Precordial Exam Flashcards
What is the order of all of the normal heart sounds and what do the correlate to?
1) S1–> sound made by closure of the AV valves ( correlates to the C wave on the JVP
2) S2–> sound made by closure of the aortic and pulmonary valves
3) S3–> Fast phase of ventricular filling after/including opening of the mitral valve.
- Best heard at the apex.
- S3 is not physiological for anyone over the age of 40
4) S4–> Ventricular filling due to atrial contraction
- can arise in the presence of systemic hypertension, recent MI, aortic stenosis, pulmonary stenosis and pulmonary hypertension
How do you characterize an apex beat?
Location
Size
Impulse
Amplitude
Duration
How can you amplify the apex beat?
1) lying on their left side–> the size could increase to <4cm
2) Asking patient to exhale fully and stop breathing for a few seconds
What are the mid systolic (loudest at the middle of systole) murmurs?
1)Aortic stenosis
Location: best heard over the aortic area (R clavicle) and apex
Radiation: radiates to the carotids
Timing: mid systolic
Intensity
Pitch
Quality: cresendo decresendo murmur
Things that alter it: sitting up, leaning foreward
PE for AS–> narrow pulse pressure, brachial radial delay, pulsus parvus et tardus, sustained PMI
2)Pulmonary stenosis
Location: best heard in the 2nd to 3rd ICS at the LSB
Radiation: radiates to the carotids
Timing: mid systolic, cresendo decresendo murmur
Intensity
Pitch
Quality: cresendo decresendo murmur
Things that alter it: inspiration
PE for PS–> accentuatued by inspiration, pulmonary ejection click, right sided S4
What are the pan systolic murmurs?
Caused by turbulence created by the regurgitation of blood during the ventricular systole in either the right or left side of heart
1)Mitral regurgitation-->
Location: best heard at apex
Radiation: radiates to axilla +/- mid-diastolic rumble
Timing: early diastolic
Intensity
Pitch
Quality: decreshendo
Things that alter it: LLDP
- prominent ( loud) S2.
- S3 present
PE of mitral regurg–>Displaced hyperdynamic apex, left parasternal lift, apical thrill
2)Tricuspid regurgitation–>
Location: 4th left intercostal space
Radiation: none
Timing: pan systolic
Intensity
Pitch
Quality: holosystolic
Things that alter it:
Best heard at LLSB, accentuated by inspiration
PE of tricuspid regurgitation–> CV waves in JVP, +ve adbominojugular reflex, Kussmaul’s sign, left parasternal lift
-
What are the early diastolic murmurs?
These are caused by incompetent aortic or pulmonary valves
1)Aortic regurgitation
Location: Best heard at LLSB or RLSB (aortic root)
Radiation: none
Timing: early diastolic
Intensity
Pitch
Quality: decreshendo
Things that alter it: sitting leaning foreward, on full expiration
PE of aortic regurg–>Waterhammer pulse, bisperiens pulse, femoral- brachial SBP >20, hyperdynamic apex, displaced PMI
Soft S1, absent S2, late S3
2)Pulmonary regurgitation
Location: LSB
Radiation: none
Timing: early diastolic
Intensity
Pitch
Quality: decreshendo
Things that alter it:
PE of pulmonary regurg–> early diastolic murmur at LLSB,
graham steel murmur 2nd and 3rd LICS increasing with inpiration
Whare the mid diastolic murmurs?
Caused by stenotic mitral or tricuspid valves
1)Mitral stenosis
Location: Apex
Radiation: none
Timing: mid diastolic
Intensity
Pitch
Quality: rumble
Things that alter it: LLDP following exertion on expiration
PE of mitral stenosis–> no A wave on JVP
2) Tricuspid stemosis
Location: 4th left ICS LSB
Radiation: none
Timing: mid diastolic
Intensity
Pitch
Quality: rumble
Things that alter it: nothing
PE of tricuspid stenosis: prominent A waves on JVP, +ve abdominojugular reflex, Kussmauls sign,
