JVP, murmurs, auscultation heart Flashcards
Grade 1 murmur
faint, only heard after listener has tuned in; may not be heard in all positions
Grade 2 murmur
quiet, but heard immediately after placing stethoscope on chest
Grade 3 murmur
moderately loud
Grade 4 murmur
loud with palpable thrill
Grade 5 murmur
very loud with thrill, may be heard when stethoscope on chest partially
Grade 6 murmur
very loud with thrill, may be heard when stethoscope off chest completely
If murmur is heard on 2nd R. interspace where is it originating?
aortic valve
A murmur on which side of the heart varies with inspiration?
Right side
What does JVP reflect?
R. atrial pressure
Where is JVP best estimated and why?
R. internal jugular vein because it is the most direct channel into the R. atrium
What is the measurement from sternal angle to R. atrium, regardless of bed position?
5 cm
What amt do we add to the number we obtained to reflect the distance from R. atrium?
5 cm
What is a normal JVP?
less than 9cm
What diseases associated with increased JVP?
HF, tricuspid valve disease, pulmonic stenosis, pericardial disease
What disease associated with decreased JVP?
dehydration and hypovolemia
What do we do if patient hypovolemic and need to measure JVP?
Lower head of bed to as low as 0 degrees
What do we do if patient hypervolemic and need to measure JVP?
raise head of the bed to 60 or 90 degrees
What is a normal Kussmaul sign?
JVP falls with inspiration due to a decrease in pressure in expanding thorax cavity
What is an abnormal Kussmaul sign?
JVP will rise with inspiration due to impaired filling of R. ventricle because fluid in pericardial space or poorly compliant myocardium/pericardium
Where to find PMI?
5th IC space, 1cm medial to midclavicular line
Normal PMI diameter
less than 2.5cm
What are we looking for with PMI?
lift, heaves, thrills (buzzing)
How do we assess thrills?
use ball of hand to feel for it
What grade murmur can you feel a thrill?
4
What position is the patient when assessing PMI?
L. lateral decubitus
What does it mean if you hear murmur and feel a thrill?
PATHOLOGY
When auscultating, when do you use diaphragm and bell?
Diaphragm for all places and bell for mitral and tricuspid
General auscultation practice
listen from apex to base or base to apex inching from each of the 5 pts to assess S1 and S2 and notice any changes in tone
What does a diastolic murmur indicate ?
Indicates a valvular heart disease
What does a systolic murmur indicate
valvular disease with a normal heart
What are the systolic murmurs?
Mitral regurgitation (harsh holosystolic; medium-high) Tricuspid regurgitation (holosystolic; medium, blowing) Ventricular septal defect (high holosystolic) Aortic stenosis (diamond; medium high) Pulmonic stenosis (diamond; medium) Hypertrophic cardiomyopathy
What are the diastolic murmurs?
Aortic regurgitation (decrescendo) Mitral stenosis (rumble)
When listening to the heart where to place stethoscope
apex or base
When moving stethoscope, where do you want your left index finger and middle fingers
right carotid artery in lower third of neck to correctly ID S1, before carotid upstroke
At the base what is louder and splits with respiration
S1
At apex what is louder
S2
i. Diastolic sound
ii. High pitch and snap that radiates to the apex and to the pulmonic area
iii. Use diaphragm
opening snap
i. Diastolic sound
ii. Dull, low in pitch and heard best in apex in left lateral decubitus
iii. Use bell
S3-physiologic
Who has physiologic S3
children, young adults, pregnant
i. Dull, low in pitch and heard best in apex in left lateral decubitus (left) or along the lower left sternal border or below xiphoid with patient supine (Right)
pathologic s3
Who has pathologic S3
adult over 40
i. Occurs just before S1
ii. Dull, low in pitch
iii. Heard with bell
S4 (atrial gallop)
Who has S4
athletes and older kids
i. Starts in apex and radiates into left axilla
ii. Intensity: soft to loud
iii. Pitch: medium to high
iv. Quality: harsh, holosystolic
mitral regurgitation
i. Starts in lower left sternal border and radiates to right of sternum to the xiphoid area
ii. Intensity: variable
iii. Pitch: medium
iv. Quality: blowing, holosystolic
v. Intensity increases with inspiration
Tricuspid regurgitation
i. Starts in 3-5th left interspaces and radiates wide
ii. Intensity: very loud with thrill
iii. Pitch: high, holosystolic
iv. Quality: harsh
ventricle septal defect
i. Starts in 2-4th interspaces between left sternal border and apex with little radiation
ii. Intensity: grade1-2
iii. Pitch: soft to medium
iv. Quality: variable
v. Decreases/disappears on sitting
innocent murmurs
i. Starts in R. second interspace and radiates to carotids, down L. sternal borders and to the apex
ii. Intensity: loud with a thrill
iii. Pitch: medium-harsh; crescendo-decrescendo higher at apex
iv. Quality: harsh; musical at apex
v. Heard best when patient sitting and leaning forward
aortic stenosis
i. Starts in 3-4th interspaces and radiates down left sternal border to the apex and possibly to the base
ii. Intensity: variable
iii. Pitch: medium
iv. Quality: harsh
v. Decreases with squatting, increases with straining down from Valsalva and standing
hypertrophic cardiomyopathy
i. Starts in 2-3rd interspaces and if loud radiates toward left shoulder and neck
ii. Intensity: soft to loud (with thrill if loud)
iii. Pitch: medium; crescendo-decrescendo
iv. Quality: harsh
pulmonic stenosis
i. Starts in 2-4th interspaces and if loud radiates to the apex and R. sternal border
ii. Intensity: grade1-3
iii. Pitch: high; use diaphragm
iv. Quality: blowing decrescendo
v. Heard best with patient sitting, leaning forward, with breath held after exhalation
aortic regurgitation
i. Starts in apex with no radiation
ii. Intensity: grade1-4
iii. Pitch: decrescendo low pitched rumble; use bell
iv. Best heard in L. lateral decubitus, with exercise and exhalation
mitral stenosis
i. Starts above the medial third of the clavicles, especially on the right and radiates into 1st-2nd interspaces
ii. Intensity: soft to moderate
iii. Pitch: low; use bell
iv. Quality: humming, roaring
v. Timing: continuous murmur without silent interval; loudest distole
venous hum
i. Starts in 3rd interspace to left of sternum with little radiation
ii. Intensity: increase when patient leans forward, exhales, and holds reath
iii. Pitch: high: diaphragm
iv. Quality: scratchy, scraping
v. Timing: 3 short components: atrial systole, ventricular systole, ventricular diastole
pericardial friction rub
i. Starts in left 2nd interspace and radiates toward left clavicle
ii. Intensity: loud and associated with thrill
iii. Pitch: medium
iv. Quality: harsh, machinery-like
v. Timing: continuous murmur in both systole and diastole with a silent interval late in diastole; loudest late systole, obscures S2 and fades in diastole
Patent ductus arteriosis
