aortic closure mean?

Answer 10

Hypertension

Question 11

Where is the best place to hear S2 splitting?

Answer 11

left sternal edge

Question 12

When might you hear S2 splitting?

Answer 12

1. pathology, like atrial septal defects with permanent splitting; 2. children may have persistent splitting when supine, but it disappears when they sit or stand; 3. splitting may occur during inspiration

Question 13

What can be heard at the upper right sternal edge?

Answer 13

S1 and S2

Question 14

What is S1 splitting due to?

Answer 14

Normal variation - typically due to small differences in mitral/tricuspid closing; limited diagnostic value

Question 15

Where/how should you listen for 3rd heart sound?

Answer 15

With bell of the stethoscope at the apex. Right sided 3rd heart sounds may be heard at the tricuspid area and may augment with inspiration. Sometimes patient should be in the left lateral decubitus position

Question 16

What is a third heart sound? What does it represent?

Answer 16

Early diastolic, low frequency filling heart sound. Related to acceleration and deceleration of blood during passive filling of the ventricle. May be normal in children and young adults. May be pathologic in adults - heart failure (less compliant ventricle).

Question 17

Where/how should you listen for 4th heart sound?

Answer 17

With bell of the stethoscope at the apex. Sometimes patient should be in the left lateral decubitus position

Question 18

What causes 4th heart sound?

Answer 18

Occurs during late diastole when atrial contraction causes rapid blood flow into the ventricle. If the ventricle is less compliant than normal, then the blood decelerates and causes low frequency sound.

Question 19

How can you tell 4th heart sound from S1 splitting?

Answer 19

1. Listen at apex; put patient in left lateral decubitus position; identify the LV impulse; if the impulse is presystolic, then it is the fourth sound; 2. put bell over apical impulse - use light pressure for 4th sound and firm pressure for S1

Question 20

What is a systolic click?

Answer 20

A sharp, high frequency sound that is best heard at the apex. There may be one, or there may be multiple heard during systole. It is caused by abrupt tensing of prolapsed mitral valve.

Question 21

How should murmur be described?

Answer 21

location, timing, contour, frequency

Question 22

Where should you listen for murmur?

Answer 22

2nd left intercostal space (pulmonary valve)

Question 23

How can you describe an innocent murmur heard at the upper left sternal edge?

Answer 23

Systolic, short, early peaking, crescendo-decrescendo, mid frequency; the result of turbulent flow. May be associated with splitting of the second sound.

Question 24

Where can you hear mitral regurgitation?

Answer 24

Mitral area; blood flows from LV to LA - radiates to axilla ; all of systole

Question 25

What are the characteristics of mid-late systolic murmur?

Answer 25

Likely due to mitral valve prolapse; Early systole is silent; clicks introduce the murmur; crescendos into S2; high frequency

Question 26

What is holosystolic mitral regurgitation?

Answer 26

Rheumatic

Question 27

What is crescendo-decrescendo mid systolic murmur?

Answer 27

Papillary dysfunction

Question 28

Where is the best location to hear aortic stenosis?

Answer 28

Upper right sternal edge - aortic area; may also palpate a thrill; crescendo-decrescendo in systole - all of systole

Question 29

How can you tell the difference between aortic stenosis and aortic sclerosis?

Answer 29

Both are heard in the upper right sternal edge and are systolic crescendo-decrescendo; sclerosis is short and early-peaking (as opposed to long and late-peaking)

Question 30

Where is aortic regurgitation best heard?

Answer 30

Lower left sternal edge (direction of diastolic flow)

Question 31

What is mitral stenosis and where is it heard?

Answer 31

Apex or mitral area with bell; narrowing of mitral valve; diastolic murmur; feel right ventricular impulse at right sternal edge; low frequency

Question 32

What is a continuous murmur?

Answer 32

systolic and diastolic component; represents patent ductus arteriosus; due to turbulent flow originating in blood vessels; high frequency

Question 33

What are some causes of continuous murmur?

Answer 33

venous hum - heard in children in clavicular area; shunts from high to low vessels - patients with patent ductus arteriosus; obstruction - patients with critical stenosis and insufficient circulation

Question 34

What is tricuspid regurgitation?

Answer 34

Often occurs with other heart disease; whole of systolic, plateau-shaped; high frequency

Question 35

When is tricuspid regurgitation augmented?

Answer 35

Inspiration

Question 36

What is pericardial rub?

Answer 36

when heart moves inside pericardial sac due to inflammation of the sac; high pitch and scratchy - may vary in intensity

Question 37

How is pericardial rub best heard?

Answer 37

With diaphragm of the stethoscope; patient should be leaning forward; best heard at end of expiration; typically best heard between lower left sternal edge and apex

Question 38

What are the components of pericardial rub?

Answer 38

3 classic components: systolic, early diastolic, presystolic (late diastolic); must have 2 components to dx - otherwise too difficult to differentiate from scratchy murmur