JVP, murmurs, auscultation heart Flashcards by Kristin Shaw

Grade 1 murmur

faint, only heard after listener has tuned in; may not be heard in all positions

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Grade 2 murmur

quiet, but heard immediately after placing stethoscope on chest

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Grade 3 murmur

moderately loud

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Grade 4 murmur

loud with palpable thrill

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Grade 5 murmur

very loud with thrill, may be heard when stethoscope on chest partially

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Grade 6 murmur

very loud with thrill, may be heard when stethoscope off chest completely

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If murmur is heard on 2nd R. interspace where is it originating?

aortic valve

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A murmur on which side of the heart varies with inspiration?

Right side

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What does JVP reflect?

R. atrial pressure

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Where is JVP best estimated and why?

R. internal jugular vein because it is the most direct channel into the R. atrium

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What is the measurement from sternal angle to R. atrium, regardless of bed position?

5 cm

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What amt do we add to the number we obtained to reflect the distance from R. atrium?

5 cm

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What is a normal JVP?

less than 9cm

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What diseases associated with increased JVP?

HF, tricuspid valve disease, pulmonic stenosis, pericardial disease

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What disease associated with decreased JVP?

dehydration and hypovolemia

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What do we do if patient hypovolemic and need to measure JVP?

Lower head of bed to as low as 0 degrees

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What do we do if patient hypervolemic and need to measure JVP?

raise head of the bed to 60 or 90 degrees

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What is a normal Kussmaul sign?

JVP falls with inspiration due to a decrease in pressure in expanding thorax cavity

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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

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Where to find PMI?

5th IC space, 1cm medial to midclavicular line

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Normal PMI diameter

less than 2.5cm

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What are we looking for with PMI?

lift, heaves, thrills (buzzing)

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How do we assess thrills?

use ball of hand to feel for it

What grade murmur can you feel a thrill?

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

At apex what is louder

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