Heart Sounds I, II, and III

Origin of Early Ejection Sound

-aortic or pulmonic in origin -due to vavle stenosis or abnormal valves

Apical Impulse/PMI 1. location 2. how big? 3. when is it bigger? (2)

1. 5th intercostal space in midclavicular line 2. <2.5 cm in diameter/1 ICS 3. HF, LVH

1. Which murmurs are high pitched? 2. Which murmurs are low pitched?

1. MR, TR, and AR 2. MS and TS

Complications of MI (6)

1. Myocardial rupture (papillary muscle, VSD, free wall rupture) 2. papillary muscle dysfunction 3. cardiogenic shock 4. pericarditis 5. aneurysm 6. thrombus

Persistant or Fixed Splitting of S2 1. describe 2. causes 3. when will P2 be louder

1. P2 and A2 are always split 2. occurs in atrial septal defect and right ventricular failure 3. if pulmonary HTN is present

Wide Splitting of S2 1. describe 2. caused by

1. P2 and A2 are always split, with distance between the sounds increasing with inspiration 2. delayed closure of pulmonic valve; caused by right bundle branch block, pulmonic stenosis

Causes of Abnormal P2: -Accentuated (3) - Diminished (2)

1. Pulmonary HTN, dilated pulmonary artery, atrial septal defect 2. pulmonic stenosis, increased AP diameter

Causes of Abnormal A2: -Accentuated (2) - Diminished (1)

1. Systemic HTN, dilated aortic root 2. aortic stenosis

Causes of Abnormal S1: -Accentuated (4) -Diminished (3)

1. Tachycardia, short PR interval, High CO states, Mitral Stenosis 2. 1st degree heart block, mitral regurgitation, decreased contractility of ventricle

Aortic Regurgitation 1. Associated with? 2. Auscultation Findings 3. Neck Vessel Findings

1. aortic stenosis or Marfan's syndrome 2. diastolic blowing murmur, midsystolic murmur, "to-fro" murmur 3. bounding pulse

Grade of systolic murmurs 1. 1/6 2. 2/6 3. 3/6 4. 4/6 5. 5/6 6. 6/6

1. barely audible 2. identified easily 3. moderately loud 4. loud with palpable thrill 5. very loud with thrill 6. can be heard without stethoscope

Grade for Diastolic Murmurs 1. 1/4 2. 2/4 3. 3/4 4. 4/4

1. barely audible 2. identified easily 3. moderately loud with a palpable thrill 4. loud with palpable thrill

S3: 1. use what to hear it? 2. Where for Left side? 3. WHere for right side?

1. bell 2. apex in left lateral decubitus 3. heard best at lower left sternal border (louder on inspiration)

S4: 1. use what to hear it? 2. where for left side? 3. where for right side?

1. bell 2. apex in left lateral decubitus (same as S3) 3. left sternal border (same as S3)

Systolic Murmurs 1. Timing 2. what starts the murmur? 3. what ends the murmur?

1. between S1 and S2; coincides with carotid upstroke 2. ejection of blood; there is a gap during isovolemic contraction 3. ventricular pressure drops below diastolic pressure

Diastolic Murmurs 1. Timing 2. what is special about right sided diastolic murmurs?

1. between S2 and S1; audible turbulence after the opening of the mitral and tricuspid valves 2. vary with respiration

Hypertrophic Cardiomyopathy 1. Auscultation Findings

1. crescendo/decrescendo murmur that radiates to the apex; murmur decreases with squatting and increases with standing

Aortic/pulmonic Regurgitation 1. when? 2. describe

1. diastolic 2. blow; shorter=more severe

Atrioventricular valve stenosis 1. when? 2. describe murmur

1. diastolic 2. loud 1st sound, OS, low frequency rumble

Opening Snap 1. When does it occur? 2. most commonly due to? 3. how?

1. early diastole 2. mitral stenosis 3. mitral valve opens earlier than normal due to high left atrial pressure; fused leaflets abruptly halt the mitral valve opening, causing the opening snap

Aortic Stenosis 1. Auscultation Findings 2. Neck vessel findings 3. PMI findings

1. ejection sound, midsystolic murmur that begins with the ES and ends before S2; radiates to the neck, may have as S4 2. carotid peak is delayed and weak (parvus et tardus); prominent A wave; 3. sustained apical impulse

Papillary Muscle Rupture 1. Auscultation Findings 2. Inspection

1. explosive early systolic murmur initiated by a sharp S1; isolated clear second sound; thudding mid-diastolic murmur (S3 rumble) 2. left subcostal heave

S4: 1. how is it created? 2. what is required? 3. normal?

1. generated in the ventricle after atrial contraction due to stiffness/decreased compliance 2. sound requires the presence of atrial contraciton 3. debated

S3 1. How is it created 2. is it ever normal? 3. cause when abnormal

1. generated in ventricle during rapid filling 2. yes, due to sudden limitation of ventricular longitudinal expansion 3. due to altered physical properties of ventricle and or increase in flow

Chronic Mitral Regurgitation 1. Auscultation Findings

1. holosystolic with outward excursion of stethoscope, thudding sound with inward return of stethoscope; best hear over LV apex and may radiate to axilla; may have S3 does not vary with respiration

S2 1. heard best at 2. source 3. cause of normal splitting

1. left second intercostal space 2. closure of aortic and pulmonic valves 3. inspiration

Mitral Stenosis 1. Auscultation Findings 2. Neck Vessel Findings

1. loud S1, split S2 is fixed (S2 and OS); mid-diastolic murmur 2. subtle monophasic pulses in suprasternal notch, conspicious biphasic pulses in JVP that are a-wave dominant

Diastolic Murmus 1. when does a rumble occur? 2. caused by?

1. mid to late diastole 2. secondary to increased flow, or turbulance caused by diseased or mitral and tricuspid valves

Midsystolic Click 1. Due to 2. what can move it? how?

1. most common due to mitral valve prolapse 2. changes in LV volume (maneuvers) Decrease in volume (standing, valsalva) makes the click come early Increase in volume (squatting, maximal isometric exercise) makes the click come later

Signs of Severe AS

1. murmur peaks later, may seem to coincide with carotid upstroke 2. A2 becomes softer or disappears 3. EC moves later or disappears 4. Carotid peak is delayed and weak (parvus et tardus)

Continous murmur 1. Define 2. Causes

1. murmur that occurs during systole and continues into diastole 2. PDA, venous hum,

Shape of a Murmur 1. Crescendo 2. Decrescendo 3. Crescendo/Decrescendo 4. Plateau

1. slowly grows louder, typically seen with presystolic murmur of MS 2. gets softer, typically aortic insufficiency or pulmonic insufficiency 3. rises to a peak intensity, then gets softer, typically seen in aortic stenosis 4. plateau- same intensity throughout cycle, seen in mitral regurgitation

Paradoxical Splitting of S2 1. describe 2. cause

1. splitting appears on expiration and disappears on inspiration; A2 follows P2 2. occurs in left bundle branch block

Aortic/pulmonic stenosis 1. when? 2. describe

1. systole 2. crescendo/decrescendo; high frequency, may decrease in intensity as severity increases

Murmurs: 1. What are the general causes? (3) 4. can they ever be normal?

1. turbulent flow around obstructions (myxoma, septal hypertrophy) 2. acceleration of blood through narrow or irregular orifices (aortic or mitral stenosis, VSD) 3. acceleration of flow due to cardiac output (anemia, thyrotoxicosis, pregnancy) 4. may be normal

Diastolic Murmurs 1. When does a blow occur? 2. What causes it? 3. Shorter murmur means?

1. usually early 2. incompetent aortic and pulmonic valves 3. the shorter the murmur, the higher ventricular pressure

S3 causes: 1. Physiologic (2) 2. Pathologic (4)

1. youth, pregnancy 2. decreased myocardial contractility, CHF, volume overload (mitral or tricuspid regurg), high flow states

S4 Causes

Hypertensive heart disease (ventricular hypertrophy) coronary artery disease aortic stenosis cardiomyopathy

How are murmurs described? 6 ways

Timing (systolic vs. diastolic, early vs late) Location (base, apex?) Shape (crescendo/decrescendo?) Intensity Pitch (high or low) Quality (blow, rumble?)

Diaphragm helps you hear...

high pitched sounds: S1, S2, midsystolic click, aortic/mitral regurgitation

Atrioventricular Regurgitation 1. when? 2. describe murmur

holosystolic, late systolic if prolapsed valve, high frequency

Bell helps you hear

low pitched sounds: S3, S4, mitral stenosis

Wide S1 splitting causes (2)

right bundle branch clock premature ventricular contractions