Midterm: Heart exam Flashcards
What is the significance of visible pulsations and/or heaves over the precordium?
(precordium=portion of body over heart and lower chest)
A relatively strong murmur (4/6) might be found
o Visible pulsations/heaves: Right ventricular enlargement
Know how to palpate for S1, S2, S3, S4 and thrills (palpable murmurs).
Thrills: palpate with the heel of the hand
S1 and S2 with firm pressure, S3 and S4 with lighter pressure.
Apical impluse at 5th interspace mid clavicular. Easier to palpate weak AI and to hear S3 and S4 in left lateral decubitus.
Know how to assess the apical pulse for size and understand the significance of that size.
Located at 5th is midclavicular, find it with one finger, then two and spread them apart until no longer palpable (2-2.5 cm). Try LLDC if too faint. A laterally displaced AI can mean the heart is enlarged. Note intensity.
Know how to differentiate S1 from S2 using palpation of the carotid.
The carotid pulse comes right after S1.
Which valves make S1 and S2 sounds? Where are these sounds best heard?
S1 is made by mitral and tricuspid valves closing. S2 sound is aortic and pulmonic valves.
S1: apex
S2:base
When (and where) is it normal for S1 to split? What constitutes an abnormally split S1?
You may normally hear some splitting in the 5th interspace at the sternal border. Split S1 results from asynchronous closure of mitral (M1) and tricuspid (T1) valves. Abnormal if the split is >60 ms apart. Could be myxoma, ASD, RBBB
How does one differentiate a split S1 from an S4 gallop?
S4 is a low-frequency gallop sound that results from a forceful atrial contraction during presystole that ejects blood into a ventricle which cannot expand further.
*** S4 occurs ~90 msec before S1,
What is the normal pattern of auscultation? Be able to name regions where each heart valve is best heard.
Carotids with bell for bruits.
Aortic and pulmonic valve on either side of sternum (aortic on right side). 2nd IS
Erbs space—good echo chamber for murmurs , 3 IS
Tricuspid and Mitral areas, 4 and 5 IS
First diaphragm and then bell.
What is a bruit? Where and how does one listen for them during the heart exam?
Turbulence in an artery dt narrowing from atherosclerosis. Listen with bell on carotids!
What sounds do the bell and diaphragm bring out?
Bell-low pitched
Diaphragm: high pitched
What positions will help accentuate certain heart sounds, i.e., aortic regurgitation, S3, and S4?
Left lateral decubitus for S3 and S4.
Sitting and leaning forward, listen on held exhale for aortic reurg.
What is physiologic splitting of S2?
How common is physiologic splitting of S2?
Split S2 results from asynchronous closure of aortic (A2) and pulmonic (P2) valves. Normally, the separation of A2 and P2 is ~40 msec during inspiration. Physiological splitting is quite common Pearl: 52.1% of normal adults in a recent study. Aortic valve closes before pulmonic dt increased filling of RV.
What is paradoxical splitting of S2?
split occuring on EXHALE. Results from delayed onset or prolongation of left ventricular systole.
Fixed splititng of S2?
results from delayed onset or prolongation of right ventricular systole, or shortened duration of left ventricular systole
How does one differentiate a split S2 from an S3 gallop?
S3 results from the impact of inflowing blood against a distended or incompliant ventricle in mid diastole. It is a low-frequency sound occurring ~120-150 msec after S2.
What are S3 and S4 sounds? What do they signify? What makes them? Where are they best heard? What bedside maneuvers can intensify them?
S4: is a low-frequency gallop sound that results from a forceful atrial contraction during presystole that ejects blood into a ventricle which cannot expand further.
S3 results from the impact of inflowing blood against a distended or incompliant ventricle in mid diastole. It is a low-frequency sound
Use the bell! Left lateral decubitus and listen around mitral/tricuspid areas.
How does one differentiate a pathologic S3 from a physiologic S3?
The most important features differentiating these sounds are the company they keep:
A pathologic S3 keeps bad company (symptoms like shortness of breath, chest pain, orthopnea, signs like wide or displaced apical pulse, peripheral edema, a bottle of nitroglycerin in the hand).
The patient with a normal or physiologic S3 looks fit and is asymptomatic! Common sense wins this hand. ☺
What is jugular venous distention? On what side is it measured? How is that done?
- Seeing a visible jugular vein with a pulse high in the column
- On the right side
- Pt at 45 degree angle.
- Using tangenital light. Measure from perpendicular of sternal angle.
What is abdominojugular reflux? When is it useful clinically? Know how to use a BP cuff to exert the correct amount of pressure.
Seeing the pulse rise in the jugular vein and remain elevated when pressure applied periumbilically—suggests backed up portal system. Positive fur sublinical RCHF.
20-35 mmHg for 15-30 seconds. . A transient (10 seconds or less) rise in the position of the jugular venous pulse is normal and constitutes a negative test.
What characteristics of a murmur do you want to be sure to note when you hear one?
Timing Configuration Location Radiation Intensity Quality Pitch Hemodynamic changes
What is the significance of a diastolic murmur?
Diastolic murmurs usually indicate heart disease.
Third heart sound, S3 Fourth heart sound, S4 Mitral stenosis murmur Tricuspid stenosis murmur Aortic regurgitation murmur Pulmonic regurgitation
S3 gallop
An S3 gallop is thought to be produced by rapid diastolic filling of the left ventricle in “stiff” ventricles.
S1∼∼∼∼∼∼∼∼S2 S3
S3 can be heard in healthy children and young adults (up to age 40).
Pathological S3 gallops can be heard in left and right diastolic overload, i.e., mitral and tricuspid regurgitation.
Diminished ventricular compliance like that caused by cardiomyopathies, CHF, or ischemic heart disease can also produce a S3 gallop.
S3 is a low-frequency, often faint sound. Having the patient walk or passively elevating the patient’s legs can aid in its detection.
S4 gallop
S4: S4 gallops are thought to be atrial contractions causing a snap.
S4 S1∼∼∼∼∼∼∼∼S2
S4 seldom occurs in normal hearts.
S4 can be caused by conditions that lead to left and right ventricular overload: systemic hypertension, pulmonary hypertension, aortic and pulmonic stenosis.
Diminished ventricular compliance like that caused by cardiomyopathies, CHF, or ischemic heart disease can also produce a S4 gallop.
S4 is often heard during acute myocardial infarction. False positives may occur with splitting S1 and S1 plus ejection sounds.
What is the clinical significance of an ejection sound?
Ejection clicks/sounds are high-pitched sounds that occur at the moment of maximal opening of the aortic or pulmonary valves. They are heard just after the first heart sound. Physical maneuvers like valsalva don’t change the timing/quality (differentiate from MVP)
