Heart sounds & murmurs

Question 1

What causes an S3?

Answer 1

1. Blood filling a dilated, failing heart
2. Best heard @ apex with bell
3. Sounds like “montreal”

Question 2

What causes an S4?

Answer 2

1. Blood filling a stiff ventricle
2. Best heard @ apex with bell
3. Sounds like “Toronto”

Question 3

What causes an opening snap?

Answer 3

1. A stenonic MITRAL or TRICUSPID valve opening during diastole
2. High pitched, does not vary with respiration
3. Mitral best heard around apex

Question 4

What causes a crescendo-decrescendo systolic murmur?

Answer 4

1. Aortic stenosis (radiates to right carotid)

2. Pulmonary stenosis (may change with respiration)

Question 5

What causes a pansystolic murmur?

Answer 5

1. Mitral regurgitation
2. Tricuspid regurgitation
3. Ventricular septal defect

Question 6

What causes a late systolic murmur?

Answer 6

1. Mitral valve prolapse (ejection click)

Question 7

Aortic Stenosis

Answer 7

1. Right upper sternal border, with radiation to carotids
2. Crescendo-decrescendo (later=more severe)
3. Mid-harsh pitch
4. Associated with pulsus parvus et tardus, apical-carotid delay, sustained apex, soft S2, S4
5. Caused by degeneration, bicuspid valve, rheumatic

Question 8

Hypertrophic obstructive cardiomyopathy

Answer 8

1. Left sternal border to apex
2. crescendo-decrescendo, dynamic: increases in volume wtih Valsalva, squat to stand
3. Mid-harsh pitch
4. Spike and dome pulse, palpable S4, MR murmuer
5. Familial disease

Question 9

Flow murmur

Answer 9

1. Left sternal border
2. crescendo-decrescendo (early peak)
3. Mid-high
4. No associated findings

Question 10

Pulmonic stenosis

Answer 10

1. Left upper sternal border
2. crescendo-decrescendo
3. Mid-high
4. Right ventricular heave, right S4
5. Typically congenital

Question 11

Mitral regurgitation

Answer 11

1. Apex, radiates to axilla
2. Pansystolic
3. Mid pitch
4. Low volume pulse, dilated left ventricle/atrium, S3
5. Degenerative, dilated left ventricle, endocarditis, papillary muscle rupture

Question 12

Mitral valve prolapse

Answer 12

1. Apex, radiates to axilla
2. Late systolic murmur + ejection click, dynamic (increases with Valsalva, squat to stand)
3. Associated with systolic click, low volume pulse, dilated LA/LV, S3

Question 13

Tricuspid regurgitation

Answer 13

1. Left lower sternal border
2. Pansystolic murmur
3. Mid pitch
4. Associated with right ventricular heave, palpable P2, right sided S3/4
5. Caused by dilated RV, endocarditis, pulmonary HTN

Question 14

VSD

Answer 14

1. Left sternal border
2. Pansystolic murmur, CONTINUES PAST S2
3. Mid-harsh
4. Associated with palpable P2, possible low volume pulse
5. Causes= congenital, post MI, traumatic

Question 15

Aortic regurgitation

Answer 15

1. Left upper sternal border, radiates to apex
2. Decrescendo
3. High pitch
4. Narrow pulse pressure, diffuse apex, S3, Water Hammer Pulse etc.
5. Causes= degeneration, bicuspid valve, aortic dilation, rheumatic

Question 16

Pulmonary Regurgitation

Answer 16

1. Left upper sternal border, radiating to lower border
2. Decrescendo (may vary with respiration)
3. High pitch
4. Palpable P2, RV heave, R S3/S4
5. Caused by pulmonary HTN, congenital

Question 17

Mitral stenosis

Answer 17

1. Apex
2. Mid diastolic rumble (increases right before S1)
3. Low pitch
4. Opening snap (sail gybe), tapping apex, noS3/S4
5. RHEUMATIC!!

Question 18

Tricuspid stenosis

Answer 18

1. Left lower sternal border
2. Mid diastolic rumble with pre-systolic increase
3. Low pitch
4. Elevated JVP, slow y descent
5. Congenital or carcinoid

Question 19

Why does the second heart sound split?

Answer 19

1. Splits because of change in pressure in the pulmonic system caused by inspiration.
2. This makes P2 later compared to A2
3. May also be PARADOXICALLY split (A2 first) in aortic stenosis

Question 20

What causes a prominent a wave on JVP?

Answer 20

1. Tricuspid stenosis, pulmonary hypertension, RVH

2. Increased resistance to forward flow RA-RV

Question 21

What causes a prominent v wave on JVP?

Answer 21

1. Back flow from RV into RA during systole (“CV” wave)

2. Tricuspid regurgitation

Question 22

What causes a canon a wave on JVP?

Answer 22

1. Simultaneous RA/ RV contraction (RA contracts against a closed valve.
2. 3rd degree heart block

Question 23

What causes a prominent/steep y wave on JVP?

Answer 23

1. Constrictive pericarditis

2. Blood quickly exits RA, fills RV. Sharp change when RV is full as no capacity to stretch.

Question 24

What causes an absent a wave on JVP?

Answer 24

1. Atrial fibrillation

2. No atrial contraction- lose the increase in pressure that results from atrial kick

Question 25

What causes a pressure gradient between the left atrium and ventricle?

Answer 25

1. Mitral stenosis

Question 26

What causes a large LA v wave?

Answer 26

1. Mitral regurgitation- blood is flowing back from LV-LA during systole

Question 27

What causes a pressure gradient between the left ventricle and aorta?

Answer 27

1. Aortic stenosis

2. Increased resistance to forward flow!

Question 28

What causes a rapidly falling aortic pressure (on Wiggers)

Answer 28

1. Aortic regurgitation

2. Pressure falls quickly during diastole