Lecture 32: Heart Sounds

Question 1

Why do we feel the carotids?

Answer 1

It is close to the heart, so it is one of the best places to feel the arterial pulse wave

Question 2

What maneuver can increase blood in venous system?

Answer 2

Hepatojugular reflux maneuver; if it stays elevated it means that the heart cannot compensate for the sudden increase in blood volume

Question 3

Components of jugular waveform

Answer 3

A = atrial contraction; v = venous contraction; c wave = valve closure/carotid contribution

Question 4

How should you palpate precordial impulse?

Answer 4

Cover territory with palms

Question 5

What can you identify/detect with palms on the heart? (5)

Answer 5

Left ventricular apex, detect ectopic impulses, detect lifts, heaves, and thrills (vibration, a “felt murmur”)

Question 6

Aortic area

Answer 6

2nd-3rd right interspace

Question 7

Pulmonic area

Answer 7

2nd-3rd left interspace

Question 8

Tricuspid area

Answer 8

Left lower sternal border

Question 9

Mitral area

Answer 9

Apex

Question 10

Splitting of the 2nd heart sound is…When does this happen more?

Answer 10

Physiologic (normal) splitting; splits more on inspiration –> blood comes into R side of chest due to suction –> more time to cross pulmonic valve

Question 11

Two causes for wide splitting

Answer 11

Delayed pulmonic valve closure and early aortic valve closure

Question 12

Three reasons for delayed pulmonic valve closure

Answer 12

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)

Question 13

Two reasons for early valve closure

Answer 13

Mitral insufficiency (short left ventricular mechanical systole), ventricular septal defect (also, short left ventricular mechanical systole)

Question 14

What could cause paradoxical (reversed) splitting

Answer 14

Delayed aortic valve closure or early pulmonic valve closure

Question 15

Three reasons for delayed aortic valve closure

Answer 15

Left BBB (delayed electrical activation of LV), hypertensive heart disease (prolonged LV systole), CAD w/ LV dysfunction (prolonged LV systole)

Question 16

One reason the pulmonic valve could close

Answer 16

Pre-excitation (WPW)

Question 17

Paradoxical splitting is wider during…

Answer 17

Expiration

Question 18

S4 gallop

Answer 18

Atrial kick

Question 19

S3 gallop

Answer 19

Sound of blood due to dilated ventricle

Question 20

S3 + S4, when would this happen?

Answer 20

Summation gallop; heart is beating fast

Question 21

Murmur grades

Answer 21

Grade 6: across the room; 5: no stethoscope; 4: you can feel it; 3: w/ stethoscope; 2: murmur; 1: quiet murmur

Question 22

Pulse with aortic stenosis

Answer 22

Pulsus parvus et tardus

Question 23

What else do you feel with aortic stenosis?

Answer 23

Precordial LV impulse/lift/systolic thril

Question 24

What finding suggests a bicuspid anomaly

Answer 24

Systolic ejection click

Question 25

Aortic stenosis murmur and when its bad

Answer 25

Crescendo-decrescendo; bad if late peaking

Question 26

Aortic regurge murmur

Answer 26

Diastolic, decrescendo

Question 27

Mitral regurge murmur

Answer 27

Holosystolic murmur

Question 28

Mitral stenosis murmur

Answer 28

Opening snap, decrescendo with ending crescendo (lap da daaaaa…)

Question 29

Mitral valve prolpase murmur

Answer 29

Mid systolic click w/ late systolic murmur

Question 30

Dynamic changes with mitral valve prolapse

Answer 30

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)

Question 31

Dynamic changes are also good for detecting what from what…

Answer 31

Dynamic left ventricular outflow track obstruction (aka LV hypertrophy, murmur gets louder) vs atrial stenosis (murmur gets softer with less ventricular filling)