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CV <3 > Lecture 4: Heart Sounds > Flashcards

Lecture 4: Heart Sounds Flashcards

1
Q

What generates the S1 sound?

A
  • MV & TV closing
  • AV (aortic) & PV (pulmonic) opening

Systole

Lub sound.
A-V valves refer to the MV and TV.

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2
Q

What generates the S2 sound?

A
  • MV & TV open
  • AV & PV close

Diastole

Dub sound.

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3
Q

Cardiac Cycle Image

A
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4
Q

What is longer in duration: S1 to S2 or S2 to S1?

A

S2 to S1 is longer, which is diastole.

Filling blood takes longer than ejecting it.

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5
Q

What part of the stethoscope is for low-pitched sounds preferably? What are the low-pitched sounds?

A
  • S3, S4, mitral stenosis.
  • Use the Bell!
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6
Q

What part of the stethoscope is for high-pitched sounds preferably? What are the high-pitched sounds?

A
  • S1, S2, AR, MR, pericardial friction rub
  • Diaphragm

Diaphragm = Ding! which is high pitched

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7
Q

What are the 5 listening posts for the heart?

A
  • Aortic (2nd ICS)
  • Pulmonic (2nd ICS)
  • Erb’s point (3rd ICS)
  • Tricuspid (4th ICS)
  • Mitral (5th ICS, mid-clavicular)

A PET Monkey

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8
Q

What positions should we listen to the heart in?

A
  • 30 supine for all precordial areas using diaphragm.
  • Left lateral decubitus for MV post using bell.
  • Leaning forward post deep exhalation for aortic post for aortic murmurs using diaphragm.

H&P skills!

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9
Q

What does standing do to venous return, arterial BP, and SV? What murmurs can it affect?

A
  • Lowers all of 3.
  • Increases MV prolapse.
  • Outflow obstruction of hypertrophic cardiomyopathy (HCM)
  • Decreases AS murmur

MVP => MR, which is leaking of blood back into the left atrium.
Low LV filling => increased oHCM.
Less blood flowing through the aortic valve = less pronounced AS sound.

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10
Q

What does squatting do to venous return, arterial BP, and SV? What murmurs can it affect?

A
  • Increases all 3.
  • Decreases MVP.
  • Decreases obstruction of HCM.
  • Increases AS murmur.
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11
Q

What maneuver do we have patients perform and what is the physiological effect?

A

Valsalva.

Valsalva decreases preload (venous return) and increases intrathoracic pressure.
Decreased preload leads to decreased SV.

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12
Q

What primarily generates the S1 sound?

A

MV closure.

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13
Q

What primarily generates the S2 sound?

A

Aortic closure

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14
Q

What is an Ej/Ec or ejection click?

A

Opening of either the AV or PV valve.

It immediately follows S1.

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15
Q

What is an OS or opening snap?

A

Opening of the MV (such as in MS)

It immediately follows S2.

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16
Q

What is S3?

A
  • S3, occurring early in diastole.
  • Best heard with bell at apex in left lateral decubitus.
  • NORMAL in children, young adults, and 3rd trimester.
  • Dull, low-pitched

Kentucky gallop

K before T = 3 before 4.
3 before 4 = 3 is early diastole, 4 is late diastole.

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17
Q

What does the presence of S3 imply in an older patient?

A
  • Decreased myocardial contractility
  • CHF
  • Volume overload of ventricle
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18
Q

What is S4?

A
  • S4, occurring late in diastole, right before S1.
  • Best heard with bell at apex in left lateral decubitus (same as S3)
  • Marks atrial contraction

Tennessee gallop

19
Q

What does the presence of S4 imply in a patient?

A

Increased resistance to ventricular filling.

Suggestive of HTN, CAD, AS, or cardiomyopathy.

20
Q

Image of Extra/Abnormal Heart Sounds

A
21
Q

When and where is S1 louder than S2?

A
  • Louder at apex.
  • Accentuated in tachycardia, high cardiac output states, and MS.

S1 is MV closure.

22
Q

When does splitting of S1 occur?

A
  • Normal along left lower sternal border.
  • Abnormal is present in RBBB and PVCs.

RBBB= right bundle branch block

sounds like 2 S1 occurring simultaneously

You are hearing both the MV and TV closing.

23
Q

What is physiologic splitting of S2?

A
  • 2nd and 3rd ICS for pulmonic valve listening.
  • Heard best during inspiration.
24
Q

What is pathologic splitting of S2?

A
  • Persistent throughout respiratory cycle.
  • Implies delayed closure of PV. (PS, RBBB)
  • Implies early closure of AV. (MR)
25
Q

Whats the difference between a murmur and an extra heart sound?

A

Duration.

26
Q

What are the 7 characteristics of a murmur?

A
  • Timing (when does it happen, i.e. early diastole, late systole, etc.)
  • Shape (Does it start loud then soft or is it consistent?)
  • Location of maximum intensity
  • Radiation (Does it go to the carotids)
  • Intensity (How loud is it)
  • Pitch
  • Quality (Is it blowing or harsh)
27
Q

What are the 3 timings for systole and diastolic murmurs?

A
  • Systolic: Mid, Pan/holo, late
  • Diastolic: early, mid, late
28
Q

What conditions can cause a continuous murmur?

A
  • PDA
  • Pericardial friction rub
  • Venous hum
29
Q

How is murmur intensity graded?

A
  1. Very faint, prob won’t hear.
  2. quiet, but you can hear it easily with a stethoscope.
  3. moderately loud.
  4. loud, with PALPABLE THRILL.
  5. very loud with thrill, may be heard with stethoscope slightly off chest.
  6. very loud with thrill, may hear with stethoscope fully off chest.

AKA grade IV = thrill

Thrill is when you can feel it with the base of your hand (like a cat purring)

30
Q

What does a pansystolic/holosystolic murmur imply?

A
  • Pathologic condition
  • Blood flow from a chamber of high pressure to low pressure through a valve that is normally closed.
31
Q

What are some examples of pansystolic murmurs?

A
  1. Mitral regurgitation
  2. Tricuspid regurgitation
  3. VSD

Since this is occurring during systole, the ventricles are HIGH pressure, since they are being squeezed. The MV and TV should be CLOSED, to prevent atrial backflow.

32
Q

What is an innocent midsystolic heart murmur?

A
  • Turbulent blood flow.
  • Grade I-III heard between 2nd to 4th ICS with minimal radiation.
  • Usually only present while standing.
  • Blowing.
33
Q

What is a physiologic midsystolic murmur?

A
  • Similar to innnocent, but may have an underlying cause.
  • Typically enhanced by anemia, pregnancy, fever, and hyperthyroidism (anything that increases blood flow)
34
Q

What is a pathologic midsystolic murmur?

A
  • Harsh
  • AS, HCM, and pulmonic stenosis are MC causes.

Sound: Supine with Ec and patient has pulmonic stenosis.

35
Q

What are diastolic murmurs due to?

A
  • Early decrescendo murmurs are usually due to incompetent semilunar valves. (usually AR)
  • Mid-late diastolic implies stenosis of an AV valve.

Sound: Early diastolic murmur due to AR in the aortic area using bell.

36
Q

What are the characteristics of a venous hum?

A
  • Common in kids
  • Continuous murmur that is LOUDER in diastole.
  • Soft and low-pitched.
  • Usually in the medial third of the clavicles, radiating into 1st and 2nd ICS.
37
Q

What causes a pericardial friction rub?

A

Inflammation of the pericardium.

38
Q

What can we have a patient do to amplify their pericardial friction rub?

A
  • Leaning forward
  • Exhaling
  • Holding their breath
39
Q

What is a PDA?

A

Congenital defect that leaves a channel between the aorta and pulmonary artery

40
Q

What does it sound like when someone has a PDA still?

A
  • Loud systolic phase, soft diastolic
  • Left 2nd ICS radiating to left clavicle.
  • Harsh, machinery-like, medium pitch
  • Usually has an associated thrill.

Sound: Adult with PDA.

41
Q

What is the most common diagnostic study order to evaluate any suspected valvular disorder?

A

TTE 2D Echo w/Doppler

Non-invasive, no radiation, minimal prep

Note: TEE refers to transesophageal, and requires anesthesia.

42
Q

What is a common modification to an echocardiogram to look for a PFO?

A

Bubble study, which uses agitated saline as a contrast to observe.

43
Q

What is a TEE and when is it used?

A
  • When a TTE has poor surface transmission.
  • Much better view of posterior heart structures and atrial structures.
  • Defines septal defects or a PFO.
  • Sensitive in detecting aortic dissection

Invasive procedure.

Very good for dxing a left atrial appendage thrombus.

44
Q
A

CV <3 (25 decks)

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