Lecture 32: Heart Sounds Flashcards
Why do we feel the carotids?
It is close to the heart, so it is one of the best places to feel the arterial pulse wave
What maneuver can increase blood in venous system?
Hepatojugular reflux maneuver; if it stays elevated it means that the heart cannot compensate for the sudden increase in blood volume
Components of jugular waveform
A = atrial contraction; v = venous contraction; c wave = valve closure/carotid contribution
How should you palpate precordial impulse?
Cover territory with palms
What can you identify/detect with palms on the heart? (5)
Left ventricular apex, detect ectopic impulses, detect lifts, heaves, and thrills (vibration, a “felt murmur”)
Aortic area
2nd-3rd right interspace
Pulmonic area
2nd-3rd left interspace
Tricuspid area
Left lower sternal border
Mitral area
Apex
Splitting of the 2nd heart sound is…When does this happen more?
Physiologic (normal) splitting; splits more on inspiration –> blood comes into R side of chest due to suction –> more time to cross pulmonic valve
Two causes for wide splitting
Delayed pulmonic valve closure and early aortic valve closure
Three reasons for delayed pulmonic valve closure
Right bundle branch block (delayed activation of R ventricle), pulmonic valve stenosis (prolonged right ventricular mechanical stystole), atrial septal defect (increased trans-pulmonic blood flow)
Two reasons for early valve closure
Mitral insufficiency (short left ventricular mechanical systole), ventricular septal defect (also, short left ventricular mechanical systole)
What could cause paradoxical (reversed) splitting
Delayed aortic valve closure or early pulmonic valve closure
Three reasons for delayed aortic valve closure
Left BBB (delayed electrical activation of LV), hypertensive heart disease (prolonged LV systole), CAD w/ LV dysfunction (prolonged LV systole)
One reason the pulmonic valve could close
Pre-excitation (WPW)
Paradoxical splitting is wider during…
Expiration
S4 gallop
Atrial kick
S3 gallop
Sound of blood due to dilated ventricle
S3 + S4, when would this happen?
Summation gallop; heart is beating fast
Murmur grades
Grade 6: across the room; 5: no stethoscope; 4: you can feel it; 3: w/ stethoscope; 2: murmur; 1: quiet murmur
Pulse with aortic stenosis
Pulsus parvus et tardus
What else do you feel with aortic stenosis?
Precordial LV impulse/lift/systolic thril
What finding suggests a bicuspid anomaly
Systolic ejection click
Aortic stenosis murmur and when its bad
Crescendo-decrescendo; bad if late peaking
Aortic regurge murmur
Diastolic, decrescendo
Mitral regurge murmur
Holosystolic murmur
Mitral stenosis murmur
Opening snap, decrescendo with ending crescendo (lap da daaaaa…)
Mitral valve prolpase murmur
Mid systolic click w/ late systolic murmur
Dynamic changes with mitral valve prolapse
More prolapse/more leak and an earlier click when the ventricle has less blood, things that empty heart of blood will cause this (expiration, Valsalva manevuer, or squat, exhale, and stand)
Dynamic changes are also good for detecting what from what…
Dynamic left ventricular outflow track obstruction (aka LV hypertrophy, murmur gets louder) vs atrial stenosis (murmur gets softer with less ventricular filling)
