Heart Sounds

Question 1

S1

Answer 1

Closure of mitral and tricuspid valves – beginning of systole
(long, soft, low-pitched sound)

Question 2

S2

Answer 2

Closure of aortic and pulmonic valves – beginning of diastole
(short, sharp, high-pitched sound)

Question 3

S3

Answer 3

Due to rapid ventricular filling – deceleration of blood against ventricular wall (volume overload)

• Physiologic: children and young adults
• Pathologic (‘S3/ventricular gallop’): ventricular volume overload (heart failure, mitral regurgitation)

Question 4

S4

Answer 4

Due to atrial contraction against stiff ventricular wall (pressure overload)

• Physiologic: trained athletes
• Pathologic (‘S4/atrial gallop’): resistance to ventricular filling due to decreased compliance (ventricular hypertrophy, restrictive cardiomyopathy)

Question 5

Points of auscultation

Pulmonic valve

Answer 5

2nd left intercostal space, parasternal

Question 6

Points of auscultation

Aortic valve

Answer 6

2nd right intercostal space, parasternal

Question 7

Points of auscultation

Mitral valve

Answer 7

5th left intercostal space, midclavicular line (apex)

Question 8

Points of auscultation

Tricuspid valve

Answer 8

Over lower sternum

Question 9

Timing in the cardiac cycle

Pan (holo) - systolic/diastolic murmur

Answer 9

Along the entire phase

Mitral regurgitation

Question 10

Timing in the cardiac cycle

Early (proto) - systolic/diastolic murmur

Answer 10

Beginning of the phase

Aortic Regurgitation

Question 11

Timing in the cardiac cycle

Mid (meso) - systolic/diastolic

Answer 11

Middle of the phase

Aortic stenosis

Question 12

Timing in the cardiac cycle

Late (tele) - systolic/diastolic

Answer 12

End of the phase

Mitral stenosis

Question 13

Timing in the cardiac cycle

Continuous murmur

Answer 13

During the entire cardiac cycle

Friction rub, VSD

Question 14

Shape (configuration) of the murmur

Aortic stenosis

Answer 14

Crescendo-decrescendo murmur

first rises in intensity, then falls

Question 15

Shape (configuration) of the murmur

Mitral regurgitation

Answer 15

Plateau murmur
(the same intensity throughout)

Question 16

Shape (configuration) of the murmur

Mitral stenosis

Answer 16

Crescendo murmur
(intensity grows louder)

Question 17

Shape (configuration) of the murmur

Aortic Regurgitation

Answer 17

Decrescendo murmur
(intensity falls)

Question 18

Location of maximal intensity (‘punctum maximum’)

Aortic murmurs

Answer 18

Loudest at the base

Question 19

Location of maximal intensity (‘punctum maximum’)

Mitral murmurs

Answer 19

Loudest at the apex

Question 20

Radiation - Where to

Aortic murmurs

Answer 20

Carotids

Question 21

Radiation - Where to

Mitral murmurs

Answer 21

Axillary line

Question 22

Intensity on a ‘6-point-scale’ (Levine scale, 1933)

Grade 1

Answer 22

Very faint murmur, heard only after listener has ‘tuned in’; may not be heard in all positions

Question 23

Intensity on a ‘6-point-scale’ (Levine scale, 1933)

Grade 2

Answer 23

Quiet, but heard immediately after placing the stethoscope on the chest

Question 24

Intensity on a ‘6-point-scale’ (Levine scale, 1933)

Grade 3

Answer 24

Moderately loud

Question 25

Intensity on a ‘6-point-scale’ (Levine scale, 1933)

Grade 4

Answer 25

Loud, with palpable thrill

Question 26

Intensity on a ‘6-point-scale’ (Levine scale, 1933)

Grade 5

Answer 26

Very loud, with thrill; may be heard when the stethoscope is partly off the chest

Question 27

Intensity on a ‘6-point-scale’ (Levine scale, 1933)

Grade 6

Answer 27

Very loud, with thrill;

may be heard with stethoscope entirely off the chest

Question 28

Diastolic heart murmurs :
Mitral stenosis
Etiology

Answer 28

• Rheumatic heart disease

- Non-rheumatic etiology: congenital, degenerative calcification, endocarditis, carcinoid heart disease

Question 29

Diastolic heart murmurs :
Aortic regurgitation
Etiology

Answer 29

• Valvular (leaflet) abnormality: endocarditis, degenerative, rheumatic
• Annulus dilatation – aortic root disease: dilatative cardiomyopathy, atrial remodeling, aortic root dissection, Marfan’s syndrome

Question 30

Graham Steell murmur

Answer 30

Early diastolic murmur due to pulmonary regurgitation from pulmonary hypertension, may be heard rarely

Question 31

Opening snap of the mitral valve - When is it best heard

Answer 31

heard best at or medial to the apex in expiration

Question 32

Diastolic heart murmurs:
Aortic regurgitation
Etiology

Answer 32

• Valvular (leaflet) abnormality: endocarditis, degenerative, rheumatic
• Annulus dilatation – aortic root disease: dilatative cardiomyopathy, atrial remodeling, aortic root dissection, Marfan’s syndrome

Question 33

Austin Flint Murmur

Answer 33

Mid-diastolic murmur heard at the apex due to antegrade flow
across a mitral valve orifice which has been narrowed by a combination of
rising LV pressure and jet of AR directed at the anterior MV leaflet

Question 34

Traube’s sign

Answer 34

(‘pistol shot femora’) – loud systolic and diastolic bruit heard with stethoscope over femoral artery

Question 35

Diastolic heart murmurs:
Mitral stenosis
Murmur Sound

Answer 35

1. Mid-/late- diastolic
2. Crescendo
3. Apex
4. Axilla
5. Low-pitched

Question 36

Diastolic heart murmurs:
Aortic regurgitation
Murmur Sound

Answer 36

1. Early diastolic (duration of murmur correlated with severity of regurgitation)
2. Decrescendo
3. Left upper sternal border
4. Left sternal area
5. High-pitched

Question 37

Systolic heart murmurs:
Mitral regurgitation
Etiology

Answer 37

• Valvular (leaflet) abnormality: endocarditis, degenerative, rheumatic
• Sub-valvular apparatus abnormality:
  Chordal rupture, papillary muscle rupture, papillary muscle dysfunction
• Annulus dilatation: dilatative cardiomyopathy, atrial remodeling, Marfan’s syndrome

Question 38

Systolic heart murmurs:
Mitral regurgitation
Murmur Sound

Answer 38

1. Holosystolic
2. Plateau
3. Apex
4. Axilla

Question 39

Systolic heart murmurs:
Aortic stenosis
Etiology

Answer 39

• Acquired: degenerative, rheumatic, Paget disease of the bone
• Congenital: bicuspid aortic valve

Question 40

Systolic heart murmurs:
Aortic stenosis
Murmur Sound

Answer 40

Murmur

1. Mid-systolic
2. Crescendo-decrescendo
3. Right upper sternal border (aortic area)
4. Carotid
   * Systolic ejection click may be heard (severe stenosis)

Question 41

Systolic heart murmurs:
Aortic stenosis
Murmur Sound - If severity worsens

Answer 41

Murmur peaks later, extends later through systole, and may obscure S2