Heart Sounds/ Murmurs- Leah (?) Flashcards
S2/ second heart sound is caused by?
- -beginning of diastole
- -closure of aortic and pulmonary valves
- tricuspid and mitral valves should be open as ventricles are being filled.
What is physiologic S1 splitting? S2 splitting?
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.
Where is the apical pulse/ PMI located in the healthy individual?
Left 5th intercostal space
Mid clavicular line
Near site of mitral valve
At what position should the heart exam be performed?
30 degrees
How are high pitched sounds best heard on exam?
- -using diaphragm of stethoscope
- -sitting up
- used to describe regurg and VSD
How are low pitched sounds best heard on exam?
Using bell of stethoscope
Patient lays on left side
Good way to detect AFIB
HR»_space; distal pulse
Typical murmur grading: two important grades to recall
1-6
- 6 is greatest and can be heard without stethoscope
- 3 requires workup
- 4 thrill (can be palpated)
“Kentucky” and “Tennessee” are used to describe?
S3
S4 (atrial kick)
Site of tricuspid valve
Left 4th intercostal space lateral to sternum
Site of pulmonary and aortic valves
Left and right 2nd intercostal spaces lateral to sternum
Aortic right, pulmonic left
All valves (APTM) should be auscultated with the diaphragm. Which should be auscultated with the bell?
Tricuspid and mitral valves should also be auscultated with the bell as they have lower pitches
Physiologic effect of the handgrip maneuver:
Increases afterload and ventricular volume
What murmurs are worsened with handgrip maneuver? Which are not?
All but aortic stenosis and HCOM are worsened with the handgrip maneuver.
- HCOM decreased
- AS unchanged
Standing from a sitting position and the valsalva maneuver effect murmurs in what way?
Improves all but HCOM and MVP which are worsened.
decrease preload
What are the physiologic effects of squatting/ leg raises?
Increased venous return, preload, peripheral vascular resistance
How do squatting and leg raises effect murmurs?
Worsens most but improves HCOM/MVP
How does breathing effect heart murmurs
Increases right heart pressure and therefore right heart murmurs
Decreases left heart murmurs except HCOM
In addition to turbulent or backwards flow, what can cause murmur like sounds? (2)
Decreased blood viscosity (anemia)
Increased blood flow (sepsis, hyperthyroidism)
Good indicator of right atrial pressure:
External jugular vein pressure
(Elevated in jugular venous distention)
*seen when head is turned to the right
Describe a positive hepatojugular reflex
- Apply pressure in RUQ of abdomen
- If positive will see JVD/ worsened JVD
How are pulses graded?
0 absent
2+ normal
4 bounding
(Others intuitive)
What does “Allens test” determine?
Patently of ulnar and radial arteries at the level of the wrist.
May also determine dominance
Common causes of bounding pulse
6
HEAP-AF
Hyperthyroid
Exercise
Atherosclerosis
PDA
Anxiety
Fever
S1/ first heart sound is caused by?
- -Tricuspid and mitral valves close (mitral causes sound; tricuspid is faint)
- -Pulmonary and aortic valves are open, ventricles contract
- -marks beginning of systole
Possible systolic murmurs (basic)
Aortic or pulmonary stenosis
Mitral or tricuspid regurgitation
Possible diastolic murmurs (basic)
Mitral or tricuspid stenosis
Aortic or pulmonary regurgitation.
