Heart Sounds -Silverstein

Question 1

The diaphragm of the stethoscope is good for hearing _____ frequency sounds.

Answer 1

high

Question 2

The bell of the stethoscope is good for hearing _____ frequency sounds.

Answer 2

low

Question 3

What is S1? Where is it heard the loudest?

Answer 3

S1=mitral and tricuspid closure

apex (5th intercostal, midclavicular)

Question 4

What is S2? Where is it heard loudest?

Answer 4

S2=aortic and pulmonary closure

loudest at the left base (P area)

Question 5

Which normal heart sound varies with the respiratory cycle?

Answer 5

S2

get physiologic splitting during inspiration
S1——-A2: P2

Question 6

What can lead to S1 splitting?

Answer 6

RBBB (due to the delayed tricuspid valve closure

RV pacing

Question 7

What can cause abnormal S2 intensity?

Answer 7

pulmonary or systemic HTN –> loud/forceful closure of the valves

or aortic or pulmonary stenosis ==> soft closure because the valves are stuck in place

Question 8

What can lead to a wide splitting of S2?

Answer 8

RBBB or pulmonic valve stenosis delaying pulmonary valve closure

still increases with inspiration

Question 9

*what should you think of when you hear fixed splitting?

Answer 9

ASD!!!

Question 10

Where is S3 heard the loudest?

Answer 10

apex in the left lateral decubitus position

Question 11

What is S3?

Answer 11

early diastole

ventricular gallop

listen with a bell (dull)

Question 12

What is S4?

Answer 12

late diastole

atrial contraction against a non-compliant ventricle (atrial gallop)

Question 13

What is an opening snap due to? What is worse, an earlier OS or a later OS?

Answer 13

Opening of stenotic AV valve (usually mitral)

Earlier OS (closer to A2) with more severe stenosis because LA pressure is higher so overcomes LV pressure earlier

Question 14

What is a Pericardial knock due to?

When will it be heard?

Answer 14

Abrupt cessation of ventricular filling in early diastole due to constrictive pericarditis

Later than OS (OS has to be open for ventricle to fill)

Earlier than S3

Question 15

What does a mid-systolic click indicate? Will this get better or worse with valsalva?

Answer 15

AV valve prolapse

leaflets bulge into the atrium during ventricular contraction

worse with valsalva

Question 16

How are murmurs graded?

Answer 16

Systolic 
1/6: Barely audible
2/6: Faint but immediately audible
3/6: Easily heard
4/6: With palpable thrill
5/6: Heard with stethoscope lightly on chest
6/6: Heard with stethoscope not touching

diastolic
1/4: Barely audible
2/4: Faint but immediately audible
3/4: Easily heard
4/4: Very loud

Question 17

Is a systolic crescendo-decrescendo murmur always pathologic?

Answer 17

no. can be normal in kids and pregnant women (high flow states)

Question 18

What can holosystolic murmurs be due to?

Answer 18

-Mitral regurgitation
Apex, radiates to axilla

-Tricuspid regurgitation
LLSB, increases with inspiration

-VSD
4-6th L intercostal, no radiation, no respiratory variation, small = louder

Question 19

What can cause an early diastolic murmur?

Answer 19

heard right after S2

aortic regurgitation–> left sternal border

pulmonic regurgitation –> may increase with inspiration

Question 20

What can cause a mid to late diastolic murmur?

Answer 20

Mitral or tricuspid stenosis

Question 21

What causes a continuous murmur?

Answer 21

PDA