more murmur Flashcards
Classic exertional pain, pressure, or discomfort in the chest, shoulder, back, neck, or arm in angina pectoris, seen in 50% of patients with this
myocardial infarction
atypical descriptors in myocardial infarction
cramping, grinding, pricking (rarely is tooth or jaw pain)
Unstable angina, non-ST elevation MI, and ST elevation infarction
clinical syndromes caused by acute MI
Anterior chest pain, tearing or ripping, often radiating into the back or neck is….
acute aortic dissection
Only WHAT can be reliably identified at the bedside during sign or symptoms of irregular heart action
atrial fibrillation
Sudden dyspnea can be seen in
pulmonary embolus, spontaneous pneumothorax, anxiety
IN what heart conditions might you see orthopnea
in left ventricular heart failure or mitral stenosis
PND or paroxysmal nocturnal dyspnea can be indicative of
left ventricular heart failure or mitral stenosis
Dependent edema appears in what part of the body
lowest body parts - feet and lower legs when sitting or sacrum when bedridden (causes may be cardiac, nutritional, or positional)
Periorbital puffiness and tight rings around the eyes are indicative of what
nephrotic syndrome
Venous pressure may appear elevated on expiration in this condition
obstructive lung disease
Increased pressure of JVP suggests most commonly….
R-sided congestive heart failure
An elevated JVP is 98% specific for what?
an increased left ventricular end diastolic pressure and low left ventricular ejection fraction
Unilateral distention of the external jugular vein is usually caused by
local kinking or obstruction
Causes of decrease carotid pulsations…
decreased stroke volume and local factors in the artery such as atehrosclerotic narrowing or occlusion
Pressure on the carotid can cause what?
reflex drop in pulse rate or blood pressure
Small, thready, or weak carotid pulsations are found in….
cardiogenic shock, bounding pulse in aortic insufficiency
What happens to the carotid pulse wave (or speed of upstroke) in aortic stenosis?
Delayed
Variations in carotid pulse amplitude is seen in
pulsus alternans, bigeminal pulse (beat-to-beat variation), parodoxical pulse (respiratory variation)
A murmur-like sounds of vascular rather than cardiac origin is called
Bruit
A carotid bruit radiating over the neck is a…
aortic valve murmur
The prevalence of assymtpomatic carodtid bruits increases with what?
Age. Reaching 8% of people over 75 y/o (increased risk of ischemic heart disease and stroke)
Low-pitched extra sounds such as S3, opening snap, diastolic rumble over the Apical Impulse is what?
Mitral Stenosis
Soft drescendo diastolic murmur while patient is leaning forward with your diaphragm over the left sternal border is what?
Aortic insufficiency (regurg)
S1 is normally louder than S2 at the apex, if it is decreased, it could be
first-degree heart block
S2 is normally louder than S1 at the base of the heart. If it is decreased, it could be
aortic stenosis
Detection of thrills upon palpation in addition to loud, harsh, or rumbling murmurs may be present in what?
aortic stenosis, patent ductus arteriosus, ventricular septal defect. (Less commonly mitral stenosis)
A heart situated on the R-side of the body would be called
dextrocardia. You would be sure to check apical impulse on the R-side of the patient
Pregnancy or a high left diaphragm may displace the apical impulse which direction
upward and to the Left
Lateral displacement of the apical impulse can be seen in these conditions
CHF, cardiomyopathy, ischemic heart disease. (deformities of thorax and mediastinal shift may also cause it)
If pt is in the L lateral decubitus position with a diffuse PMI w/diameter >3cm, what does this indicate?
Left ventricular enlargement
Increase PMI amplitude can reflect?
Hyperthyroidism, severe anemia, pressure overload of L ventricle (as in aortic stenosis), or volume overload of the L ventricle (as in mitral regurgitation)
A sustained high-amplitude impulse over PMI suggests
L ventricular hypertrophy from pressure overload (as in HTN). If such a long duration impulse occurs laterally, consider volume overload
A sustatined low-amplitude (hypokinetic) impulse may result from
dilated cardiomyopathy
A brief middiastolic impulse indicates what?
S3
An impulse just before the systolic apical beat itself indicates what?
S4
A marked increase in amplitude w/little or no change in duration occures in what?
chronic volume overload of the R ventricle (as in from an atrial septal defect)
An impulse w/increased amplitude and duration occurs in what?
w/ pressure overload of the R ventricle as in pulmonic stenosis or pulmonary HTN
In obstructive pulmonary disease, hyperinflated lung may prevent palpation of what?
an enlarged right ventricle in the L parasternal area. The impulse is felt easily, high in the epigastrium where heart sounds are also often heard best
The 2nd L interspace overlies what?
The pulmonary artery
A prominnet pulsation here often accompanies dilatation or increased flow in the pulmonary artery.
Pulmonic or L 2nd ICS
A palpable S2 over the L 2nd ICS suggests increased pressure in the?
pulmonary artery (as in pulmonary HTN)
The 2nd R interspace overlies what?
Aortic outlfow tract (I realize she won’t ask us this but if you know landmarks = easier to figure out abnormalities)
A palpable S2 over the aortic area or R 2nd ICS suggests?
systemic HTN; a pulsation here suggests a dilated or aneurysmal aorta
What may have a hypokinetic apical impulse that is displaced far to the Left?
A markedly dilated failing heart
What may make the apical impulse undectable?
A large pericardial effusion
A L-sided decubitus position accentuates what?
S3, S4, mitral murmurs (especially MITRAL STENOSIS)
A sitting and leaning forward position accentuates what?
aortic murmurs (especially AORTIC REGURGITATION)
Expiratory splitting between S2 suggests?
Pathology! (It’s normal upon inspiration) could be from delayed closure of the pulmonic valve (pulmonic stenosis or R bundle branch block) in WIDE SPLITTING, or atrial septal defefct and R ventricular failure in FIXED SPLITTING
Persistent splitting results from
delayed closure of the pulmonic valve or early closure of the aortic valve
A systolic click is the most common sound between S1 and S2, heard in?
MVP
Diastolic murmurs usually indicate what?
Valvular heart disease
Diastolic murmurs happen between?
S2 and S1
What type of murmur begins typically arise from blood flow across the semilunar valves?
Midsystolic (see pg 384-385 for etiology)
What type of murmur often occur with regurgitant flow across the AV valves?
Pansystolic (see pg 383)
This is the murmur of mitral valve prolapse and is often, not always preceded by a systolic click…
A late systolic murmur
What type of murmurs accompany regurgitant flow across incompetent semilunar valves?
Early diastolic murmurs (think immediately after S2 without a discernible gap)
What type of murmurs reflect turbulent flow across the AV valves?
middiastolic and presystolic murmurs
This presystolic murmur is a crescendo between S2 and S1
mitral stenosis
This early diastolic murmur is a decrescendo
aortic regurgitation
This midsystolic murmur is a crescendo-decrescendo pattern
aortic stenosis (and innocent flow murmurs)
A loud murmur that often radiates up into the neck (esp on the R side)
arotic stenosis
Emphysematous lungs may do what to a murmur?
May diminish the intensity (in thin folks, the degree of turbulence may be louder than an obese person)
A medium-pitched, grade 2/6, blowing decresendo diastolic murmur, heard best in the 4th L interspace, with radiation to the apex is what?
Aortic Regurgitation
A 60 y/o person w/angina, you hear a harsh 3/6 mid-systolic crescendo-descrendo murmur in the R 2nd interspace radiating to the neck is what?
Aortic stenosis (or possibly aortic sclerosis, a dilated aorta, or increased flow across a normal valve)
If after you hear a murmur 2/6 in the 2nd and 3rd L interspace and you begin to evaluate any splitting, or ejection sounds while the patient is sitting up, but all is normal…you suspect
an innocent or functional murmur w/no pathologic significance.
This is the only murmur that increases in intensity during the Valsave manuever (strain phase)
Hypertrophic cardiomyopathy
This murmur decreases intensity during the Valsave maneuver
Aortic stenosis
Squatting (or release of the Valsava) decreases intensity in
Hypertrophic cardiomyopathy
Squatting decreases prolapse of this murmur
MVP
Alternately loud and soft Korotkoff sounds or a sudden doubling of the apparent heart rate as the cuff pressure declines indicates
pulsus alternans (almost always indicates L-sided heart failure)
A difference between Korotkoff sounds of > 10mmHg indicates
a paradoxical pulse and suggests pericardial tampodnade (possible constrictive percarditis but most commonly obstructive airway disease) see p 377
If the JVP is >5cm above the sternal angle and HOB is >30 degrees, you find that there are brisk carotid upstrokes, a bruit is heard over the L carotid artery, and the PMI is diffuse + high pitched harsh 2/6 holosystolic murmur best heard at the apex radiating to the axilla, what 2 things can you suspect?
Suggests CHF w/volume overload and Mitral Regurgitation
