Harvey Lab

Question 1

Normal Heart Sounds

Answer 1

First Heart Sound (S1)
Closure of the mitral and tricuspid valves
Loudest at the apex of the heart

Second Heart Sound (S2)
Closure of the aortic and pulmonic valves
Loudest at the base of the heart

Question 2

Physiologic Splitting of the S2 Heart Sound

Answer 2

S2 can split into a distinct A2 (aortic) and P2 (pulmonic) heart sounds.
D/T increased blood volume to the right ventricle.
Occurs during inspiration.
Negative intrathoracic pressure during inspiration also causes increased venous return to the right side of the heart.

Question 3

S3 heart sound (the 3rd heart sound)

Answer 3

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”

Question 4

S4 heart sound (the 4th heart sound)

Answer 4

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.

Question 5

S3 heard in kids and young adults

Answer 5

Children and young adults often have physiologic S3 filling sounds. Over mitral

Question 6

Clicks

Answer 6

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”

Question 7

Systolic and Diastolic Rubs: Pericardial Friction Rubs

Answer 7

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

May show expiratory augmentation

Question 8

How to describe a heart murmur:

Answer 8

Timing
Location
Radiation
Shape
Intensity
Pitch
Quality

Question 9

Heart murmurs: timing, location, radiation

Answer 9

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
Mitral Regurgitation – axilla
Aortic Stenosis – up the neck

Question 10

description of aortic stenosis murmur (example)

Answer 10

aortic area
radiate to neck
diamond shape
medium pitch
harsh quality
associated signs: decreased A2, efjection click, S4, narrow pulse pressure, slow rising and delayed pulse

Question 11

Description of mitral regurge murmur, (example)

Answer 11

location: apex
radiation: axilla
shape: holosystolic
pitch: high
quality: blowing
associated signs: decreased S1, S4, laterally displaced diffuse PMI

Question 12

Heart murmur shapes

Answer 12

the shape of a murmur is determined by its intensity over time.
Types of shapes
Crescendo
Decrescendo
Crescendo – Decrescendo
Plateau

Question 13

Heart murmur intensity grades

Answer 13

1/6- very faint, heard only after listener has “tuned in,” may not be heard in all positions

2/6 quiet, but heard immediately after placing the stethoscope on the chest

3/6 moderately loud

4/6 loud, with palpable thrill

5/6 very loud, with thrill. May be heard when the stethoscope is partly off the chest

6/6 very loud, with thrill. May be heard with stethoscope entirely off the chest.

Question 14

Heart murmurs: pitch, quality, other useful characteristics

Answer 14

Pitch
High , medium or low
Quality

Described in terms of blowing, harsh, rumbling or musical

Other useful characteristics
Changes with respiration
Changes with position
Lying down, leaning forward, LLD
Other maneuvers
Valsalva, squatting

Question 15

Effects of standing/ strain phase of valsalva

Answer 15

decreased left ventricular voume from decreased venous return to heart

decreased vascular tone: decreased arterial blood pressure.

increases prolaps of mitral valve, click moves earlier in systole and the murmur lengthens

Increases outflow obstruction of HOCM and the intensity of the murmur

decreases blood volume ejected int oteh aorta and the intensity of aortic stenosis murmur

Question 16

Effects of squatting/ release of valsalva

Answer 16

Increased left ventricular volume from increased venous return to heart.

Increased vascular tone; increased arterial blood pressure and peripheral vascular resistance

Decreases prolapse of mitral valve and delays the click; murmur shortens

decreases outflow obstruction and intensity of HOCM murmur

increases blood volume ejected into the aorta; increases intensity of the murmur

Question 17

Mild rheumatic mitral regurgitation.

What would we hear? possible causes?

Answer 17

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.

Question 18

: Severe congenital aortic regurgitation.

What would we hear?

Answer 18

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.

Question 19

Severe aortic stenosis d/t congenital bicuspid valve.

What might we hear?

Answer 19

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 20

Ventricular septal defect

in young girl. What might we hear?

Answer 20

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 21

Large patent ductus arteriosus.

What might we hear?

Answer 21

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.

Question 22

Acute viral pericarditis

What might we hear?

Answer 22

S1 and S2 are normal. Physiologic splitting of the S2. There is a three component pericardial friction rub and shows expiratory augmentation.

Question 23

: Acute anterior wall myocardial infarction. What might we hear?

Answer 23

There is as S3 and S4 (gallop rhythm). S3 indicates significant LV dysfunction. Crackles in the lungs reflect acute pulmonary congestion.

Question 24

atherosclerotic heart disease (ASHD) with angina pectoris and left carotid bruit.

what might we hear?

Answer 24

S4 present reflects enhanced left atrial contraction into a ventricle with decreased compliance d/t ASHD.