Phys Di 2 Flashcards
Where do you listen for aortic valve sounds?
right 2nd intercostal space at sternal border
Where do you listen for pulmonic valve sounds?
left 2nd intercostal space at sternal border
Where do you listen for tricuspid valve sounds?
4th/5th left intercostal space
Where do you listen for mitral valve sounds?
left 5th ICS lateral = Apex
What do you listen for with the diaphragm?
- most sounds
- high pitched murmurs
- clicks
- snaps
What do you listen for with the bell?
- low pitched
- filling sounds
- such as gallops
- some murmurs
S1 sound cause
closure of the mitral and tricuspid valves
When does S1 occur?
- start of systole
- ventricular contraction
Is splitting of S1 normal?
- no
- asynchrony of mitral and tricuspid closure
S2 sound cause
closure of the AP valves
What does S2 occur?
- start of diastole
- ventricular filling
Is splitting of S2 normal?
- it can be (physiological split)
- related to breathing
- RIGHT ventricular systole is lengthened with deep inspiration
- A closes before P
Wide physiological splitting of S2
- abnl
- occurs during inspiration and expiration but WIDER on inspiration
- delayed closure of pulmonic valve
- RBBB or pulm. HTN
fixed splitting of S2
- abnl
- unaffected by respiration
- delayed pulmonic valve closure w/ RV output > LV output
- large ASD; VSD; right heart failure
paradoxic splitting
- abnl
- audible splitting w/ expiration (disappears during inspiration)
- delayed aortic valve closure (P2 before A2)
- aortic stenosis; LBBB
S3 and S4 are best heard:
- what device
- what position
- pt position
- bell
- mitral position
- pt in left lateral decubitus position
When are S3 and S4 heard? What do they sound like?
- heard in diastole
- soft and low pitched
What is a loud and intense S3 referred to as?
- ventricular gallop
- “ken-TUCK-y”
normal causes of S3 gallop
can be normal in young people
abnormal causes of S3 gallop
- when increased vol. leads to exaggerated diastolic filling
- CHF
- regurg
- shunts
What is the most common cause of the S3 gallop?
CHF
specific timing of S3
- EARLY diastole
- related to volume overload
S4 timing
- LATE diastole (just before S1)
- pre-systolic sound
S4 is due to?
-d/t PRESSURE overload and stiff ventricles
Describe the S4 heart sound
- “TEN-ne-see”
- atrial gallop
- NEVER normal
conditions causing S4
- when ventricles are stiffened by hypertrophy or fibrosis:
- hypertrophic cardiomyopathy
- aortic stenosis
What is an extra valve sound?
- short sound
- caused by noisy valve
Examples of extra valve sounds
- opening sound (mitral_
- ejection click (aortic)
- non-ejection click (mitral)
- prosthetic valve sound
Murmurs
- prolonged sound
- cause is disruption of blood flow
murmur causes
- diseased valves
- high output demands
- structural defects (ASD, VSD)
misc. extra heart sounds
- overlies heart sounds
- cause is outside the heart
- pericardial friction rub
- precordial knock
Characterization of murmurs
- timing: systolic or diastolic
- location best heard
- intensity (grade I-VI)
- radiation (carotids, axilla?)
- What does it sound like?
Descriptive words for murmur quality
- harsh
- raspy
- machine-like
- vibratory
- musical
- blowing
- grating
- etc
other considerations of murmurs
- does it crescendo/decresendo?
- is the pitch low or high?
maneuvers to consider with murmurs
- does it change w/ posture?
- val salva
- respirations
heart murmur intensity grading
I: barely audible in quiet room II: quiet but clearly audible III: moderately loud IV: loud, associated w/ a thrill V: very loud, thrill easily palpable VI: very loud, audible w/o stethoscope, thrill visible
thrill
- a fine, palpable, rushing vibration (palpable murmur)
- intensity IV-VI murmurs can be felt
What can cause a left sternal border thrill?
severe mitral regurg
What can cause a right sternal border thrill?
severe atrial regurg
The most common murmurs are systolic murmurs d/t what? (3)
- aortic stenosis
- mitral regurg
- mitral valve prolapse
systolic murmur flow chart
slide 52
aortic stenosis murmur is best heard:
upright and 2nd right ICS
aortic stenosis murmur exam findings
- SYSTOLIC murmur
- harsh, medium pitch, cresc-decrescendo
- radiates to carotids
- +/- ejection click
- like …….. gull ….. or dove…….. ??
Description of aortic stenosis
calcification of valve cusps restricts forward flow
causes of aortic stenosis murmur
- congenital bicuspid valve
- rheumatic fever
- degeneration
aortic regurg murmur is best heard:
upright at left sternal border, leaning forward
aortic regurg murmur exam findings
- early DIASTOLIC
- high pitched, soft, blowing, decrescendo
aortic regurg description
valve incompetence allows backflow to left ventricle
aortic regurg murmur causes
- rheumatic fever
- congenital
- syphilis
- marfan syndrome
mitral stenosis murmur best heard:
- left lateral decubitus
- bell** at apex
mitral stenosis murmur exam findings
- opening snap followed by DIASTOLIC rumble
- low pitch, does not radiate
mitral stenosis description
narrowed valve restricts forward flow
mitral stenosis murmur causes
- rheumatic fever
- 3:1
- W:M
mitral regurg murmur best heard:
- upright at apex
- increases w/ inspiration
mitral regurg murmur exam findings
- holosystolic
- high pitched
- blowing**
- quite loud
- radiates to left axilla (splitting of S2)
mitral regurg murmur description
valve incompetence allows backflow from V to A
mitral regurg murmur causes
- rheumatic fever
- MI
- myxoma
mitral valve prolapse murmur best heard:
-upright at apex and left lower sternal border
mitral valve prolapse murmur exam findings
- late SYSTOLIC
- crescendo murmur preceded by mid-systolic click
- high pitched, blowing
mitral valve prolapse description
redundant valve tissue prolapses into atrium late in systole
mitral valve prolapse murmur causes
- congenital
- associated w/ pectus excavatum
- W>M
What are the less common heart murmurs?
- tricuspid stenosis
- tricuspid regurg
- pulmonic stenosis (rare)
- ventricular septal defect
- patent ductus arteriosus
tricuspid stenosis murmur best heard:
- w/ bell
- 4th left ICS
tricuspid stenosis murmur exam findings
- diastolic rumble
- accentuated early and late
- low pitch, louder on inspiration
- JVP prominent
tricuspid stenosis murmur description
calcification of valve cusps restricts forward flow
tricuspid stenosis murmur examples of cause
- rheumatic fever
- congenital defect
- right atrial myxoma
tricuspid regurg murmur best heard:
- diaphragm
- left 4th ICS
tricuspid regurg murmur exam findings
- holosystolic
- soft
- radiates up left sternal border
- increased on inspiration
tricuspid regurg murmur description
valve incompetence backflow to right atrium
tricuspid regurg murmur examples of cause
- congenital
- endocarditis (IVDU)
pulmonic stenosis murmur best heard:
-diaphragm at 2nd left ICS
pulmonic stenosis murmur exam findings
- systolic ejection murmur
- medium pitch
- coarse
- increased on inspiration
pulmonic stenosis murmur description
valve restricts forward flow
pulmonic stenosis murmur cause
almost always congenital
ventricular septal defect murmur best heard:
diaphragm at left sternal border
ventricular septal defect murmur exam findings
- holosystolic
- loud, coarse, high pitched
- does NOT radiate to neck
ventricular septal defect murmur description
-regurg of blood through defect
ventricular septal defect murmur cause
congenital
PDA murmur best heard:
1st-3rd ICSs
PDA murmur exam findings
- harsh, loud, continuous murmur
- machine-like
- unaltered by posture
PDA murmur description
left to right shunt through defects
PDA murmur cause
congenital
what are the special maneuvers for systolic murmurs
- squatting/leg elevation
- valsalva/standing
- handgrip
- others
special maneuvers effect on preload/afterload
- squatting/leg elevation: increases preload
- valsava/standing: decreases preload
- handgrip: increases afterload
aortic stenosis murmur changes with special maneuvers
- squatting/elevation: increases
- valsalva/standing: decreases
- handgrip: increases
mitral valve prolapse murmur changes with special maneuvers
- squatting: decreases
- valsalva: increases
- handgrip: no change
- other: increases in left lateral decubitus
hypertrophic cardiomyopathy murmur changes w/ special maneuvers
- squatting: decreases
- valsalva: increases
- handgrip: decreases
- other: increases in left lateral decubitus
mitral regurg murmur changes w/ special maneuvers
- squatting: no change
- valsalva: decreases
- handgrip: increases
- other: increases w/ inspiration
VSD murmur changes w/ special maneuvers
- none w/ squatting or valsalva
- handgrip: increases
- other: increases w/ bilateral aterial occulation (BP cuffs inflated)
when is a benign murmur best heart?
supine position
what is the only change w/ maneuvers for benign murmurs?
it disappears w/ valsalva
bruit
unexpected sound of blood moving through narrowed artery
bruit info
- can be radiation of heart murmur
- can be caused by local obstruction
- very low pitched and quiet
- use bell
Where to auscultate for bruits
- carotid*
- aortic*
- renal*
- iliac*
- temporal
- femoral
arterial pulsations
- bounding wave of blood produced by ventricular systole
- diminishes w/ increasing distance from the heart
- reflect blood flow and CO
review locations for pulses
slide 63
what comparisons should you check for in palpating pulses?
- compare for b/l symmetry
- compare upper vs lower extremity
characteristics of pulse to palpate for
- rhythm/rate (regular or irregular)
- contour
- intensity/amplitude(strength)
why does deep inspiration normally increase the pulse rate?
bainbridge reflext
bainbridge reflex
- inspiration increases chest vol.
- this decreases intra-thoracic pressure
- venous return to right heart and stretches atra
- sends message to medulla to decrease PSNS tone
- heart rate increases
pulse amplitude scale
0: absent
1: diminished, barely palpable
2: expected, normal
3: full, increased
4: bounding
patterns can vary d/t changes in:
- rate
- rhythm
- intensity/pressure
- contour
what arteries are best for evaluating contour?
carotids
small and weak pulse description
- barely palpable pulse
- decreased amplitude
- no bounding wave of blood
bounding pulse description
- increased pulse pressure
- rapid raise, breif peak, rapid fall
- sign of: atherosclerosis, PDA, anxiety, hyperthyroidism, exercise
water-hammer pulse
- aka collapsing pulse
- jerky carotid pulse
- rapid rise, greater amplitude, then quickly collapses
- rapid upstroke: d/y lg. SV and/or vigorous contraction
- steep drop/collapse: d/t rapid runoff of blood from the aorta
water-hammer pulse is a sign of what condition?
aortic regurg
pulsus bisferiens
- bifid pulse
- 2 systolic peaks “double peak”
- palpable abnormality
- best palpated in carotid a.
pulsus bisferiens is associated with what?
-severe aortic regurg +/- aortic stenosis
pulsus paradoxus
-exaggerated decrease in pulse amplitude (and BP) on inspiration*
pulsus paradoxus is a cardinal sign of what?
**cardiac tamponade
can also be a sign of constrictive pericarditis, lung dz, large PE
pulsus alternans
- pulse intensity alternates b/w those of greater and lesser SV
- rhythm is regular
- every other beat is weak
- better felt in distal arteries
pulsus alternans is a sign of what?
left ventricular failure**
bigeminal pulse
- 2 beats in rapid succession followed by longer interval
- normal beat followed by PVC
- regularly irregular
- every other beat is weak, easily confused w/ alternating pulse
- 2nd beat is weak and early
how do you describe a normal pulse?
Rate is 72 bpm and regular, normal intensity and contour, symmetric and synchronous bilaterally. Femoral and radial pulse are synchronous.
what to pay special attention to in palpation of edema
- new onset
- unilater or bilateral
- dependent
- pitting or not
words to know
anasarca; acites; pitting edema;myxedema; lymphedema
signs of venous occlusion
- unilateral swelling
- ruddy
- congested appearance
- warm to touch
grading the pitting edema
0+: none
1+: mild, 2 mm
2+: moderate, 4mm; disappears in 10-15 secs
3+: moderately severe, 6mm; may last > 1min
4+: severe, 8mm; can last > 2 min
pulsus paradoxus by sphygmomanometer
- taking BP and noting reading as the dsappear w/ inspiration and reappear during inspiration
- postive: if difference b/w 2 systolic measurments is >10mmHg
why do pulsus paradoxus by sphygmomanometer?
if JVD is elevated and suspect cardiac tamponade
pulsus paradoxus test is very predictive of what?
cardiac tamponade
screening test for DVT
- measurement of limb circumference
- proves if unilateral swelling is present
- normal is < 1cm difference
homan’s sign
- another screening test for DVT
- pt seated, firmly dorsiflex ankle
- produces pain in 35% of pts w/ DVT
- not sensitive, poor predictor
ankle-brachial index
- measure systolic pressure in lower leg
- use doppler to hear korotkoff sounds
- compare reading to brachial systolic pressure
- abnl is <1.0
- predictor of peripheral a. dz, arterial occlusion
