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Primary Care Skills
Interpreting Abnormal Heart Sounds
| Question | Answer |
|---|---|
| *When you auscultate the heart, the first and second heart sounds define: | the duration of systole and diastole |
| *Closure of the mitral valve produces: | the first heart sound, S1 |
| *Closure of the aortic valve produces: | the second heart sound, S2 |
| Factors that increase the force and velocity of ventricular pressure tend to increase the intensity of: | S1 |
| The position of the AV valves at onset of systole also affects: | S1 intensity, as well as exercise and excitement |
| If ventricular contraction occurs against a wide open valve, | the LV leaflets attain a higher velocity (louder S1) than if the valves were partially closed |
| S1 is normally loudest at the: | apex |
| Bradycardia is associated with | an apparent softening of S1, since the AV valves are already closed at the onset of ventricular contraction |
| Splitting of S1 | (may occur in normal pts); is best heard over the left sternal border |
| A normal second heart sound (S2) is produced by the: | pressure changes and vibration of valves by movement of aortic and pulmonic leaflets towards respective ventricles |
| Since systole (the time of ventricular contraction) is usually shorter than diastole (time of ventricular relaxation) | there is a longer pause between S2 and S1 than between S1 and S2 |
| S1: duration and pitch | long, low (best heard at apex) |
| S2: duration and pitch | short, high (best heard in aortic/pulmonic areas) |
| Palpation of the apical impulse or carotid pulse will assist in the identification of: | S1, since S1 occurs slightly before pulse |
| S3 physiological heart sound is a: | low-pitched vibration occuring early diastole during time of rapid ventricular filling; sound is produced by abrupt transmission of forces to the chest wall when the blood mass enters the right ventricle |
| *An S3 is commonly heard | in normal children and adolescents and in some young adults (may persist until 40 esp in women) |
| *When S3 is heard in pts over 30yo, it is called: | a gallop sound; a sign of pathology such as left ventricular failure (CHF) or volume overload of ventricle from valvular heart disease such as mitral regurgitation |
| S3 occurs after __ and is best heard at __ when the pt is __ | S2; apex; left semilateral position |
| S3 or S4 will normally disappears completely when the pt __ or __; conversely __ accentuates a physiologic S3 | sits; stands (lowering heart rate); exercise |
| *A 4th heart sound is seldom heard in young adults unless | they are well conditioned athletes (it is frequent in infants and small children) |
| *A 4th heart sound may be heard in apparently healthy older people, but it is also frequently a/w: | decreased ventricular compliance from heart disease (ex: Acute MI) |
| *S4 is usu only head at: | apex w/pt in left semilateral position |
| *Physiologic S4 is poorly transmitted and is: | rarely accompanied by a shock (when it can be felt and heard) |
| *Wide transmission of a loud S4 associated with a shock is: | pathologic and is referred to as an S4 gallop |
| *Most heart murmurs | occur w/o other evidence of CV abnormality and may be considered innocent murmurs (normal varient) and vary w/age |
| *Murmurs are caused by: | turbulance and flow disturbance in vessels or through valves (sometimes murmurs will radiate and be mistaken as a bruit in the carotids) |
| if a vessels is completely blocked: | you won't hear a bruit! need to do an ultrasound |
| Systolic murmur | innocent; children, adolescents, YAs; flow murmur reflecting pulmonic flow; heard best at 2nd-4th interspaces; may be intermittent |
| *Aortic Systolic murmur | common in middle-aged and older adults (1/3 of 60yos, 1/2 of 85yos) |
| Cause of Aortic Systolic Murmur | aging thickens/calcifies bases of aortic cusps and audible vibrations result from turbulence produced by flow into a dilated aorta |
| Concern a/w Aortic Systolic Murmurs | in most people the process of "aortic sclerosis" doesn't impede blood flow, but true aortic stenosis can obstruct flow; differentiating may require an echo or notice of delayed carotid upstroke (abnormal = stenosis) |
| *Systolic Murmur of Mitral Regurgitation | a similar process to that of aortic sclerosis, usu occurs 10yrs later (70yo) |
| *Cause of Mitral Valve Regurgitation/Sclerosis | degenerative changes w/calcification of mitral annulus (valve ring); impaired ability of normal closure during systole; extra load on heart dt mitral valve leakage |
| *Where do murmurs originate? | large blood vessels and the heart (dt flow obstruction and turbulence; also in tortuous vessels in kids have innocent flow interruption) |
| *Diastolic murmurs | usu indicate valvular heart disease (heard btw S2 and S1) |
| *Systolic murmurs | MAY indicate valvular disease, but often occur when heart is entirely normal (heard btw S1 and S2) |
| *Midsystolic murmurs | most often are related to blood flow across the aortic and pulmonic valves (heard after S1 and stops before S2) |
| *Pansystolic (holosystolic) murmur | often occur with regurgitant (backward) flow across the AV valves (heard starting with S1 and stopping at S2 w/o a gap between the murmur and heart sounds) |
| *Late Systolic Murmur | the murmur of mitral valve prolapse (heard in late or mid-systole; persists up to S2; seen mostly in women) |
| *Early diastolic murmur | typically a/w regurgitant flow across incompetent semilunar (aortic/pulmonic) valves |
| *Mid-diastolic murmur | typically reflect turbulent flow across the AV valve (heard a short time after S2 and then fades to absent before the next S1) |
| *Late diastolic (presystolic) murmur | similar to mid-diastolic murmur (reflects turbulent flow across AV valve), except it is usu heard late in diastole and continues up to S1 withough fading |
| *Grade 1 murmur | faint; must listen close |
| *Grade 2 murmur | quiet, heard right away |
| *Grade 3 murmur | moderately loud |
| *Grade 4 murmur | loud with palpable thrill |
| *Grade 5 murmur | very loud with thrill |
| *Grade 6 murmur | typically can hear w/o a stethoscope |
| *Most likely causes of murmurs in children: | Patent ductus arteriosus, atrial septal defect, ventricular septal defect, coarctation of aorta (all are pretty much fatal if not fixed) |
| *Innocent murmurs in children | Still's murmur, venous hum, pulmonary flow murmur |
| *Variations in the first heart sound: Accentuated S1 | tachycardia (anemia, exercise, hyperthyroidism); Mitral stenosis |
| *Variations in the first heart sound: Diminished S1 | First degree heart block (mitral valve closes "less loudly"); Mitral Regurgitation; Congestive Heart Failure; Coronary heart disease |
| *Variations in the first heart sound: Varying S1 (intensity) | Complete heart block; Atrial fibrillation |
| *Variations in the first heart sound: Split S1 | May be normal; Right BBB; PVCs (premature ventricular contraction) |
| *Variations in the second heart sound: Pathological splitting | all of these involve splitting during expiration and all suggest heart disease |
| *Variations in the second heart sound: Wide Splitting | caused by: 1. delayed closure of pulmonic valve (pulmonary stenosis, RBBB); 2. Early closure of aortic valve (mitral regurgitation); Persists thru respiratory cycle |
| *Variations in the second heart sound: Fixed Splitting | wide splitting that does not vary (intensity) with respiration; occurs with: 1. Atrial Septal Defect; 2. Right Ventricular Failure |
| *Variations in the second heart sound: Paradoxical or Reversed Splitting | appears on expiration and disappears on inspiration; occurs mostly with: LBBB |
| *Extra heart sounds in systole: Early Systolic Ejection Sound | occurs shortly after S1; high pitch, sharp, clicking; Heard best with diaphragm; indicative of cardiovascular disease |
| *Extra heart sounds in systole: Aortic Ejection Sound | heard at base and apex (typically louder at apex); accompanies a dilated aorta or aortic valve disease; Congenital Stenosis or Bicuspid valve |
| *Extra heart sounds in systole: Pulmonic Ejection Sound | heard best at 2nd and 3rd left interspaces; when S1 is unusually loud; Dilation of Pulmonary Artery, Pulmonary Hypertension or Pulmonic Stenosis |
| *Extra heart sounds in systole: Systolic Clicks | usu due to mitral valve prolapse; heard mid or late systole |
| *What is an opening snap? | a very early diastolic sound usu produced by the opening of a stenotic mitral valve; heard best just medial to the apex and along the lower left sternal border; heard best with the diaphragm (high pitched snapping sound) |
| *Cardiovascular Sounds with Both Systolic and Diastolic Components: Pericardial Friction Rub | At least 2 components (may have 3): Atrial Systole; Ventricular Systole; Ventricular Diastole; quality is scratchy, scraping, high-pitched; Best heard at 3rd interspace; Due to: Pericarditis |
| *Cardiovascular Sounds with Both Systolic and Diastolic Components: Patent Ductus Arteriosus | Continuous murmur in both sytole and diastole; Loudest in late systole; obscures S2 and fades in diastole; Sounds harsh/machine-like; Medium-pitch; Heard best at 2nd interspace; Due to: Congenital abnormality w/open channel btw aorta and pulmonary artery |
| *Cardiovascular Sounds with Both Systolic and Diastolic Components: Venous Hum | A continuous murmur w/o a silent interval; Loudest in diastole; Heard best above medial 3rd of clavicles on R 1st/2nd interspaces; Soft-moderate intensity; Literally a low humming/roaring sound; Benign; Best heard with bell |
Created by:
bscaryp