Heart Sounds and Murmurs Exam #1 Flashcards
Define Auscultation
Auscultation: listening to heart sounds by using our stethoscope. The timing of the heart sounds and duration of the murmur. Ruling out valvular disease or ischemic disease.
Auscultation is used to detect HR and rhythm and any cardiac murmurs, rubs, or gallops; crackles or wheezes in the lungs; pleural rubs; movement of gas or food through the intestines; valscular or thyroid bruits; fetal heart tones; and other physiological phenomena.
Define Frequency
Frequency: is the loudness of a sound. The higher the frequency, the higher the pitch. If the LV is not contracting well, the murmur will not be as intense in sound as it would when the LV is normal. ex: when you have a SV going through a stenotic mitral valve, it will produce a murmur.
Define Holosystolic
all throughout the entire ejection period.
Relating to the entire duration of systole.
Define Intensity
Intensity: will change with the intensity of the degree of the stenosis
Define Listening Post
where you will listen to the murmur
Define Non Compliant
non-compliant: relative to the left and right ventricle. It means stiff.
Define Pansystolic
Throughout systole; used to describe the murmur of mitral regurgitation (SYN; holosystolic)
Define Pitch
pitch: sound of the murmur through auditory sensation of that murmur.
Define Diastolic Rumble
diastolic rumble: flow or turbulence through your mitral or tricuspid valves. sound during diastole, can be a vibration or the sound combination of two murmurs. Can also be the sound two murmurs. can be normal or abnormal. (can not palpate it)
Define Opening Snap
open snap: mitral or tricuspid stenosis, it is the snap of the leaflet trying to open
Define Crecendo
Crescendo: means the sound is getting increasingly louder.
Define Decrecendo
decreasing sound
Define Bruit
continuous sound. Bruit (/ˈbruːt/) is the unusual sound that blood makes when it rushes past an obstruction (called turbulent flow) in an artery when the sound is auscultated with the bell portion of a stethoscope.
Define Gallop
Gallop: samation of sounds or murmurs
An extra heart sound (a 3rd or 4th heart sound) typically heard during diastole.
Define Murmur
Murmur: produced by blood flow. We can have a systolic ejection murmur. There is also something called an innocent murmur. Can be normal or abnormal
Define Systolic ejection murmur
Systolic ejection murmur: can be normal or abnormal.
Systolic ejection or midsystolic murmurs are due to turbulent forward flow across the right and left ventricular outflow tract, aortic or pulmonary valve, or through the aorta or pulmonary artery.
Define Thrill
Thrill: An abnormal tremor accompanying a vascular or cardiac murmur felt on palpation. Its a vibration from a stenotic lesion.
Define Friction Rub
caused by pericarditis.
When the heart and the paracardium rub together
Cardiac Listening Posts:
Aortic
two listening posts.
2nd RIGHT intercostal space for the
aortic route or
ascending.
If the patients aortic route is dilated we will move the stethoscope.
also where you listen to aortic stenosis. Follow the jet up the neck.
Cardiac Listening Posts:
Secondary Aortic
2nd left intercostal space. May be the 3rd intercostal space depending on the size of the patient.
2nd LEFT is the Aortic valve and
2nd RIGHT acending aortic route.
Cardiac Listening Posts:
Pulmonic
2nd LEFT mid clavicular space.
If patient has PS the stethoscope would be
moved laterally
Cardiac Listening Posts:
Tricuspid
3rd or 4th LEFT intercostal space.
Cardiac Listening Posts:
Mitral
PMI mid clavicular or mid axillary (3rd-6th intercostal muscle depending on size of the patient.)
Cardiac Listening Posts:
LVOT
left sternal boarder in the 3rd or 4th intercostal spaces.
What are we listening for at the listening posts?
We are trying to listen in the direction blood is flowing.
How does the heart sit in the mediastinum?
60 degrees to the left, posterior and the apex is anterior.
Where is our PA located?
Our PA is anterior and to the left
where would the physician ascultate if he was evaluating MR?
just below the left scapula
If you are facing the patient, where is the LA located and what direction is flood flowing through the Mitral valve?
If your facing the patient, the left atrium is the most posterior chamber of the heart so the mitral valve jet is going towards the back.
if the patient has AI what other listening posts could we use instead of the 3rd and 4th intercostal?
PMI because the jet is going towards the APEX.
Physical Characteristics of sound:
Infrasound:
below the sound of hearing. It is the sound we palpate.
PMI would be below hearing but we can feel it.
Physical Characteristics of sound:
Sound
Sound: anything above 20 Hz is normal hearing.
Sound can also be expressed in decibels. It is the intensity or loudness of a signal.
Physical Characteristics of sound:
Ultrasound
Ultrasound: imaging, kidney stones, therapeutic measure.
Larger than 20 kHz. Transducer are in mHz.
Physical Characteristics of sound:
Sound Intensity
Intensity changes the amount of wavelengths.
Physical Characteristics of sound:
Sound Frequency
Sound frequency: number of vibrations per unit time. The number of wavelengths.
Physical Characteristics of sound:
Pitch
Pitch: changes with frequency. Auditory sound. loading conditions.
Physical Characteristics of sound:
How does Frequency, Intensity, and Pitch change each other?
Anything that alters mechanics, alters Frequency, Intensity, and Pitch.
If we had critical AS or PS, and the pt had poor ventricular function do you think the intensity or the frequency is going to be the same if the LV was normal?
No, because the pressure is low which decreases the frequency and intensity.
Erbs point:
Anatomical landmark in the area of the AO and the PA.
3rd left intercostal space.
We can hear S2 the best there.
What is the hardest Murmur to hear?
AI is one of the hardest murmurs to hear so it usually goes undetected.
When we talk about normal or abnormal flow, the sounds do produce what?
does produce a frequency and wavelengths.
The patients LV mechanics related to sound:
BP goes up, frequency goes up, intensity goes up, and pitch goes up.
What causes the murmur to be muffled?
if patient has a pericardial effusion, the murmur will be muffled.
First Heart sound S1 :
coincides with the R wave ( onset of systole ) , often louder over the LV apex.
Events leading to the formation of S1:
a. mitral and tricuspid valve closure
b. aortic and pulmonic valves open
c. onset of maximal ejection
d. acceleration of blood flow
Where can we hear S1 the best?
We can hear S1 best at the Apex
Second Heart Sound S2:
a. Aortic & Pulmonic closure, MV & TV opening .
b. End of systole/Beginning of diastole
c. Physiologic splitting
S2 Physiologic Splitting:
- Due to increase venus return to the right heart on inspirations.
When we take a breath in it lowers our thoracic pressure and increased volume to the right heart therefore P2 is a little delayed. - Heard best in the 3rd LEFT intercostal space at Herbs point.
- S2 sounds louder because of the pressure on the left
S2 occurs
S2 is made up of
at the end of the T wave
Made up of A2 and P2
AO and PA close and MV and TV open
Third Heart Sound S3
a. Low frequency vibration which occurs during rapid Left ventricular filling in early Diastole.
b. Normal in children and infants, Not in adults
c. left sided sound
Factors which promote a normal S3 :
- Fever
- Exercise
- Venus return due to exercise
(when we exercise there is more venus return)
heard best in the mitral and tricuspid valve area.
When does S3 happen?
Where is it heard?
- AO and PV close MV and TV open and then S3 happens
- occurs during rapid passive filling
- Heard in the Mitral and Tricuspid valve area
What produces an S3?
MS, high pressures, Severe systolic or diastolic failure of the LV.
Fourth Heart sound:
a. Low frequency vibration during active filling, follows the P wave . Difficult to hear.
b. The only active part of diastole is when the atria contract (a kick) the rest is pressure.
c. S4 is Always abnormal.
d. RV and LV failure. Can be CHF which is a system failure.
When does S4 happen?
Occurs during Active Ventricular filling at the end of diastole just after the P wave
Normal reasons for S4 are:
increased HR or BP, changes in loading condition
Systolic Murmurs:
b. Forward flow through a _____ valve.
c. Retrograde flow through a _____ valve.
a. Produced by normal / abnormal turbulent flow through the LVOT / RVOT referred to as systolic ejection murmurs.
b. Forward flow through a stenotic (AS or PS) valve.
c. Retrograde flow through a mitral or tricuspid valve.
Characteristics of Systolic Ejection Murmurs:
a. Usually Harsh
b. Occur during systole
c. Can be normal
What would mimik an AS murmur?
Sub aortic stenosis
LVOT or RVOT obstruction
We can True AS or True PS or outflow track obstruction.
Pansystolic / Holosystolic Murmurs Characteristics:
a. Even intensity throughout Systole.
Depending on the severity, it can last the entire length of systole.
b. Extend / merge with S2
If it is a lot of regurge it will extend all the way to S2.
Examples of holosystolic murmurs :
Mitral Regurge
Tricuspid Regurge
as the stenosis increases,
the peak of the sound will be delayed.
What does the word “Functional” mean?
normal
Lets say you have a lot of AI, and that AI jet hits your MV causing your MV will close early, do we have MR during diastole?
yes
Diastolic Murmurs:
b. Abnormal Diastolic murmurs would be produced from blood flowing across a ______ valve, which valves would be involved?
c. Or regu
a. During Diastole we can have murmurs due to normal flow or sounds from the MItral and Tricuspid valves opening / closing .
* ***The leaflets, cordae, and valves opening and closing can make sounds
b. Abnormal Diastolic murmurs would be produced from blood flowing across a MS, TS valve , which valves would be involved?
c. Or regurgitant flow across the AI, PI valves .
Diastolic Murmurs
Characteristics of MS, TS:
- the murmur of MS and TS follow the stages of ventricular Diastole
- Opening snap
- early crescendo to decrescendo leading to pre-systolic accentuation
• Associated murmurs :
tricuspid regurge
opening snap
mitral regurge
Diastolic Murmurs
Characteristics of AI , PI :
A decrescendo murmur , dependent on the severity of the lesion and the PG between what 2 chambers ?
where are the murmurs heard the best ?
- A decrescendo murmur , dependent on the severity of the lesion and the PG between what 2 chambers ? LV and AO because it is systemic
- It is a soft pitched blowing murmur
- where are the murmurs heard the best ?LVOT and Apex
What if the pt had PI?
2nd or 3rd left mid clavicular.
whats the Erbs point?
3rd left, good for S2 and for AO and PA.
What makes A2 and P2?
Aortic and pulmonic valve closure.
Systolic Murmurs :
- Pulmonic Stenosis
- Aortic Stenosis
- LVOT/ RVOT obstruction
- Mitral Regurge
- Tricuspid Regurge
- VSD’s- Ventricular septal defects. Produces the same sound as AS and occurs during systole.
Diastolic Murmurs :
- Aortic Insufficiency
- Pulmonic Insufficiency
- Tricuspid stenosis
- Mitral Stenosis
- ASD-Atrial septal defects
Diastolic murmurs, AI and PI are from what pressure gradients?
AI it is the pressure gradient between the systemic LV and Aorta valve
PI is the pressure gradient between the RV and the Pulmonic valve
Grades of Murmurs
Grade I: barely audible
Grade II : quiet but heard immediately after placing the stethescope on the chest wall
Grade III : moderate / loud
Grade IV : Loud but there can be a palpable thrill
Grade V : very loud
Grade VI : stethoscope is off the chest and you can hear it.
Click Murmurs :
Click Murmurs : sounds produced from valvular chordae, leaflets opening , closing
if the patients chordae are to long you will hear click murmurs. could be normal.
Tumor Plops:
Tumors interfere with MV flow and make a sound. Interferes with the LA filling and it makes a plop sound. It is a low frequency plop.
if it is a fixed tumor in the MV you will not hear it in the LV.
Continuous Murmurs:
A Patent Ductus Arteriosus (PDA)
Austin Flint Murmur:
due to AI (AI occurs during diastole) stream jet that hits the MV
Breath Sounds :
breathing heard through the chest wall .
They are heard over large airways produced by turbulent flow.
As air travels through the airways beyond the segmental bronchi these sounds diminish because they are filtered by the chest wall pleurae and air filled Lung tissue .
Normal Breath sounds:
Normal breath sounds heard over the chest wall area are soft and low pitched, they are softer and shorter during expiration than during inspiration.
Define Pneumothorax:
Punctured lung
Define Atelectasis:
When the alveoli close
Definition: A collapsed or airless condition of the lung. A condition in which the lungs of a fetus remain partially or totally unexpanded at birth.
Define Crackles:
When the patient takes a breath in and there are crackles they are due to fluid in the lungs.
Definition: Produced by air passing over retained airway secretions or the sudden open of collapsed airways. I may be heard on inspiration or expiration. It is a adventitious lung sound as opposed to a wheeze, which is continuous.
Inspiratory Wheezes: • Expiratory Wheezes:
When patient takes a breath in and exhales you can hear it. It is due to inflamed and narrow airways.
Definition: a continuous musical sound caused by narrowing of the lumen of a respiratory passageway. It can occur with MS.
Rales:
CRACKLE -sound produced due to the alveoli and bronchi
Diminished Heart Sounds:
low blood pressure, ventilator, chest wall thickness, lung disease
Labored Breathing:
hard for the patient to breath
Short of Breath:
mechanically labored breathing
Respiratory Rate
breaths per minute 14-20 is normal
why does a patient cough up blood?
blood in the lungs, capillaries
when we have fluid in the alveoli, what does that effect?
Gas exchange
Lung disease causes cardiac diseases and…
cardiac disease causes lung disease. This happens over a long period of time.
