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ACNP805: Acute Diagnostic Reasoning > Heart Sounds Exam > Flashcards

Heart Sounds Exam Flashcards

1
Q

Where are the traditional areas of auscultation?

A

$ Mitral area: cardiac apex
$ Tricuspid area: 4th & 5th intercostal spaces along left sternal border
$ Aortic area: 2nd intercostal space along right sternal border
$ Pulmonic area: 2nd intercostal space along left sternal border

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2
Q

Where is the left ventricular area?

A

Centered around traditional mitral area at the cardiac apex. Extends laterally in the 3rd & 4th interspaces to left sternal border in one direction, to the anterior axillary line in the other.

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3
Q

What is best heard in the left ventricular area? Murmurs? Heart sounds?

A

Murmurs: Aortic & mitral regurg or stenosis; hypertrophic obstructive cardiomyopathy

Heart sounds: aortic component of S2; left atrial or ventricular gallop (S3, S4)

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4
Q

Where is the right ventricular area?

A

Extension of traditional tricuspid area in 3rd & 4th interspaces, now including lower sternum & both sternal borders

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5
Q

What is best heard in right ventricular area? Murmurs? Heart sounds?

A

Murmurs: Tricuspid stenosis or regurg; pulmonary regurg; ventricular septal defect

Heart sounds: Right ventricular or atrial gallop; opening snap of tricuspid valve

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6
Q

Where is the left atrial area?

A

Anterior: above & to the left of the apex
Posterior: Between the spine & border of the scapula at the level of the scapula tip

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7
Q

What is best heard at the left atrial area? Murmurs?

A

Murmur: mitral regurg

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8
Q

Where is the right atrial area?

A

Right sternal border in 4th & 5th interspaces

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9
Q

What is best heard in the right atrial area? Murmurs?

A

Murmur: tricuspid insufficiency

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10
Q

Where is the aortic area?

A

Broad strip curving upward & to the right from the third left interspace to just above the right sternoclavicular joint

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11
Q

What is best heard in the aortic area? Murmurs? Heart sounds?

A

Murmur: aortic stenosis & insufficiency; increased aortic flow, dilation of the ascending aorta, abnormalities of the carotid or subclavian arteries

Heart sounds: aortic ejection click & A2.

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12
Q

Where is the pulmonic area?

A

Extension of traditional pulmonary area, taking in 2nd & 3rd interspaces along left sternal border

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13
Q

What is best heard in pulmonic area?

A

Murmurs: pulmonary stenosis & insufficiency; increased pulmonary flow; stenosis of main branch of pulmonary artery; patent ductus arteriosus.

Heart sounds: pulmonary ejection sound & pulmonary component of second heart sound (P2)

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14
Q

Describe the position for cardiac auscultation

A

Patient recumbent & relaxed. Perform exam from patient’s right side. May raise legs to increase venous return. Mitral thrills & murmurs best noted when patient is on left side.

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15
Q

Describe the difference btwn normal & abormal rate of rise in carotid or radial arteries:

A

Normal: sharp tap

Abnormal: Nude or weak tap followed by nudge or push (aortic stenosis); collapsing quality (aortic insufficiency, patent ductus, hypertrophic obstructive cardiomyopathy)

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16
Q

Describe palpation of pulsus alternans. What does it indicate?

A

Alternating strong & weak pulses. Indicates severe advanced myocardial disease & decreased left ventricular function. Often disappears with appropriate CHF treatment.

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17
Q

Describe brachio-radial delay & apical-carotid delay. What do they indicate?

A

Palpate both radial & brachial pulses simultaneously (or the point of maximum impulse & carotid). Any delay is abnormal.

Indicates: aortic stenosis

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18
Q

Inching technique: 7 steps

A

1) Begin at aortic area with diaphragm
2) Move to pulmonary area
3) Move to left ventricular area with diaphragm
4) Switch to bell, same area
5) Right ventricular area: diaphragm, then bell
6) Point of maximum impulse: diaphragm & bell
7) Patient sit up, lean forward. Left sternal border @ 3rd & 4th interspace, Valsalva.

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19
Q

S1 becomes louder because of:

A

$ Normal physiology in children, young adults, patients with thin chest wall
$ Mitral stenosis with mobile valve
$ Short PR interval
$ High output states (tachycardia due to exercise, emotion, fever, anemia; pregnancy)
$ Atrial septal defect (in which T-component is loud)

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20
Q

Causes of S4 Gallop

A

LV Systolic Overload (systemic hypertension; LV outflow obstruction; cooarctation of the aorta)
RV Systolic Overload (pulmonary hypertension; right ventricular outflow obstruction; pulmonary artery stenosis)
Diminished ventricular compliance and/or elevated ventricular end-diastolic pressure (cardiomyopathies; ventricular failure; ischemic heart disease; myocardial infarct)
Other causes associated with augmented ventricular filling (thyrotoxicosis; anemia; mitral regurg; large arteriovenous fistulae)
Complete heart block (S4 occurs randomly in diastole)

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21
Q

S1 becomes softer because of:

A 
$ Mitral regurg
$ Long PR interval
$ Diminished LV contractility (CHF, acute MI, cardiomyopathy)
$ Obesity
$ COPD
$ Pericardial effusion
$ Aortic stenosis
$ Hypothyroidism
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22
Q

S1 varies in intensity from beat to beat because of:

A

$ AV dissociation (ventricular tach, AV block, or paced ventricular)
$ Type 1 second degree AV block
$ Atrial fib with normal mitral valve
$ Atrial flutter with varying AV conduction

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23
Q

Wide splitting of S1 occurs because of:

A 
$ right BBB
$ PVCs
$ Ventricular tach
$ Atrial septal defect
$ Tricuspid stenosis
$ Ebstein's anomaly
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24
Q

Wide splitting of S2 occurs because of:

A

Delayed pulmonic closure:
* Delayed right ventricular activation (RBBB, paced beats, PVCs)
* Prolonged right ventricular mechanical systole (pulmonic stenosis, acute massive pulmonary embolus, cor pulmonale)
* Decreased impedance of pulmonary vascular bed (atrial septal defect, pulmonary artery dilation, pulmonic stenosis)
* Unexplained auditory expiratory splitting in otherwise normal heart
Early aortic closure:
* Shortened left ventricular ejection time (mitral insufficiency or VSD)

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25
Paradoxical splitting of S2 occurs because of:
Delayed aortic closure * delayed left ventricular activation (LBBB, paced beats, right ventricular ectopy) Prolonged left ventricular systole *complete LBBB *LV outflow tract obstruction * Hypertensive CV disease * Arteriosclerotic heart disease (chronic ischemic heart disease, angina pectoris, cooarctation of the aorta) Decreased impedance of systemic vascular bed * poststenotic dilation of the aorta secondary to aortic stenosis or insufficiency * patent ductus arteriosis * aortopulmonary window Early pulmonic closure * Early right ventricular activation (WPW) * Tricuspid regurg * Impaired LV contractility
26
Causes of S3 Gallop
LV Diastolic overload (mitral regurg; aortic regurg; left to right shunt; high output states) RV Diastolic overload (tricuspid regurg; pulmonary regurg; left to right shunt; high output states) Diminished ventricular compliance and/or elevated ventricular mean diastolic pressure (cardiomyopathies; ventricular failure; ischemic heart disease) Normal physiology (up to 30-40 years of age)
27
Listen for S3: bell or diaphragm?
Bell.
28
Where to listen for mitral stenosis?
Diaphragm; between apex & lower left sternal border at 4th intercostal space.
29
Where to listen for tricuspid stenosis?
Bell; lower right sternal border
30
Where to listen for pericardial friction rub?
Diaphragm; 3rd/4th interspace at left sternal border
31
Where to listen for pericardial knock?
Diagphragm; lower left sternal border. In milkd constrictive pericarditis, may only be heard on inspiration.
32
Where to listen for left atrial tumor plop?
Diaphragm; point of maximum impulse with patient in left lateral position.
33
Where to listen for mitral valve vegetation plop?
Diaphragm at the left upper parasternal border
34
Where to listen for aortic ejection sounds?
Diaphragm at left ventricular apex & aortic area.
35
Where to listen for pulmonic ejection sounds?
Diaphragm; localized area in 2nd/3rd interspaces at left sternal border. Little to no radiation. Decreases in intensity during inspiration, & is only right-sided heart sounds that does so.
36
Where to listen for mitral valve prolapse systolic click?
diaphragm; at apex with patient in left lateral position. Click will decrease in intensity as the stethoscope is moved toward base of heart.
37
Grade I Murmur
Audible only with concentration & adjustment of stethoscope. Often not heard during first few seconds.
38
Grade II Murmur
Faint, but heard immediately upon auscultation
39
Grade III Murmur
Intermediate intensity. Not loud, but somewhat louder than grade II.
40
Grade IV Murmur
Loud but still of intermediate intensity. Generally associated with palpable vibration or thrill. Detection of thrill indicates grade IV or higher.
41
Grade V Murmur
Very loud & heard only with one edge of stethoscople against chest wall. Thrill present.
42
Grade VI Murmur
Audible with stethoscope removed slightly from chest. Thrill present. Heard with ear near the chest, without stethoscope.
43
Murmurs to Memorize: Mitral stenosis
low-pitched rumbling diastolic murmur best heard at apex with patient positioned on left side.
44
Murmurs to Memorize: Mitral insufficiency
Blowing, frequently holosystolic murmur best heard at or within apex, conducted to the axilla
45
Murmurs to Memorize: Aortic stenosis
Rough, ejection type systolic murmur best heard in aortic area & suprasternal notch & conducted up into carotid arteries
46
Murmurs to Memorize: Tricuspid stenosis
Low-pitched, rubmling diastolic murmur best heard at lower end of sternum & increasing with inspiration
47
Murmurs to Memorize: Tricuspid insufficiency
Blowing, pansystolic murmur best heard at lower end of sternum & increasing with inspiration
48
Murmurs to Memorize: Pulmonary stenosis
Rough, ejection-type systolic murmur best heard in pulmonary area, well heard in back, increasing with inspiration
49
Murmurs to Memorize: Pulmonary insufficiency
similar to aortic insufficiency but may increase on inspiration
50
6 Cardinal clinical signs of pathological murmur in children
1) Holosystolic murmur 2) Harsh murmur 3) Abnormal heart sound 4) Early or mid-systolic click 5) Grade III murmur or higher (disputed because innocent murmur can be up to & including grade III) 6) Heard over upper left sternal border (also disputed because this is common in healthy neonate)
51
5 types of innocent murmurs heard in childhood
1) Still's murmur (vibratory systolic murmur) 2) physiological pulmonary ejection murmur 3) Supraclavicular arterial bruit 4) Venous hum 5) Peripheral pulmonary stenosis of the newborn
52
Where to listen for Still's vibratory systolic murmur?
Bell; lower mid-precordium. Left lower sternal border across to the apex, patient in supine position
53
Where to listen for innocent pulmonary systolic ejection murmur?
Diaphragm along left sternal border, 2nd/3rd interspace, patient in supine position. Best during inspiration.
54
Where to listen for innocent supraclavicular arterial bruit?
Bell; over supraclavicular fossa & over sternomastoid muscle bilaterally. Patient sitting.
55
Where to listen for innocent venous hum?
Bell; right supraclavicular space
56
Where to listen for innocent peripheral pulmonary stenosis of newborn?
Bell; during systole at upper left sternal border & axillary areas
57
Where to listen for innocent aortic systolic murmur?
Bell; aortic area
58
Where to listen for mammary artery souffle?
Diaphragm; anterior chest wall over breast
59
Where to listen for aortic stenosis?
Diaphragm; 2nd right intercostal space. Also apex & precordium, both clavicles & carotids & the suprasternal notch
60
Where to listen for biscuspid aortic valve?
Has systolic murmur & ejection sound which do not alter with respiration. Diaphragm @ apex & aortic area. To hear diastolic murmur: use diaphragm @ left sternal border with patient sitting leaning forward.
61
Where to listen for pulmonic valve stenosis?
Diaphragm @ 2nd/3rd left intercostal space in supine patient after brief exercise or held breath. When loud, also heard over the upper left back, base of left neck, & suprasternal notch
62
Where to listen for Tetralogy of Fallot?
With the bell @ left sternal border between 3rd/4th interspace (listening for the pulmonary outflow tract rather than ventricular septal defect)
63
Where to listen for dilation of proximal pulmonary artery?
With the diaphragm @ base of heart
64
Where to listen for atrial septal defect?
Wide, fixed split S2 and systolic murmur. Diaphragm at 3rd interspace left sternal border, pulmonic area. To hear diastolic rumble, bell of stethoscope @ lower left sternal border
65
Where to listen for pulmonary stenosis?
diaphragm @ upper left sternal border, the axilla, & back
66
Where to listen for coarctation of the aorta?
Systolic murmur. Diaphragm over aortic & pulmonic area. Similar murmur in supraclavicular & interscapular regions. S1 usually normal, but maybe associated systolic ejection sound, best heard over aortic & mitral areas & over carotid arteries.
67
What are the normal diastolic heart sounds?
There are none; diastole should be silent.
68
Where to listen for chronic severe aortic regurgitation?
Diastolic murmur; Diaphragm firmly at the left then right sternal borders @ 3rd/4th interspaces with patient seated, leaning forward, breath held in expiration
69
Where to listen for systolic ejection murmur of chronic severe aortic regurgitation?
Bell & diaphragm; right sternal border @ 2nd intercostal space
70
Where to listen for Austin Flint murmur?
Bell; over point of maximum impulse with patient in left lateral position
71
Where to listen for pulmonary regurgitation?
Diaphragm in pulmonary area
72
Where to listen for diastolic rumble of mitral stenosis?
Bell applied with LIGHT PRESSURE at point of maximum impulse with patient in left lateral position. Must be placed extremely precisely over that point; murmur will vanish if stethoscope is moved slightly
73
Where to listen for tricuspid stenosis?
Bell applied with light pressure on lower left sternal border (in xiphoid area) with patient in recumbent position.
74
Where to listen for patent ductus arteriosis?
Bell; @ 2nd left interspace (pulmonic area), possibly 3rd interspace. Check carefully for other causes; coronary arteriovenous fistula produces murmur heard over 3rd & 4th interspaces here.
75
What are the normal sounds associated with the ball-and-cage type prosthetic aortic heart valve?
``` S1 to AO (aortic opening) interval = 0.07 sec AO > AC Grade II-III systolic ejection murmur NO DIASTOLIC SOUNDS Multiple systolic clicks may be present ```
76
What are the normal sounds associated with the bioprosthetic aortic heart valve?
``` S1-AO interval: .03-.08 sec AO rarely heard AC usually heard Grade II-IV systolic ejection murmur NO DIASTOLIC MURMUR ```
77
What are the normal sounds associated with the tilting disc aortic heart valve?
``` S1-AO interval: .03-.08 sec AO rarely heard AC usually heard Grade II-IV systolic ejection murmur Audible diastolic murmur rare ```
78
What are the normal sounds associated with the St. Jude bi-leaflet aortic heart valve?
``` AO may not be heard AC heard in all patients AC > AO Grade II-IV systolic ejection murmur in 1/3 NO DIASTOLIC MURMURS S1 normal S1-AO= 0.06-0.08 sec ```
79
What are the abnormal sounds associated with the ball & cage style aortic valve?
Absent AO or AO < AC (ball variance or thrombosis) S1-AO variable (sticking poppet) Absent AO or AC (AI, sticking popet, ball variance, thrombosis) Diastolic murmur
80
What are the abnormal sounds associated with the bioprosthetic aortic valve?
``` Diastolic murmur (AI) Grade III-IV pansystolic ejection murmur + decreased AC (fibrosis & calcification) Dominant frequency of AC may increase with degenerative changes & stiffening ```
81
What are the abnormal sounds associated with the tilting disc type aortic valve?
Loss of AC (abnormal disc motion; thrombosis) Grade II-VI diastolic murmur (AI) AI may also be silent
82
What are the abnormal sounds associated with the St. Jude bi-leaflet type aortic valve?
Diastolic murmur (AI)
83
What are the normal sounds associated with the ball & cage type prosthetic mitral valve?
``` A2-MO interval 0.10-0.15 sec MO > MC Grade II/VI systolic ejection murmur NO DIASTOLIC MURMUR Prosthetic s3 frequently present ```
84
What are the abnormal sounds associated with the ball & cage type prosthetic mitral valve?
``` a2-MO < 0.06 seconds (abnormal valve function; increased left atrial pressure) a2-MO > 0.15 sec or variable a2-MO (suggests sticking poppet) Diastolic murmur (clots obstructing valve orifice; prosthetic valve regurg & increased diastolic flow across prosthesis; aortic regurg/Austin Flint murmur) Absent MO (valve dehiscence; ball variance; thrombosis) ```
85
What are the normal sounds associated with the bioprosthetic mitral valve?
A2-MO interval: 0.07-0.11 sec Grade II/VI systolic ejection murmur Possible diastolic rumble MO heard in 50% of cases
86
What are the abnormal sounds associated with the bioprosthetic mitral valve?
A2-MO not of diagnostic value Diastolic rumble MAY indicate prosthetic stenosis Regurgitation may be silent Flail leaflet with mitral regurg may cause musical murmur
87
What are the normal sounds associated with the tilting disc type mitral valve?
A2-MO interval 0.05-0.09 sec MC always heard MO rarely heard Grade II/VI systolic ejection murmur
88
What are the abnormal sounds associated with the tilting disc type mitral valve?
Paravalvular leak & thrombosis may be silent Holosystolic murmur (mitral regurg) II/VI diastolic murmur (stenosis or malfunction) Absent MC + loud systolic murmur (jamming of disc or acute mitral regurg) Absent mechanical valve sounds (thrombus; obstruction
89
What are the normal sounds associated with the St. Jude bi-leaflet type mitral valve?
``` A2-MO 0.04-0.08 sec MC 0.05-0.07 sec after R wave on ECG MO= 1/10 amp of MC; may not be heard No murmurs Mid-diastolic rumble possible ```
90
What are the abnormal sounds associated with the St. Jude bi-leaflet type mitral valve?
holosystolic murmur (mitral regurg) Changing diastolic murmur or new diastolic murmur (orificial stenosis) Absent or decreased MC in normal function patient suggest jamming (MC decreased in afib with long RR, LV dysfunction, 1st deg AV block) Apical systolic murmur (valvular & paravalvular leak)
91
Caravallo's manuver & purposes
Deep inspiration followed by post-inspiratory apnea. Purposes: 1) Events generated by R heart (except ejection sound of pulmonary stenosis) are augmented during inspiration. 2) Increases splitting of S2 when present. 3) R vs L ventricular S3: R S3 will vary, L s3 won't 4) Pulmonary stenosis: only R sound that will decrease or disappear with inspiration 5) Tricuspid stenosis: diastolic murmur accentuated 6) Holosystolic murmurs: Heard best at lower left sternal border. Tricuspid regurg will increase.
92
Muller maneuver & purposes
Deep inspiratory effort against closed glottis, hold as long as possible (usually 10 seconds) Purposes: Venous return increased, increase in R stroke volume. Increase in R heart sounds.
93
Exercise purposes
Increased cardiac output; pulmonary flow is increased, as is left side flow across mitral. Purposes: 1) Ventricular or atrial septal defect (flow rumble) 2) Mitral regurg: diastolic mitral flow murmur after exercise means regurg is at least moderate
94
Supine position & purposes
Lying on back. Purposes: 1) Murmurs elicited: Still's innocent murmur; innocent murmur of pulmonary valve in teens, some adults; diastolic flow murmur (increased tricuspid flow) of atrial septal defect) 2) Murmurs increased: patent ductus arteriosis; pulmonary valve stenosis & ejection sounds) 3) Murmurs increased in left lateral supine: Mitral valve; s3 better heard; diastolic flow murmurs of ventricular septal defect, mitral valve regurg, severe anemia
95
Standing from squatting purposes
1) Hypertrophic obstructive cardiomyopathy: increases 2) Ventricular septal defect, aortic stenosis, right side murmurs: Decrease or no change 3) Mitral regurg: Varied response
96
Squatting from standing purposes
1) Mitral insufficiency: increases 2) hypertrophic obstructive cardiomyopathy: decreases 3) mitral valve prolapse: decreases; click-murmur complex moves closer to S2 4) Aortic insufficiency or L ventricular S3/S4: May increase
97
Sudden recumbency/passive leg raising
Augment venous return, emphasize L & R filling sounds. 1) Pulmonic & aortic stenosis: increase, lengthen 2) HOCM & mitral prolapse: decrease, shorten
98
Valsalva manuever & phases
Expiration against closed glottis. Phase 1: Systolic & diastolic pressures rise bc increased intrathoracic pressure Phase 2: Strain period. Reflex increase in heart rate. Intrathoracic pressure increases, venous return to R heart plummets, reduces CO. Systolic pressure falls, pulse pressure falls. Phase 3: Release of strain. BP falls. Phase 4: Overshoot. Venous return surges. Increased stroke volume, CO, art pressure. Normal hearts have reflex bradycardia.
99
Valsalva purposes
1) HOCM: Phase II, all murmurs diminish except HOCM & mitral prolapse. Systolic click of mitral prolapse assumes honk or whoop. 2) R murmurs: during phase 4, accentuated re: venous surge 3) L murmurs: After 5-10 beats, L murmurs will return to baseline 4) s2: During phase 4, 2 components of s2 may be id'd and compared
100
Isometric hand grip manuever & purposes
Clench washcloth or fist forcefully; instruct patient to grab your L hand while your R uses stethoscope; palms together, fingers toward opposite hand wrist, then hook fingers together & try to pull apart. DON'T VALSALVA. Purposes: 1) Mitral regurg: Increases, but difficult to differentiate from ventr septal defect 2) L ventri s3, s4: Accentuated in 50% of pts with CAD or CHF 3) Aortic regurg, ventri septal defect: accentuated 4) Mitral stenosis: Diastolic rumble accentuated.
101
Carotid sinus massage: risk & purposes
Supine, neck extended (small pillow under shoulders) & head turned away. Press carotid body against lateral processes of vertebrae. May hurt for few seconds. RISK OF CARDIAC STANDSTILL. Purposes: 1) s3/s4: Slows heart rate, allows to hear 2) Summation gallop: unmasked by slowing
102
Long cycle length value
1) Systolic ejection murmurs: increase in stroke volume & may augment intensity of aortic or pulmonic stenosis & HOCM murmurs. 2) Regurg systolic murmurs: No change.
103
Transient hypoxemia procedure & purpoes
Having patient inhale 10% oxygen mixture, resulting in pulmonary hypertension. No clinical place. May be used in physiological experiments.
104
Transient arterial occlusion with BP cuff
BP cuff on both arms simultaneously, 20-40 mmHg above patient's systolic. 20 sec after inflation, L regurg murmurs will increase. 1) Ejection murmurs display no or slight reduction, but HOCM dramatically decrease 2) Mitral regurg & ventri septal defect: augments, but cannot differentiate
105
Amyl nitrate: what is it, how is used?
Vasodilator. Wrap vial in towel, break, & hold within inches of patient's nose (who is lying flat bc lightheadedness) while examiner listens. Inhale for 2-3 deep inhalation. Discard into water.
106
Amyl nitrate: clinical value
1) aortic stenosis, HOCM: augmented 2) Mitral regurg: diminished (bc drop in LV systolic pressure, therefore reduced retrograde flow) 3) Aortic regurg: dminishes (re: transient drop in peripheral vascular resistance) 4) V septal defect: variable. 5) Mitral prolapse: May vary. May increase in duration, click may be earlier or fade. 6) Apical diastolic rumble: increases if it's mitral stenosis, decreases if Austin Flint. 7) Aortic stenosis increases 8) Pulmonic stenosis vs small V septal defect: pulmonic will increase, V septal defect will decrease 9) V septal defect vs infundibular stenosis with intact V septum: Infundibular stenosis will increase, V sept will decrease
107
Phenylephrine increases these murmurs
Mitral & aortic insufficiency Ventricular septal defect Patent ductus arteriosis Tetralogy of Fallot
108
Phenylephrine administration
By IV, 10 mg in 250mg of isotonic solution. BP is monitored. Usually should increase systolic pressure by 20 mmHg before recognizable murmur change.
109
Phenylephrine clinical value
1) Mitral regurg increased | 2) HOCM decreased

ACNP805: Acute Diagnostic Reasoning (7 decks)

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