Heart Sounds - Johnston

Question 1

Listening posts:

Answer 1

AV - R 2nd ICS at SB
PV - L 2nd ICS at SB
TV - L 4th ICS at SB
MV - L 5th ICS at MCL

Question 2

6 gradings of a heart murmur

Which have thrill, which do not?

Answer 2

Grade 1 - very faint
Grade 2 - quiet, soft, easily heart WITH STETH
Grade 3 - Moderately loud
——–
Grade 4 - LOUD with PALPABLE THRILL
Grade 5 - VERY LOUD with thrill, heard partially without steth
Grade 6 - Heard WITHOUT STETH

Question 3

What type of murmurs are heard between S1 and S2? Between S2 and S1?

Answer 3

S1-2 = systolic (TV, MV closure)
S2-1 = diastolic (AV, PV closure)

Question 4

S3 sound. Use what part of steth?

Answer 4

Kent-Tuck-y

dull, low pitch. Use bell.

Question 5

S3 is physiologic in what age group and pathologic in what age group?

Answer 5

Physiologic in kids, YA

Pathologic in older adults = HF

Question 6

S4 sound. Use what part of steth?

Answer 6

Ten-Nes-See.
Bell.
FORCEFUL ATRIAL CONTRACTION against stiffened low compliant ventricle.

Question 7

Name the diastolic murmurs

Answer 7

AR, PR
MS, TS
Atrial myxoma

Question 8

Name the systolic murmurs

Answer 8

MR (MVP), TR
AS, PS
VSD
Aortopulmonary shunts

Question 9

NAme the continuous murmurs

Answer 9

PDA machinery
AV fistula
ASD with high LA pressure
Coarctation of the aorta

Question 10

Valvular heard disease - the most commonly encountered conditions

Answer 10

Degenerative (senile calcification)
Myxomatous degeneration (MVP)
Congenital (bicuspid AV)

Question 11

Two most common etiologies of chronic MR

Answer 11

MVP

MAC

Question 12

Four most common etiologies of acute MR.

Answer 12

Rupture of chordae tendineae
Rupture of papillary mm
Ischemic papillary muscle dysfunction
IE; valve performation

Question 13

What is this?
Asympomatic for years
Acute - volume overload, orthopnea, PND, RHF/LHF

Answer 13

MR

Question 14

What has this murmur: blowing, prominent at apex; radiates to left axilla. May have systolic click. Decreased S1 or normal S1

Answer 14

MR

Question 15

What is this?

• 4th decade
• DOE, cough, orthopnea, PND, pulm edema, hemoptysis, arterial emboli, Afib.
• MALAR RASH
• Ortner syndrome

Answer 15

MS

Question 16

What has this murmur:

• Rumbling, diastolic murmur, low pitch, best heard at apex with bell.
• Increased S1, opening shape after S2

Answer 16

MS

Question 17

Etiology of AS

Answer 17

• Degenerative (calcific or senile)
• Congenital bicuspid aortic valve
• Rheumatic or post inflammatory scarring

Question 18

AoV Area in normal aortic valve v. in severe AS

Answer 18

Normal is 4square cm.

Severe AS if AoV is less than 1square cm.

Question 19

S/s of what?

6th decade&raquo_space; ** exertional DYSPNEA, ANGINA, SYNCOPE, HF **

Answer 19

AS

Question 20

What is the prognosis of AS?

Answer 20

Without tx, prognosis is poor.

- Die w/in three years of developing SYNCOPE, w/in two years of onset of HF.

Question 21

Pathophysiology of AS

Answer 21

Obstruction leads to PRESSURE OVERLOAD; LVH

Question 22

AS PE

Answer 22

• Narrowed Pulse Pressure, dec. SV and systolic pressure
• Delayed pulses - Parvis/Tardus
• Harsh systolic murmur, 2nd ICS RSB, radiates to supra sternal notch/carotids.
• Gallavardin phenomenon (murmur radiates to apex)

Question 23

Causes of acute AR

Causes of chronic AR

Answer 23

Acute - IE, aortic dissection, BAV

Chronic - Syphilis, ankylosing spondylitis

Question 24

AR PE

Answer 24

Diastolic, decrescendo murmur, 3rd ICS LSB. Soft systolic murmur may be present.
- De Musset Sign, Austin flint murmur

Question 25

What indicates TR? (ECG and PE)

Answer 25

ECG: Prominent “V” wave in JVP
PE: blowing systolic murmur LSB; increase with inspiration (Carvallo’s sign).

Question 26

Tricuspid Regurgitation (TR) is associated with what three things?

Answer 26

pulmonary HTN, inferior MI, RV infarction

Question 27

Tricuspid Stenosis (TS) is associated with what three things?

Answer 27

MS, TR, RHD

Question 28

What indicates TS? (ECG and PE)

Answer 28

ECG: Prominent “A” wave in JVP ascites
PE: (Possible) Pulsatile hepatomegalia, Carvallo’s sign, Diastolic murmur LSB that increases with inspiration (Carvallo’s sign) and decreases with expiration.

Question 29

Pulmonary Regurgitation (PR or PI) - PE

Answer 29

Blowing diastolic murmur 2 LEFT SB (Graham Steell).

Most cases are due to pulmonary HTN

Question 30

Murmur in PR/PI

Answer 30

• 2nd-3rd ICS, LSB

- Radiates to L shoulder and increases on inspiration/RVH

Question 31

***Will you hear an S4 in afib?

Answer 31

No - atria beating too fast to contract. So you cannot have S4 in afib.