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SMP - Cardiopulmonary Exam 1 > PSW 3 - Heart Sounds > Flashcards

PSW 3 - Heart Sounds Flashcards

1
Q

What are the 4 parts of the cardiovascular exam?

A
  1. Inspection
  2. Palpation
  3. Percussion
  4. Auscultation
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2
Q

Describe the inspection portion of the CV exam.

A

Check for prominent venous pulsations that are multiphasic or respiraphasic at the meniscus height of the jugular for volume assessment

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3
Q

Describe the palpation portion of the CV exam.

A

Parts to palpate:

  1. Heart apex: for overall heart size
  2. Left sternal border: to assess possible RV increased pressure or thrills
  3. Right sternal border: ascending aorta
  4. Base of the heart: to assess possible aortic thrills or pulmonary thrills
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4
Q

What is a thrill? What are they associated with?

A

Vibratory sensation felt on the skin overlaying an area of turbulent flow

Associated with murmurs

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5
Q

Describe the percussion portion of the CV exam.

A

Not very useful in CV exam

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6
Q

What is another name for increased RV pressure?

A

RV “heave”

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7
Q

What are the 3 different parts of the stethoscope? What is each used for?

A
  1. Diaphragm: high frequency sounds
  2. Bell: low frequency sounds
  3. Corrugated diaphragm: medium frequency sounds
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8
Q

How hard should you push the diaphragm of the stethoscope down on the skin on the patient?

A

Hard enough to leave a circle on the skin

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9
Q

How hard should you push the bell of the stethoscope down on the skin on the patient?

A

Lightly at first

If you think you heard a sound then press it harder so it becomes a diaphragm and see if it filters out low the pitched sounds

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10
Q

Which heart sounds are low pitched sounds which require us to use the bell of the stethoscope to hear them?

A

S3 and S4

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11
Q

In what position should the patient be for auscultation?

A

BOTH upright and supine positions

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12
Q

What are the 5 surface areas used to listen to heart sounds? What are these areas also used for?

A
  1. Pulmonary valve: left upper sternal border in the second intercostal space
  2. Aortic valve: right upper sternal border in the second intercostal space
  3. Tricuspid valve: Left lower border of sternum at the 5th intercostal space
  4. Mitral valve: Bare area of the pericardium = 5th intercostal space about 1 inch to the left of the sternum
  5. Apex beat of the heart: 5th intercostal space, 3.5 inches from midline on the left (or 1-2 inches below nipple)

Also used during EKGs

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13
Q

Are the heart valves heard at the skin level where they are located?

A

NOPE, downstream from the blood flow

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14
Q

What makes heart sounds?

A

CLOSING of heart valves

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15
Q

What is S1?

A

Closing of the AV valves

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16
Q

In what order should you listen to heart sounds?

A
  1. Right upper sternal border (aortic valve): listen to overall heart beat
  2. Left upper sternal border (pulmonary valve): check for S2 splitting
  3. Erb’s point: listen to pulmonary and tricuspid sounds together
  4. Bell at apex to listen to mitral sounds
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17
Q

Are sounds in the right and left hearts different?

A

Yes, the left hearted sounds are louder

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18
Q

Where is Erb’s point on the chest?

A

Left side of sternum in third intercostal space

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19
Q

What does an S3 sound mean clinically MOST OFTEN?

A

Decompensated heart failure with increased left sided filling pressures

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20
Q

Which events occur FIRST in NORMAL individuals? Why? Can you hear this upon auscultation?

A

All left-sided events (closing), due to normal electrical activation

YES, we can hear each valve closing independently

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21
Q

Do heart valves made sounds when the open?

A

NOPE, not in NORMAL hearts

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22
Q

Frequency of S1?

A

High

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23
Q

What part of stethoscope to use to hear S1?

A

Diaphragm

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24
Q

Which S1 valve transmits sound widely? Explain.

A

Mitral: heard throughout the precordium

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25
Q

Where is the tricuspid valve heard?

A

ONLY in tricuspid area

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26
Q

How long after the mitral valve closing can the tricuspid valve closing be heard?

A

30 msec

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27
Q

What are the 3 abnormalities that can be heard with S1? Explain each.

A
  1. Rheumatic heart disease OR mitral valve stenosis increased S1 intensity
  2. 1st degree AV block: decreased intensity
  3. Atrial fibrillation: variable intensity
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28
Q

What is S2?

A

Closure of semilunar valves

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29
Q

Frequency of S2?

A

High frequency

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30
Q

What part of stethoscope to use to hear S2?

A

Diaphragm

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31
Q

What does S2 vary with?

A

Respiration

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32
Q

How does respiration affect S2? What is this known as?

A
  1. Inspiration => intrathoracic pressure decreases => increased abdominal pressure => increased venous return + expansion of pulmonary venous capacity => increased volume in RV compared to LV => increased time in systole to eject increased volume => delayed closure of pulmonary valve compared to the aortic valve by 40-50 msec
  2. Expiration => semilunar valve sounds come back closer together

PHYSIOLOGICAL SPLITTING

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33
Q

Which S2 valve transmits sound widely? Explain.

A

Aortic valve heard through the precordium

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34
Q

Which S2 valve is louder?

A

Aortic valve: ALWAYS louder than the pulmonary valve in ALL AREAS (even the pulmonary ones)

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35
Q

Where is the S2 pulmonary valve heard?

A

ONLY heard in pulmonary area

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36
Q

What are 2 types of S2 abnormalities?

A
  1. Increased pulmonic component

2. Abnormal splitting

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37
Q

Describe the increased pulmonic component S2 abnormality.

A

This happens if you can hear the physiological splitting in non pulmonic areas => due to any process that increases the pulmonary arterial pressure (e.g. pulmonary hypertension)

38
Q

What are the 3 types of S2 abnormal splitting? Describe each. What is this known as?

A
  1. Paradoxic splitting: delayed or prolonged LV ejection due to abnormal electrical activation (LBBB or RV pacemaker) or severe aortic valve disease => sounds split during expiration and come back together during inspiration
  2. Fixed splitting: due to atrial septal defect where blood from right side can go to left side and so S2 has a constant spliting between valves that does NOT change with respiration
  3. Wide splitting: delayed or prolonged RV ejection due to RBBB or pulmonic stenosis

PATHOLOGICAL SPLITTING

39
Q

Frequency of S3?

A

Low

40
Q

What is S3 due to? In what patients can we hear this sound?

A

RAPID ventricular filling

  1. Children: normal
  2. Adults up to 20s (especially runners): normal
  3. Pregnant women: normal
  4. Older adults: pathological and could be due to heart failure or severe volume overload with either mitral or tricuspid regurgitation
41
Q

Where do we listen for S3 and S4?

A

Apex of the heart (mitral valve surface projection)

42
Q

What is tricuspid/mitral regurgitation?

A

During systole, half of the ventricular volume goes back into the atrium in addition to it filling with blood from veins

43
Q

What is S4 due to?

A

Contraction of atria caused heart to vibrate: ALWAYS pathological

Present when there is decreased compliance (e.g. hypertrophy) in the ventricle

NOT pathognomic of anything but could be due to aortic stenosis, HT, or acute myocardial infarction

44
Q

What is a gallop?

A

Heart beat with 3 or 4 sounds

45
Q

Frequency of S4?

A

Low

46
Q

In what pathological condition is it IMPOSSIBLE to hear S4?

A

A-fib

47
Q

What is a summation gallop?

A

Happens when S3 and S4 occur so close as to be indistinguishable

48
Q

What are 3 extra sounds one can hear during auscultation?

A
  1. Ejection sound
  2. Opening snap
  3. Mid-systolic click
49
Q

In what valve is an ejection sound more common?

A

Aortic valve

50
Q

Ejection sound:

  1. Correlation?
  2. Portion of cardiac cycle?
  3. Frequency?
  4. Normal or abnormal?
  5. Transmission?
  6. Location for hearing?
  7. Most common cause?
A
  1. Opening of one of the semilunar valves
  2. Early systole
  3. High frequency
  4. Always abnormal
  5. Wide transmission
  6. Base and apex of the heart
  7. Bicuspid aortic valve (instead of 3 valves)
51
Q

What is bicuspid aortic valve?

A

Congenital abnormality that 2 to 3% of people in the US have

52
Q

Opening snap:

  1. Correlation?
  2. Portion of cardiac cycle?
  3. Normal or abnormal?
  4. Location for hearing?
  5. Cause?
  6. Assessment of severity?
  7. Sound following?
A
  1. Opening of the mitral valve
  2. Early diastole
  3. Abnormal
  4. Apex of the heart
  5. Mitral stenosis due to rheumatic heart disease
  6. Time between A2 and opening snap correlates to severity
  7. Diastolic murmur comes after
53
Q

What is A2?

A

Aortic valve closing in S2

54
Q

What is rheumatic heart disease?

A

Cardiac inflammation and scarring triggered by an autoimmune reaction to infection with group A streptococci. In the acute stage, this condition consists of pancarditis, involving inflammation of the myocardium, endocardium, and epicardium. Chronic disease is manifested by valvular fibrosis, resulting in stenosis and/or insufficiency.

55
Q

What is a mid-systolic click due to?

A

Mitral valve prolapse

56
Q

Can S3 and S4 come from either side of the heart?

A

Yes, but left side sounds are more common

57
Q

What are the 3 types of murmurs?

A
  1. Systolic
  2. Diastolic
  3. Continuous
58
Q

Systolic murmur: physiologic or pathologic?

A

Could be innocent (flow murmur) or pathologic

59
Q

Diastolic murmur: physiologic or pathologic?

A

ALWAYS pathologic

60
Q

What are murmurs?

A

Turbulence in the blood flow

61
Q

2 examples of patients that could have innocent systolic murmurs?

A
  1. Young patient with a fever

2. Anemic pregnant patient

62
Q

What are abnormal heart murmurs associated with?

A

Issue with valve opening or closing

63
Q

What are 4 causes of heart murmurs that happen when the valve should be open? When do we hear each?

A
  1. Aortic stenosis - systole
  2. Mitral stenosis - diastole
  3. Pulmonic stenosis - systole
  4. Tricuspid stenosis - diastole
64
Q

What are 4 causes of heart murmurs that happen when the valve should be closed?

A
  1. Aortic insufficiency - diastole
  2. Mitral insufficiency - systole
  3. Pulmonic insufficiency - diastole
  4. Tricuspid insufficiency - systole
65
Q

What are 6 ways of describing murmurs?

A
  1. Systolic vs diastolic vs continuous
  2. Levine’s grade I-VI scale for systolic murmurs
  3. Timing: entire during of systole/diastole or part of it
  4. Pitch
  5. Location best heard
  6. Radiation: what direction does it go in
66
Q

Describe Levine’s scale to grade systolic murmurs. Which grades are most common?

A

I. Faintest murmur that can be heard with difficulty
II. Faint but can be identified immediately*
III. Moderately loud*
IV. Loud and associated with a palpable thrill
V. Very loud but cannot be heard without the stethoscope
VI. Loudest and can heard without a stethoscope

67
Q

What will an aortic stenosis sound like?

A

Harsh murmur

68
Q

What will a valve insufficiency murmur sound like?

A

Blowing sounding murmur

69
Q

In between what heart sounds do systolic ejection murmurs take place? How does this relate to cardiac cycle? Do the murmur vary throughout?

A

Start a little after S1 (once semilunar valves open at end of IC) and all the way until S2 (when semilunar valves close at beginning of IR) => during the whole ejection phase

Yes, loudest at the “middle” of the murmur

70
Q

What do we call murmurs having to do with AV valve insufficiencies?

A

Regurgitant pansystolic murmur

71
Q

In between what heart sounds do regurgitant pansystolic murmurs take place? How does this relate to cardiac cycle? Do the murmur vary throughout?

A

Start right at S1 at the start of isometric contraction (do not need open semilunar valves to have regurgitation) and ends after S2 until the end of isometric relation (until LVP «&laquo_space;LAP and AV valves open) - often overrides the heart sounds which you cannot even hear

No, homogeneous murmurs

72
Q

In between what heart sounds do diastolic murmurs take place? How does this relate to cardiac cycle? Do the murmur vary throughout?

A

Start at S2 (start of isometric relaxation), which sometimes overrides the S2 sound, and end at S1 when the AV valves close (start of isometric contraction)

No, homogeneous murmurs

73
Q

What are the 4 diastolic murmurs due to?

A
  1. Aortic insufficiency
  2. Pulmonary insufficiency
  3. Mitral stenosis
  4. Tricuspid stenosis
74
Q

What are the 2 ejection systole murmurs due to?

A
  1. Aortic stenosis

2. Pulmonary stenosis

75
Q

What are the 2 regurgitant pansystolic murmurs due to?

A
  1. Mitral insufficiency

2. Tricuspid insufficiency

76
Q

What 3 abnormal sounds would be heard with mitral stenosis? List them in order of the cardiac cycle.

A
  1. Louder S1 because QRS depolarization forces the mitral valve shut even when blood is still coming out and LAP&raquo_space; LVP
  2. Opening snap
  3. Diastolic murmur with increased murmur towards the end due to atrial contraction
77
Q

What is different about the ejection systole murmur heard with aortic stenosis?

A

It ends before S2 because as the valve gets closer to closing the pressure goes down and the turbulence decreases so the murmur is not as loud and we cannot hear it

78
Q

Describe LVP and AP during ejection with aortic stenosis.

A

LVP (abnormally high curve during SYSTOLE)&raquo_space;»» AP (normal curve) because of the high resistance in the aorta

79
Q

How does aortic stenosis affect the pulse? What is this called?

A

Pulse is delayed and weak = pulsus parvus et tardus

80
Q

What is an Austin Flint murmur?

A

Aortic insufficiency cascades to the anterior mitral leaflet of the mitral valve so when blood fills in during diastole you can generate turbulence across the mitral valve which is being held down in place by the regurgitated blood => diastolic murmur at both the right upper sternal border at the second intercostal space and the apex of the heart

81
Q

What kind of murmurs are innocent murmurs?

A

Systolic ejection murmurs

82
Q

To where does an aortic stenosis murmur radiate?

A

The neck

83
Q

How to tell the difference between an innocent ejection murmur or a pathological one?

A

Innocent one will not radiate to the neck and will not sound harsh

84
Q

What is the vasculature like distal to the aortic stenosis?

A

Vasodilated to try to get as much of the CO as possible

85
Q

Where is the base of the heart located anatomically?

A

Behind the sternum, so cannot palpate it

86
Q

What is the point of maximal impulse of the heart?

A

PMI is generated when the apical part of the LV taps against the inner surface of the anterior chest wall during systole. The PMI when palpated gives a rough estimate of the size of the heart (mid clavicular line= normal, mid axillary line = heart enlarged)

87
Q

What would cause a faint S2?

A

Aortic valve stenosis

88
Q

How does LBBB affect heart sounds?

A

Paradoxic splitting of S1 and S2: delayed or prolonged LV ejection due to abnormal electrical activation

89
Q

Can CO be increased during exercise when you have aortic stenosis?

A

NOPE

90
Q

When are the pulse and the HR not the same?

A

When arterial pressures are VERY low

SMP - Cardiopulmonary Exam 1 (28 decks)

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