Pressure-volume loops and cardiac cycle- Splitting-Auscultation of the heart-Heart murmurs

Question 1

What phase of the cardiac cycle corresponds with the period between the closing of the aortic valve and the opening of the mitral valve?

Answer 1

Isovolumetric relaxation

Question 2

What phase of the cardiac cycle corresponds with the period just before mitral valve closure?

Answer 2

Reduced filling

Question 3

What does S1 correspond to? In which area is S1 loudest?

Answer 3

Mitral and tricuspid valve closure; the mitral area (i.e., the midclavicular line in the fifth intercostal space)

Question 4

What does the S2 sound correspond to? In which area is it loudest?

Answer 4

Closure of the aortic and pulmonary valves; the left upper sternal border

Question 5

You hear an abnormal heart sound occurring during rapid ventricular filling. What is it? What structural heart changes is it related to?

Answer 5

S3; dilated ventricles (e.g., from increased filling pressures associated with mitral regurgitation and congestive heart failure)

Question 6

During a well-child check, you hear an S3 sound in a boy with no significant medical issues. Does this indicate a cardiac defect?

Answer 6

No, as an S3 sound can be a normal finding in children and pregnant women

Question 7

What causes the S4 heart sound, or atrial kick?

Answer 7

The left atrium pushing against a stiff left ventricular wall in a patient with ventricular hypertrophy

Question 8

You hear a late diastole sound, best heard at apex in the left lateral decubitus position. Do you expect a high or low atrial pressure?

Answer 8

High atrial pressure (the sound described here is the S4 heart sound).

Question 9

During which phase of the cardiac cycle is ventricular volume the highest? The lowest?

Answer 9

Atrial systole; isovolumetric relaxation

Question 10

The a, c, and v waves of the jugular venous pulse are associated with which physiologic events, respectively?

Answer 10

Atrial contraction, right ventricular contraction, and filling against a closed tricuspid valve

Question 11

The y descent on the jugular venous pulse represents what? The x descent?

Answer 11

y = flow of blood from right atrium to right ventricle; x = atrial relaxation & displacement of tricuspid during ventricular contraction

Question 12

The a wave of the jugular venous pulse is absent in ____, and the x descent is absent in ____.

Answer 12

Atrial fibrillation, tricuspid regurgitation

Question 13

You measure O2 consumption of a heart during the period between mitral valve closing and aortic valve opening. High or low O2 consumption?

Answer 13

High, as the period described is the isovolumetric contraction period, which has the highest oxygen consumption of all cardiac cycle phases

Question 14

During which phase of the breathing cycle is S2 splitting normally increased?

Answer 14

Inspiration, as inspiration → ↑venous return → ↑RV filling, stroke volume, and ejection time → delayed pulmonic valve closure

Question 15

On auscultation of a patient with a ventricular septal defect, does the splitting of P2 and A2 widen during inspiration?

Answer 15

Yes, as fixed splitting is only in atrial septal defects (not ventricular), due constant ↑ RA/RV volumes & flow through the pulmonic valve

Question 16

Wide splitting of the S2 heart sound is associated with ____ stenosis.

Answer 16

Pulmonic stenosis, which causes delayed RV emptying and therefore a delayed pulmonic sound (S2 is also present in right bundle branch block)

Question 17

What is the name of the phenomenon that occurs when P2 (pulmonic valve) precedes A2 (aortic valve) in the heart sound S2? What causes it?

Answer 17

Paradoxic splitting, as seen in aortic stenosis or left bundle branch block; it is due to delayed aortic valve closure

Question 18

During auscultation of a patient with aortic stenosis, does the time between pulmonic and aortic valvular closure change during inspiration?

Answer 18

Yes, it decreases, and P2 precedes A2 (paradoxical splitting) (on inspiration, splitting could also be eliminated as P2 moves closer to A2

Question 19

How does normal inspiration affect intrathoracic pressure and pulmonary blood flow?

Answer 19

Inspiration ↓ intrathoracic pressure and pulmonary impedance, which ↑ pulmonary blood flow and delays closure of pulmonic valve

Question 20

What type of splitting is seen in conditions that slow right ventricle emptying (e.g., pulmonic stenosis and right bundle branch block)?

Answer 20

Wide splitting, as the delayed right ventricular emptying causes delayed pulmonic sound, regardless of breath

Question 21

You examine a patient with a cardiac defect and hear a fixed split. What defect does the patient have, and why is there a fixed split?

Answer 21

Atrial septal defect (causes left-right shunt, increasing flow through pulmonic valve); regardless of breathing, pulmonic closure is delayed

Question 22

In what areas are the murmurs of aortic stenosis and aortic regurgitation best heard?

Answer 22

Aortic area (i.e., right sternal border and second intercostal space) and left sternal border, respectively

Question 23

In what areas are the murmurs of pulmonic stenosis and pulmonic regurgitation best heard?

Answer 23

Pulmonic area (i.e., left sternal border at second intercostal space) and left sternal border, respectively

Question 24

A 60-year-old man has tricuspid stenosis. Where can you best hear the murmur? Would the murmur be louder on inspiration or expiration?

Answer 24

Tricuspid area; inspiration (right heart sounds are louder on inspiration)

Question 25

Which murmurs are heard during systole?

Answer 25

Aortic/pulmonic stenosis, flow murmurs, aortic valve sclerosis, mitral/tricuspid regurgitation, hypertrophic cardiomyopathy, VSD, MVP

Question 26

What four murmurs are heard during diastole?

Answer 26

Aortic/pulmonic regurgitation, mitral stenosis, tricuspid stenosis, and ASD

Question 27

A 65-year-old man has mitral regurgitation. Would his murmur be expected to increase or decrease with the hand-grip maneuver?

Answer 27

Increase (hand grip increases systemic vascular resistance and afterload)

Question 28

Most murmurs decrease in intensity with Valsalva. What murmur increases with Valsalva? What maneuvers decrease this murmur’s intensity?

Answer 28

Hypertrophic cardiomyopathy; rapid squatting and hand grip

Question 29

An increase in afterload will cause what three murmurs to increase in intensity?

Answer 29

Mitral regurgitation, aortic regurgitation, and ventricular septal defect

Question 30

A patient with a mitral valve prolapse squats down suddenly. What will happen to the timing of the patient’s murmur?

Answer 30

The onset of the click/murmur will be later

Question 31

A patient with a mitral valve prolapse performs a Valsalva maneuver. What will happen to the timing of the patient’s murmur?

Answer 31

The onset of the click/murmur will be earlier

Question 32

A patient with a mitral valve prolapse clenches his fists. What will happen to the timing of the patient’s murmur?

Answer 32

The onset of the click/murmur will be later

Question 33

You hear a systolic murmur in a man. Its intensity increases w/Valsalva and decreases w/hand grip. Does it ↑ or ↓ with rapid squatting?

Answer 33

↓ (the murmur described here is the murmur of hypertrophic cardiomyopathy)

Question 34

A man has a systolic murmur. You are not sure if it is aortic stenosis or hypertrophic cardiomyopathy. How do you differentiate?

Answer 34

Have the patient perform Valsalva (HOCM intensifies, AS softens) or squat rapidly (HOCM softens, AS intensifies)

Question 35

Phase ____ (I/II/III/IV) of the Valsalva maneuver is used to detect murmur changes.

Answer 35

II

Question 36

A patient squats rapidly. What happens to preload and venous return of the heart?

Answer 36

Preload and venous return both increase

Question 37

A patient performs the hand-grip maneuver. What happens to the heart’s afterload?

Answer 37

Increases

Question 38

A patient performs the Valsalva maneuver. Phase II is reached, and the patient is standing. What happens to the heart’s preload?

Answer 38

Decreases

Question 39

Which heart murmurs are described as holosystolic, high-pitched, and blowing?

Answer 39

Mitral and tricuspid regurgitation

Question 40

You hear a murmur that is loudest at the apex and radiates toward the axilla. What maneuver increases the volume of this murmur?

Answer 40

Hand grip, which increases afterload, increasing the murmur intensity (the murmur described is the mitral regurgitation murmur)

Question 41

What type of murmur is loudest at the left sternal border at the fifth intercostal space and radiates to the right sternal border?

Answer 41

Tricuspid regurgitation

Question 42

Describe the pressures in the left ventricle (LV) and aorta in a patient with aortic stenosis (AS) vs. those in a healthy patient.

Answer 42

In AS, pressure in LV is much higher than in aorta, as LV squeezes blood past a stenotic valve; this results in a greater pressure gradient

Question 43

What does the term “pulsus parvus et tardus” mean?

Answer 43

Pulses are weak compared to the heart sounds, and the strongest part of the peripheral pulse occurs late after the S1 is heard

Question 44

Which heart valve disease process often is due to age-related calcification and can be associated with syncope?

Answer 44

Aortic stenosis, which on exertion can present as Syncope, Angina, Dyspnea (SAD)

Question 45

What is the most frequent murmur causing valvular lesion?

Answer 45

Mitral prolapse

Question 46

Which heart murmur usually is benign but can predispose to infective endocarditis?

Answer 46

Mitral prolapse

Question 47

What are four examples of pathologic processes that can cause aortic regurgitation?

Answer 47

Aortic root dilation, bicuspid aortic valve, rheumatic fever, and endocarditis

Question 48

An 80-year-old woman reports that her mother told her she had rheumatic fever as a child. What valvular abnormalities may she have?

Answer 48

Mitral stenosis, aortic regurgitation, mitral valve prolapse, mitral regurgitation, tricuspid regurgitation

Question 49

In mitral stenosis, ↓ interval between the S2 and opening snap sounds correlates with ____ (increased/decreased) severity.

Answer 49

Increased, as chronic mitral stenosis can result in dilation of the left atrium

Question 50

Describe the relationship between left atrium pressure and left ventricle pressure during diastole for a patient with mitral stenosis.

Answer 50

In mitral stenosis, left atrial pressure greatly exceeds left ventricular pressure during diastole