Heart sounds

Question 1

Hypertrophic cardiomyopathy (HCM) murmur

Answer 1

Crescendo-decrescendo systolic murmur heard best at the left sternal border (functional stenosis);

If you move the stethoscope to the apex you will here a holosystolic blowing murmur due to the functional mitral regurgitation that accompanies the functional stenosis

Question 2

What increases the intensity of HCM murmurs

Answer 2

Anything that decreases preload (i.e. decreases venous return); Valsalva and standing both decrease venous return and thus increase the murmur

Question 3

Why does decreasing the venous return increase the murmur in HCM?

Answer 3

Decreases the ventricular size and decreases the area the blood flows across in systole thus increase the venturi effect and bring the mitral valve leaflet closer to the outflow tract

Question 4

Heart sounds heard best at the right 2nd intercostal space

Answer 4

Aortic stenosis and aortic valve sclerosis; this is the “aortic area”

Question 5

Heart sounds heard best at the left sternal border

Answer 5

Aortic and pulmonary regurgitation, HCM

Question 6

Heart sounds heard best at the left 2nd intercostal space

Answer 6

Pulmonic stenosis; this is the “pulmonic” area

Question 7

Heart sounds heard best at the left 5th intercostal space at the sternal border

Answer 7

Tricuspid regurgitation and stenosis, ASD and VSD; tricuspid area

Question 8

Heart sounds heard best at the 5th intercostal space at the mid-clavicular line

Answer 8

Mitral regurgitation and stenosis; mitral area

Question 9

Inspiration increases the intensity of what heart sounds

Answer 9

Right side; increases venous return to RV

Question 10

Expiration increases the intensity of what heart sounds

Answer 10

Left; increase blood return to LV by “squeezing” blood of the pulmonary circulation

Question 11

Hand grip increases the intensity of what sounds?

Answer 11

MR, AR, VSD and MVP

Question 12

Hand grip decreases the intensity of what murmurs?

Answer 12

HCM, AS (decreases the pressure gradient by increasing systemic resistance)

Question 13

Valsava decreases intensity of what murmurs?

Answer 13

Most murmurs

Question 14

Valsava increases the intensity of what murmurs

Answer 14

MVP, HCM

Question 15

Rapid squatting decreases the intensity of what murmurs

Answer 15

MVP, HCM

Question 16

Rapid standing increases intensity of what murmurs

Answer 16

HCM

Question 17

Systolic heart sounds

Answer 17

AS, PS, MR, TR, VSD

Question 18

Diastolic heart sounds

Answer 18

AR, MR, MS, TS

Question 19

What indicates the intensity of the MS

Answer 19

Interval between S2 and opening snap; earlier the OS the more severe the MS

Question 20

Why does leaning forward increase AS

Answer 20

Brings the aorta valve closer to the chest wall

Question 21

MVP is the leading risk factor for what?

Answer 21

Subacute bacterial endocarditis

Question 22

Holosystolic, high pitched “blowing” murmurs

Answer 22

MR/TR

Question 23

What enhances MR murmurs

Answer 23

Anything that increases systemic resistance (hand grip, squatting) or LA return (expiration)

Question 24

What enhances TR murmurs

Answer 24

Anything that increases venous return (inspiration)

Question 25

Major causes of MR

Answer 25

Ischemic heart disease, MVP, or LV dilation, rheumatic fever, infective endocarditis

Question 26

Major causes of TR

Answer 26

RV dilatation, rheumatic fever, infective endocarditis

Question 27

Holosystolic, harsh sounding murmur

Answer 27

VSD

Question 28

Where is VSD loudest?

Answer 28

Tricuspid area (left 5th intercostal space at the sternal boarder)

Question 29

Maneuvers that increase VSD

Answer 29

Things that increase systemic resistance (hand grip, sudden squatting)

Question 30

Crescendo-decrescendo systolic murmur with an ejection click

Answer 30

Aortic stenosis

Question 31

Where does the murmur radiate to in AS

Answer 31

Carotids and heart base

Question 32

Weak pulses with a delayed peak are found in what murmur

Answer 32

AS; this is pulsus parvus et tardus

Question 33

Sequelae of AS

Answer 33

SAD; syncope, angina, dyspnea

Question 34

Common causes of AS

Answer 34

Bicuspid aortic valve, age related aortic calcific stenosis

Question 35

Late-systolic murmur with a mid-systolic click

Answer 35

MVP

Question 36

When is MVP loudest

Answer 36

S2; crescendos from the mid-systolic click

Question 37

What can MVP predispose to?

Answer 37

Infective endocarditis

Question 38

Causes of MVP

Answer 38

Myxomatous degeneration (most common), rheumatic fever, chordae rupture

Question 39

Connective tissue diseases that may cause MVP

Answer 39

Ehler Danlos, Marfans

Question 40

MVP is enhanced by what?

Answer 40

Diseases that decrease venous return (Valsava, standing quickly)

Question 41

Immediate high-pitched “blowing” diastolic decrescendo murmur

Answer 41

Aortic regurgitation

Question 42

Bounding pulse and head bobbing indicate what murmur

Answer 42

AR

Question 43

Common causes of AR

Answer 43

Aortic root dilatation, bicuspid aortic valve, endocarditis, rheumatic fever

Question 44

What increase AR murmur

Answer 44

Increased systemic resistance (hand-grip)

Question 45

Tx for AR is what

Answer 45

Vasodilators/afterload reducers (ACE inhibitors, hydralazine)

Question 46

Diastolic murmur with an opening snap, rumbling

Answer 46

MS

Question 47

MS often caused by what

Answer 47

Rheumatic fever

Question 48

Chronic MS can result in what?

Answer 48

LA dilatation

Question 49

What enhances MS murmur

Answer 49

Things that increase LA return (expiration)

Question 50

Continuous machine-like murmur

Answer 50

Most likely PDA; however, it could also be transposition of the great vessels