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Heart part 2 murmurs

Advanced Physical Assessment

QuestionAnswer
Systole MT close (S1) and then AP open
Diastole AP close (S2) and then MT open
Aortic stenosis happens when systole b/c you use the aortic valve during systole- no blood flow during diastole
Which one of the valves closes first? aortic closes 1st/last to open then pulmonic (mitral 1st to close last to open/t)
Mitral and tricuspid fill the ventricles so they are diastolic
Aortic and pulmonic move blood during systole
Regurgitation with mitral valve happens when systole because this is when it’s supposed to be closed
Closure of the valve is noisy and creates the heart sound- systole
systolic murmurs are aortic stenosis or mitral valve (mr ass)
Isovolumetric phase when all the valves are stopped/red
During inhalation more blood on rt side of the heart
During exhalation more blood on the left side of the heart
The more you fill the heart with blood sounds and murmurs get louder
Diastole AP close/ MT open- mitral valve narrow- diastolic murmur or aortic regurgitation because it’s supposed to be closed= diastole
S1 is systole MT close
S2 is the start of diastole AP close- louder at the base
S3 is only heard in healthy children and prego any others = HF
Those with heart failure who have s3 increase Lasix, pulmonary congestion
All innocent murmurs are systolic
Aortic murmurs can be heard all over the place- not just the base (2/3rd ICS) – apex is the 5th ICS
Base means 2nd and 3rd ICS- aortic murmurs can be heard there but all over the chest
What is important with murmurs when*and where
S1 is heard the loudest at the apex s2 is better at the base
S1 you can hear it sometimes higher than normal- mild mitral stenosis- cannot even hear the murmur
Splitting S2 the right side gets filled with inspiration- the pulmonic will have more work to do and closes late because there’s too much pressure- heard on inspiration- longer and louder
Test ?- Wide split- abnormalities of S2 any condition that increases the pressure or volume on the right side of the heart- pulmonary htn- pulmonic condition happens later and aortic happens earlier so it widens the split.
Test ?- fixed splitting of s2 A fixed split S2 always indicates an atrial septal defect (ASD). A fixed split S2 occurs when there is always a delay in the closure of the pulmonic valve
Higher pressure higher sound
Pulmonary htn abnormal S2 1) 2nd heart sound is loud 2) 2nd heart sound is widely split because the pulmonic component occurs late- loud P2- valve closes late- higher pressure
S3 and S4 diastolic heart sounds heard with the bell- also mitral stenosis murmur- low pitched sounds
S3- low pitched, use your bell, best heard at the apex, in left lateral- one of 2 conditions to turn pt to the left
In those over 40 years, S3 is usually pathologic and indicative of LV failure- S3 has very high specificity but low sensitivity for LV failure- give lasix
S3 has high_____ but low_________ specificity, sensitivity you can say pt has chf if s3 is present, but if not present, you cannot exclude chf
Gallop3 word for s3 – HF- ORDER LASIX
In tachycardia diastole gets shortened-
Test question- left ventricular gallop S3 left sided so it’s softer during inspiration because we put more blood on the right side- ask pt to exhale to hear better
Aortic ejection click clicks during systole because that’s when it opens and it’s stiff- mitral stenosis is early diastole because that’s when it opens
MVP click/mitral valve prolapse leaflets loose when there’s less blood in the heart- blood goes back the other way- the jacket is big when you lose wt- mid systole (closes)- high pitch
Opening snap Mitral stenosis- early diastole because it’s still- click
An S1 or S2 caused by a mechanical valve (following MVR or AVR respectively), will acoustically sound similar to a click- An absent mechanical valve click =valve dysfunction
What’s the difference between murmur and bruit? nothing- it’s outside the heart
Abnormal viscosity anemia- decreased blood viscosity- Increased velocity of blood flow through normal structures- usually systolic
Abnormal velocity hyperdynamic states- sepsis, hyperthyroid- Increased velocity of blood flow through normal structures
Abnormal valve valvular stenosis- decreased diameter of a valve- Decreased diameter of a valve, or vessel- mitral you will hear the murmur during diastole (filling→still going this direction), aortic you will hear during systole as iit’s leaving ventricle
Abnormal direction regurgitation-Flow through an abnormal orifice-valvular regurgitation, VSD left to right shunt- not cyanotic- , PDA patent ductus arteriosus  (this happens during systole- valves don’t close- MR)
VSD/ventricular septal defect is a hole between the left ventricles- blood goes left (red blood) to right (blue blood)- get cyanotic when the blue gets to the left- too late for the pt→ NOT CYANOTIC
Timing systolic or diastolic- all innocent murmurs are systole-
Diastolic examples Aortic (most common)/ Pulmonic regurgitation, Mitral/ Tricuspid stenosis (goes forward during diastole)
Systolic examples Flow/innocent murmurs (anemia, hyperdynamic states), Aortic/ Pulmonic stenosis, Mitral/ Tricuspid regurgitation, Ventricular Septal Defect/VSP, Hypertrophic Obstructive Cardiomyopathy, HOCM
Combined murmur example PDA
What if you have a valve that is so stenosed that it doesn’t close tightly aortic regurgitation (diastolic murmur) and stenosis (systolic murmur)- sounds continuous but it’s 2 murmurs in the cycle
PDA continuous murmur- machine-like
AS murmur radiate to the carotid arteries→ radiation
MR murmur radiates to the axilla→ radiation
Test question- Decrescendo usually diastolic murmurs as AR & mild MS- loud S1, opening snap- use bell- turn to the side- prego
Crescendo-Decrescendo usually systolic murmurs as AS
Uniform (aka: “holosystolic”when it occurs in systole): usually the systolic murmur of MR
Once you feel the intensity 4/6- grade 4
Grade 1- 6 barely audible- experience needed, grade 6 is audible w/o stethoscope- grade 4- feel the thrill
MS quality rumbling
MR quality musical blowing
AR quality blowing
AS quality harsh
PDA quality machine-like
More blood in the heart louder murmur EXCEPTIONS are MVP & HOCM where more blood in the heart decreases murmurs, and less blood in the heart increases their murmurs
Atrial stenosis harsh
How to put more blood in the heart/preload squatting- raising the leg of the pt- except MVP mitral valve prolapse& HOCM
Hypertrophic obstructive cardiomyopathy (HOCM) (decreased murmur intensity) systolic murmur like AS but more blood makes AS more loud but not this one (squatting, leg raise or supine)
Hand grip will put more blood in the heart for MR, AR and VSD- amyl nitrate does the opposite
Squatting/Leg raise increase venous return/preload- thus increase all murmurs except MVP&HOCM- Valsalva and standing do the opposite
Valsalva/Standing decrease venous return/preload- thus decrease all murmurs except MVP&HOCM
A pt flailing/knodding his head about is a sign of AR
Possible Test question- Hand grip increases the resistance/afterload- for regurgitations-will make it louder- goes in an abnormal direction- mitral regurgitation if louder, otherwise aortic stenosis
You hear a systolic murmur over the apex- what are 2 conditions MR ASS Mitral regurg and atrial stenosis- ask pt to squeeze his hand
Venous hum innocent murmur- obliterate the jugular vein to silence – systolic-
Stills murmur innocent murmur- systolic- put over- IJV- Mid systolic murmur
Abnormal S1- mild MS- turn to the left- ask for an echo- LOUD S1
Cardiac valve lesions SOB- get echo
Abnormal S2 loud in p HTN, massive PE, ASD (fixed split)
Abnormal s1 a-fib
Diastole abnormal sounds S3 and opening snap (mild MS or severe MS)
Abnormal systolic click MVP, aortic ejection click
MVP and HOCP the 2 where if you put more blood in the heart, the sounds are decreased
Mitral regurgitation caused by htn, ischemia
Pericarditis treat with nsaids- pr interval depression on ecg- ST segment elevation in the majority of leads
Marfan tall woman loose connective tissue- decrescendo- blowing- AR- lean forward and make a fist
75 y/o woman with dyspnea and exertional chest pain for several months w/continuous murmur heard well at the apex combined AS and AR- heard all over the place
Tetralogy of Fallot PS- central cyanosis- fingers, toes, tongue, squatting, parasternal heave, A cyanotic congenital heart defect with 4 abnormalities- Stenotic pulmonary valve-Ventricular septal defect- Overriding aortic valve-Hypertrophy of right ventricle
sharp stabbing chest pain is NOT angina
sign for heart attack levinne’s
Scratchy- Sharp, stabbing chest pain. in back, neck or left shoulder-worse w/coughing, swallowing, deep breathing, lying flat, or moving- relieved by sitting up and leaning forward- Difficulty breathing when lying down, a dry cough, anxiety, fatigue pericarditis- give NSAIDS/ASA- all leads elevated ST and PR interval depression
Ventricular Septal Defect in child systolic- recurrent respiratory infections- If left untreated, the Lt to Rt shunt turns into Rt to Lt one and the patient becomes cyanotic (Eisenmenger syndrome)
Vitals: BP 88/56, radial pulse rate 116, Apical pulse rate: HR counted at the apex 140- irregular rhythm A-fib- synchronized cardioversion (only v-fib not synchronized)
young female with chest pain/palpitations mitral valve prolapse
heart failure + aortic stenosis= the end
Acute rheumatic fever Aimless jerky movements Sydenham chorea- pharyngitis hx- carditis, polyarthritis, chorea, erythema marginatum- rash, sc nodules
Blood flow for infants RA to the LA via the foramen ovale; the RV pumps blood through the DA (closes in 24-48h) into the aorta rather than into the lungs. The foramen ovale then later closes w/pressure
80 y/o man with recurrent syncope less blood to the brain- aortic stenosis- harsh- crescendo/decrescendo- blowing- listen to the carotid
CHF weight increased, increased venous distention, Lungs bibasilar crackles, dyspnea, uses 3 pillows, edema, S3 (may or may not be there)
Cor pulmonale rt heart failure and hypertrophy secondary to lung dz (COPD)- light headed, syncope
h/o chest pressure. Sub-sternal, radiates into left neck. Diaphoresis, nausea Acute coronary syndrome- most common physical finding for MI is nothing story/EKG/ and enzymes
a-fib synchronized cardioversion except for v-fib
25 yo female with chest pain mitral valve prolapse
Pt with aortic stenosis with chf is done
HOCM s/s SOB
Holosystolic murmur best heard systolic murmur at the apex which radiates to the AXILLA-
SYSTOLIC MURMUR WHICH RADIATES TO THE AXILLA MRASS MR, if he wants you to say aortic, he would chose the carotid
Early diastolic decrescendo, LLSB/apex, Corrigan pulse: bounding carotid pulse (water-hammer), DeMusset’s sign:head “bob” w/beat, Traube’s sign: pistol-shot pulse, Duoroziez’s sign: bruit when the femoral artery compressed, Quincke’s pulses-nails AR
Hoarseness of voice (aka: Ortner’s syndrome): the dilated left atrium will press on the left recurrent laryngeal nerve resulting in hoarseness is seen in Mitral stenosis
Young male athlete HOCM
Aortic regurgitation diastolic, Corrigan pulse, traube’s sign, quincke’s sign, …
Intermittent claudication PAD- arteries in legs are clogged
Created by: arsho453