Heart Sounds/ Murmurs- Leah (?)

Question 1

S2/ second heart sound is caused by?

Answer 1

• -beginning of diastole
• -closure of aortic and pulmonary valves
• • tricuspid and mitral valves should be open as ventricles are being filled.

Question 2

What is physiologic S1 splitting? S2 splitting?

Answer 2

S1: unexpected, if present is caused by tricuspid valve closure with deep EXPIRATION)

S2: aortic valve closure expected to be heard before pulmonary valve closure because left heart pressure is greater than right. Worsened with INSPIRATION.

Question 3

Where is the apical pulse/ PMI located in the healthy individual?

Answer 3

Left 5th intercostal space
Mid clavicular line
Near site of mitral valve

Question 4

At what position should the heart exam be performed?

Answer 4

30 degrees

Question 5

How are high pitched sounds best heard on exam?

Answer 5

• -using diaphragm of stethoscope
• -sitting up
• used to describe regurg and VSD

Question 6

How are low pitched sounds best heard on exam?

Answer 6

Using bell of stethoscope

Patient lays on left side

Question 7

Good way to detect AFIB

Answer 7

HR&raquo_space; distal pulse

Question 8

Typical murmur grading: two important grades to recall

Answer 8

1-6

• 6 is greatest and can be heard without stethoscope
• 3 requires workup
• 4 thrill (can be palpated)

Question 9

“Kentucky” and “Tennessee” are used to describe?

Answer 9

S3

S4 (atrial kick)

Question 10

Site of tricuspid valve

Answer 10

Left 4th intercostal space lateral to sternum

Question 11

Site of pulmonary and aortic valves

Answer 11

Left and right 2nd intercostal spaces lateral to sternum

Aortic right, pulmonic left

Question 12

All valves (APTM) should be auscultated with the diaphragm. Which should be auscultated with the bell?

Answer 12

Tricuspid and mitral valves should also be auscultated with the bell as they have lower pitches

Question 13

Physiologic effect of the handgrip maneuver:

Answer 13

Increases afterload and ventricular volume

Question 14

What murmurs are worsened with handgrip maneuver? Which are not?

Answer 14

All but aortic stenosis and HCOM are worsened with the handgrip maneuver.

• HCOM decreased
• AS unchanged

Question 15

Standing from a sitting position and the valsalva maneuver effect murmurs in what way?

Answer 15

Improves all but HCOM and MVP which are worsened.

decrease preload

Question 16

What are the physiologic effects of squatting/ leg raises?

Answer 16

Increased venous return, preload, peripheral vascular resistance

Question 17

How do squatting and leg raises effect murmurs?

Answer 17

Worsens most but improves HCOM/MVP

Question 18

How does breathing effect heart murmurs

Answer 18

Increases right heart pressure and therefore right heart murmurs

Decreases left heart murmurs except HCOM

Question 19

In addition to turbulent or backwards flow, what can cause murmur like sounds? (2)

Answer 19

Decreased blood viscosity (anemia)

Increased blood flow (sepsis, hyperthyroidism)

Question 20

Good indicator of right atrial pressure:

Answer 20

External jugular vein pressure
(Elevated in jugular venous distention)
*seen when head is turned to the right

Question 21

Describe a positive hepatojugular reflex

Answer 21

• Apply pressure in RUQ of abdomen

- If positive will see JVD/ worsened JVD

Question 22

How are pulses graded?

Answer 22

0 absent
2+ normal
4 bounding

(Others intuitive)

Question 23

What does “Allens test” determine?

Answer 23

Patently of ulnar and radial arteries at the level of the wrist.
May also determine dominance

Question 24

Common causes of bounding pulse

6

Answer 24

HEAP-AF

Hyperthyroid
Exercise
Atherosclerosis
PDA

Anxiety
Fever

Question 25

S1/ first heart sound is caused by?

Answer 25

• -Tricuspid and mitral valves close (mitral causes sound; tricuspid is faint)
• -Pulmonary and aortic valves are open, ventricles contract
• -marks beginning of systole

Question 26

Possible systolic murmurs (basic)

Answer 26

Aortic or pulmonary stenosis

Mitral or tricuspid regurgitation

Question 27

Possible diastolic murmurs (basic)

Answer 27

Mitral or tricuspid stenosis

Aortic or pulmonary regurgitation.