Cardio - Physio (Heart Auscultation & Murmurs)

Question 1

What are the 4 major areas for auscultating the heart? Where is each located?

Answer 1

(1) Aortic - right 2nd intercostal space (medial) (2) Pulmonic - left 2nd intercostal space (medial) (3) Tricuspid - left 5th intercostal space (medial) (4) Mitral - left 5th intercostal space (lateral); Think: “APT M”

Question 2

For what category of heart sounds do you listen at the Aortic area? Give 3 examples.

Answer 2

AORTIC AREA: Systolic murmur (1) Aortic stenosis (2) Flow murmur (3) Aortic valve sclerosis

Question 3

What are 2 categories of sounds that you would listen for at the left sternal border? Give at least one example of each category.

Answer 3

LEFT STERNAL BORDER: Diastolic murmur - (1) Aortic regurgitation (2) Pulmonic regurgitation; Systolic murmur (1) Hypertrophic cardiomyopathy

Question 4

For what category of heart sounds do you listen at the Pulmonic area? Give 2 examples.

Answer 4

PULMONIC AREA: Systolic ejection murmur (1) Pulmonic stenosis (2) Flow murmur (e.g., physiologic murmur)

Question 5

For what 2 categories of heart sounds do you listen at the Tricuspid area? Give 2 examples of each category.

Answer 5

TRICUSPID AREA: Pansystolic murmur (1) Tricuspid regurgitation (2) Ventricular septal defect; Diastolic murmur (1) Tricuspid stenosis (2) Atrial septal defect

Question 6

For what 2 categories of heart sounds do you listen at the Mitral area? Give an example of each category.

Answer 6

MITRAL AREA: Systolic murmur (1) Mitral regurgitation; Diastolic murmur (1) Mitral stenosis

Question 7

Explain the common early presentation of ASD and the progression of sound later in its course.

Answer 7

ASD commonly presents with a pulmonary flow murmur (increased flow through pulmonary valve) and a diastolic rumble (decreased flow across tricuspid); blood flow across the actual ASD does not cause a murmur because there is no significant pressure gradient. The murmur later progresses to a louder diastolic murmur of pulmonic regurgitation from dilatation of the pulmonary artery.

Question 8

What effect does inspiration have as a beside maneuver used during heart auscultation?

Answer 8

Increase intensity of right heart sounds

Question 9

What 3 effects does hand grip have as a beside maneuver used during heart auscultation, and why?

Answer 9

(1) Increase intensity of MR, AR, VSD murmurs (2) Decrease intensity of AS, hypertrophic cardiomyopathy/murmurs (3) MVP: increase murmur intensity, later onset of click/murmur; Hand grip (increase systemic vascular resistance)

Question 10

What 3 effects does Valsava have as a beside maneuver used during heart auscultation, and why? What other maneuver has these effects, and why?

Answer 10

(1) Decrease intensity of most murmurs (including AS) (2) Increase intensity of hypertrophic cardiomyopathy murmur (3) MVP: decrease murmur intensity, earlier onset of click/murmur; Valsava (phase II - reduced venous return and compensation), standing (decreased venous return)

Question 11

What 3 effects does Rapid squatting have as a beside maneuver used during heart auscultation, and why?

Answer 11

(1) Decrease intensity of hypertrophic cardiomyopathy murmur (2) Increase intensity of AS murmur (3) MVP: Increase murmur intensity, later onset of click/murmur; Rapid squatting (increase venous return, increase preload, increase afterload with prolonged squatting)

Question 12

What are 3 examples of systolic heart sounds?

Answer 12

Systolic heart sounds include (1) aortic/pulmonic stenosis, (2) mitral/tricuspid regurgitation, (3) ventricular septal defect

Question 13

What are 2 examples of diastolic heart sounds?

Answer 13

Diastolic heart sounds include (1) aortic/pulmonic regurgitation (2) mitral/tricuspid stenosis

Question 14

What characterizes the sound of mitral/tricuspid regurgitation (MR/TR)?

Answer 14

Holosystolic, high-pitched “blowing murmur”

Question 15

Where are the sounds of mitral and tricuspid regurgitation heard loudest, and to where do they radiate?

Answer 15

MITRAL - loudest at apex and radiates toward axilla; TRICUSPID - loudest at tricuspid area and radiates toward sternal border

Question 16

What enhances the sound mitral versus tricuspid regurgitation?

Answer 16

MITRAL - Enhanced by maneuvers that increase TPR (e.g., squatting, hand grip); TRICUSPID - Enhanced by maneuvers that increase RA return (e.g. inspiration)

Question 17

What are 3 common causes of mitral regurgitation? What commonly causes tricuspid regurgitation? What are 2 conditions that cause either MR or TR?

Answer 17

MR if often due to ischemic heart disease, MVP, or LV dilation; TR commonly caused by RV dilation; Rheumatic fever and infective endocarditis can cause either MR or TR

Question 18

What characterizes the sound of aortic stenosis (AS)?

Answer 18

Crescendo-decrescendo systolic ejection murmur.

Question 19

Compare the aortic and LV pressures during systole given an aortic stenosis.

Answer 19

LV&raquo_space; aortic pressure during systole

Question 20

Where is the sound of aortic stenosis (AS) heard loudest, and to where does it radiate?

Answer 20

Loudest at heart base; radiates to carotids

Question 21

What is the effect that aortic stenosis (AS) has on pulses? What is this called?

Answer 21

“Pulsus parvus et tardus” - pulses are weak and a delayed peak

Question 22

What are 3 symptoms that can result from aortic stenosis?

Answer 22

Can lead to Syncope, Angina, and Dyspnea on exertion. Think: “SAD”

Question 23

What are 2 common causes of aortic stenosis?

Answer 23

Often due to age-related calcific aortic stenosis or bicuspid aortic valve

Question 24

What characterizes the sound of VSD?

Answer 24

Holosystolic, harsh-sounding murmur

Question 25

Where is VSD heard loudest? What maneuver can be done to accentuate the sound, and why?

Answer 25

Loudest at tricuspid area, accentuated with hand grip maneuver due to increased afterload

Question 26

What characterizes the sound of mitral valve prolapse (MVP)?

Answer 26

Late systolic crescendo murmur with midsystolic click (MC; due to sudden testing of chordae tendinae).

Question 27

What causes the midsystolic click in MVP?

Answer 27

Late systolic crescendo murmur with midsystolic click (MC; due to sudden testing of chordae tendinae).

Question 28

What is the most frequent valvular lesion?

Answer 28

Mitral valve prolapse (MVP)

Question 29

Where is MVP best heard? When is it loudest?

Answer 29

Beast heard over apex; Loudest just before S2

Question 30

Is MVP usually benign or malignant?

Answer 30

Usually benign

Question 31

To what condition can MVP predispose patients?

Answer 31

Can predispose to infective endocarditis

Question 32

What 3 conditions can cause MVP?

Answer 32

Can be caused by myxomatous degeneration, rheumatic fever, or chordae rupture

Question 33

What maneuvers cause MVP sound to occur earlier? Give 2 examples.

Answer 33

Occurs earlier with maneuvers that decrease venous return (e.g., standing or Valsalva)

Question 34

What characterizes the sound of Aortic regurgitation (AR)?

Answer 34

High-pitched “blowing” early diastolic decrescendo murmur

Question 35

What results from chronic AR? What are 2 symptoms with which this can pressure?

Answer 35

Wide pulse pressure when chronic; can present with bounding pulses and head bobbing

Question 36

What are 4 causes of AR?

Answer 36

Often due to aortic root dilation, bicuspid aortic valve, endocarditis, or rheumatic fever.

Question 37

What maneuver is used to increase AR murmur? What substances decrease intensity of AR murmur?

Answer 37

Increase murmur during hand grip; Vasodilators decrease intensity of murmur

Question 38

What occurrence precedes mitral stenosis (MS), and why?

Answer 38

MS follows opening snap (OS; due to abrupt halt in leaflet motion in diastole, after rapid opening due to fusion at leaflet tips)

Question 39

What characterizes the sound of MS?

Answer 39

Delayed rumbling late diastolic murmur

Question 40

What correlates with increased severity of MS?

Answer 40

Decreased interval between S2 and O2 correlates with increased severity

Question 41

Compare the LA and LV pressures during diastole in the context of MS.

Answer 41

LA&raquo_space; LV pressure during diastole.

Question 42

To what condition does MS often occur secondary?

Answer 42

Often occurs secondary to rheumatic fever

Question 43

In what can chronic MS result?

Answer 43

Chronic MS can result in LA dilation

Question 44

What kind of maneuvers enhance the sound of MS? Give an example.

Answer 44

Enhanced by maneuvers that increase LA return (e.g., expiration)

Question 45

What characterizes the sound of PDA?

Answer 45

Continuous machine-like murmur

Question 46

At what point is PDA loudest? Where is PDA best heard?

Answer 46

Loudest at S2; Best heard at left infraclavicular area

Question 47

What are 2 common causes of PDA?

Answer 47

Often due to congenital rubella or prematurity

Question 48

Name 4 systolic heart murmurs.

Answer 48

(1) Mitral/tricuspid regurgitation (MR/TR) (2) Aortic stenosis (AS) (3) VSD (4) Mitral valve prolapse (MVP)

Question 49

Name 2 diastolic heart murmurs.

Answer 49

(1) Aortic regurgitation (AR) (2) Mitral stenosis (MS)

Question 50

Name a continuous heart murmur.

Answer 50

PDA