Heart sounds

Question 1

What makes S1?

Answer 1

Closure of mitral valve and tricuspid valve

Question 2

What can cause wide splitting of S1?

Answer 2

Right bundle branch block

Question 3

What makes S2?

Answer 3

Closure of aortic valve and pulmonary valve

Question 4

What can accentuate splitting in S2?

Answer 4

Inspiration

Question 5

Why does inspiration accentuate S2 splitting?

Answer 5

Blood is drawn into heart by negative intrathoracic pressure increasing right ventricular filling so it takes longer for blood to be ejected

Question 6

What can cause the absence of S2 splitting?

Answer 6

Diseases of aortic or pulmonary valve

Question 7

When is S3 heard and why?

Answer 7

Early diastole due to early ventricular filling

Question 8

What are some physiological causes of S3?

Answer 8

Fit, young adults

Athletes with slow heart rate and compliant ventricles

Question 9

What are the pathological causes of S3?

Answer 9

Abnormalities of left ventricle
Usually dilated with reduced compliance or when there is rapid filling of the left ventricle e.g. in severe mitral regurgitation

Question 10

What is an ejection click?

Answer 10

Abrupt, high frequency systolic sound

Associated with abnormal aortic or pulmonary valve

Question 11

What is the likely cause of an ejection click in an asymptomatic patient?

Answer 11

Bicuspid aortic valve

Can also occur in hypertension

Question 12

What is an opening snap associated with?

Answer 12

Valve opening in mitral or tricuspid stenosis

Question 13

Why does an opening snap occur?

Answer 13

Due to high atrial pressure

Question 14

What is a pericardial rub?

Answer 14

Intermittent scratchy sound with systolic and diastolic components

Question 15

What causes a pericardial rub?

Answer 15

Pericarditis due to inflamed visceral and parietal pericardium rubbing together

Question 16

What are you likely to hear with prosthetic valves?

Answer 16

Additional sharp clicking opening sounds which correspond to an ejection sound and an opening snap
Closing sound corresponds to component of heart sound contributed by that valve

Question 17

What is a pericardial knock?

Answer 17

Early diastole due to high pressure in atrium rapidly decompressing into restricted left ventricle producing audible reverberation

Question 18

Why is a right sided murmur likely to be louder during inspiration?

Answer 18

Right heart blood flow increases during inspiration

Question 19

What group of people are likely to have an innocent murmur?

Answer 19

Children
Pregnancy
Fever
Anaemia
Hyperthyroidism

Question 20

Describe a mid-ejection systolic murmur

Answer 20

Increases in early systole and decreases in late systole (crescendo decrescendo pattern)

Question 21

What can cause a mid-ejection systolic murmur?

Answer 21

Aortic and pulmonary stenosis
Aortic sclerosis and HOCM
Atrial septal defects

Question 22

How can you differentiate between aortic/pulmonary stenosis and aortic sclerosis?

Answer 22

Aortic sclerosis doesn’t radiate to carotids unlike aortic / pulmonary stenosis

Question 23

What is a pan systolic murmur?

Answer 23

Murmur intensity that doesn’t vary much throughout systole

Stops when mitral valve opens

Question 24

What can cause a pan systolic murmur?

Answer 24

Mitral and tricuspid regurgitation

Question 25

What is a late systolic murmur?

Answer 25

Commences in mid to late systole Often preceded by ejection click. Stops when mitral valve opens

Question 26

What can cause a late systolic murmur?

Answer 26

Mitral valve prolapse

Question 27

What is the likely cause of a murmur getting softer and disappearing?

Answer 27

When a lesion is very severe the transvalvular flow starts to fall and can cause heart failure

Question 28

What is an early diastolic murmur?

Answer 28

Commences immediately following S2 and decreases during diastole (decrescendo)

Question 29

What can cause an early diastolic murmur?

Answer 29

Aortic or pulmonary regurgitation

Question 30

Why does the murmur caused by aortic or pulmonary regurgitation occur at the start of diastole?

Answer 30

Biggest pressure difference between outflow vessel and ventricle is at beginning of diastole

Question 31

What can cause a mid diastolic murmur?

Answer 31

Mitral stenosis

Question 32

How can you accentuate a mitral diastolic murmur?

Answer 32

Turn patient on left side and listen at cardiac apex with bell

Question 33

What is a continuous murmur?

Answer 33

Occurs throughout cardiac cycle. Systolic component usually louder than diastolic component.

Question 34

What can cause a continuous murmur?

Answer 34

Patient ductus arteriosus | Acute communication between right and left side of heart e.g. ruptured sinus of Valsalva or infective endocarditis

Question 35

Describe the murmur heard in aortic stenosis

Answer 35

Ejection systolic murmur | Heard loudest over aortic area during expiration and if sitting forward

Question 36

Where does an aortic stenosis murmur radiate to?

Answer 36

Carotid artery

Question 37

Why is an aortic stenosis murmur heard loudest at the cardiac apex in elderly people?

Answer 37

Due to hyper inflated lungs

Question 38

Why does aortic stenosis cause reverse splitting of S2?

Answer 38

Aortic valve closes after pulmonary valve due to the longer time required for blood to exit the left ventricle

Question 39

Describe the associated features with aortic stenosis

Answer 39

Slow rising pulse with narrow pulse pressure Non-displaced, heaving apex beat Reduced or absent S2 Reverse splitting of S2

Question 40

Describe the murmur heard in pulmonary stenosis

Answer 40

Ejection systolic murmur | Heard loudest in pulmonary region during inspiration

Question 41

Where does pulmonary stenosis radiate to?

Answer 41

Left shoulder (infraclavicular region)

Question 42

Describe the associated features with pulmonary stenosis

Answer 42

Prominent 'a waves' in JVP Widely split S2 P2 may be soft and inaudbile Right ventricular dilatation

Question 43

Why does pulmonary stenosis cause a widely split S2?

Answer 43

Blood from ventricle takes longer to pass through narrow pulmonary valve so pulmonary valve closure occurs much later than aortic valve closure

Question 44

What can right ventricular dilatation lead to?

Answer 44

Right ventricular heave Tricuspid regurgitation Peripheral signs of right-sided HF e.g. peripheral oedema, ascites

Question 45

Describe the murmur in mitral stenosis

Answer 45

Snapping sound when mitral valve opens Heard loudest over apex in left lateral decubitus position on expiration Low-pitched rumbling, mid-diastolic murmur

Question 46

What are some features associated with mitral stenosis?

Answer 46

Signs of pulmonary hypotension | Low-volume pulse which may be irregularly irregular

Question 47

Describe the murmur in tricuspid stenosis

Answer 47

Mid-diastolic murmur | Loudest at 3-4th ICS, left sternal edge during inspiration

Question 48

What are the signs of right atrial enlargement?

Answer 48

Raised JVP with giant 'a waves' Peripheral oedema Ascites

Question 49

Describe the murmur in mitral regurgitation

Answer 49

Pansystolic murmur | Heard loudest over mitral area on expiration in left lateral decubitus position

Question 50

Where does a mitral regurgitation murmur radiate to?

Answer 50

Axilla

Question 51

Describe the murmur in tricuspid regurgitation

Answer 51

Pansystolic murmur | Heard loudest over tricuspid region during inspiration

Question 52

What features are associated with tricuspid regurgitation?

Answer 52

Large 'v waves' in JVP Visibile / palpable hepatic pulsations Signs of right sided HF

Question 53

Describe the murmur in aortic regurgitation

Answer 53

Mild AR produces soft, short, early diastolic murmur | Severe, chronic AR has loud and short murmur

Question 54

Where does an aortic regurgitation murmur radiate to?

Answer 54

Left sternal edge

Question 55

Why does a collapsing pulse occur in aortic regurgitation?

Answer 55

Due to blood flowing back into LV after systole leading to abrupt drop in BP after ventricular contraction. This causes a sudden drop in arterial pressure and subsequent collapse of arterial vessel walls

Question 56

Describe the murmur in pulmonary regurgitation

Answer 56

Early decrescendo murmur | Heard loudest over left sternal edge during inspiration

Question 57

Describe the murmur heard in mitral valve prolapse

Answer 57

Mid-systolic click followed by a mid or late systolic murmur | Heard loudest at apex during expiration