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AGPCNP Board Prep > Ch16: Heart Sounds and Murmurs > Flashcards

Ch16: Heart Sounds and Murmurs Flashcards

1
Q

clinical presentation of ACS in someone 75yo or older

A
  • dyspnea
  • neuro symptoms (syncope, weakness, acute confusion)
  • chest pain or pressure in <50% of cases
  • unusual fatigue in weeks leading up to event
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2
Q

_____ should be considered with any acute illness in the elder

A

ACS (get ECG)

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3
Q

most valvular disease is found in the _____ side of the heart

A

left (aortic and mitral)

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4
Q

which side of the heart is a higher pressure system

A

left sided (arterial)

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5
Q

what is the PMI

A

palpable sensation of the underlying left ventricle

normally at 5th intercostal space, mid-clavicular line

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6
Q

displaced PMI usually indicates….

A

increased LV volume

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7
Q

when PMI is displaced, it usually moves…..

A

laterally, towards mid-axillary line

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8
Q

unusually forceful, sustained PMI indicates….

A

pressure overload, poorly-controlled HTN

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9
Q

best patient position for palpating PMI

A

left lateral decubitus (side lying) position

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10
Q

(3) reasons the PMI may be difficult to palpate

A
  • COPD (increase in AP diameter of thorax)
  • obesity
  • thick chest wall (e.g., body builder)
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11
Q

heart sound heard best at the 2nd intercostal space, right sternal border

A

aortic valve

murmur will often radiate to the neck

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12
Q

heart sound at the 2nd intercostal space, left sternal border

A

pulmonic valve

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13
Q

heart sound at the 5th intercostal space, mid-clavicular line

A

mitral valve

murmur will often radiate to the axilla

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14
Q

significance of S1

A

marks the beginning of SYSTOLE

produced by closure of the mitral and tricuspid valves (atrioventricular valves)

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15
Q

where/how is S1 heard best

A

apex of the heart (bottom; closer to pt feet)

listen with the diaphragm of stethoscope

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16
Q

significance of S2

A

end of systole

closure of the aortic and pulmonic valves (semilunar valves)

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17
Q

where/how is S2 heard best

A

base of the heart (top, towards the head)

with the diaphragm

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18
Q

significance of physiologic split S2

A

physiologic

widening of the normal interval between aortic and pulmonic components of the second heart sound (delay in the pulmonic component)

benign finding particularly <30yo

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19
Q

where/how is a physiologic split S2 heard best

A

pulmonic region (2nd ICS, left sternal border – this is because is due to a delay in the pulmonic valves after closure of the aortic valve)

increases during inspiration

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20
Q

for whom is it common to have a physiologic split S2

A

majority of adults <30yo, benign finding

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21
Q

how to differentiate a physiologic vs. pathologic split S2

A

PHYSIOLOGIC = INcreases with INspiration

PATHOLOGIC = fixed (no change with inspiration), or paradoxical split (narrows or closes with inspiration)

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22
Q

where is a pathologic split S2 heard

A

(same place) pulmonic region (2nd ICS, left sternal border

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23
Q

significance of a pathologic split S2 …

A
  • uncorrected atrial-septal defect (congenital heart defect; only congenital heart defect more commonly found in females > males) - USUALLY FIXED SPLIT
  • LBBB and other conditions that delay aortic valve closure - USUALLY PARADOXICAL SPLIT
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24
Q

significance of pathologic S3 heart sound

A

marker of ventricular overload and/or systolic dysfunction

most often occurs in heart failure (alongside dyspnea, tachycardia, crackles)

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25
Q

when/where is S3 heard best

A
  • heard in early diastole
  • low pitched, best heard with the bell (might miss with diaphragm)
  • can sound like it is “hooked on” to the back of S2
  • can resolve with treatment of underlying condition
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26
Q

significance of S4 heart sound

A

marker of poorly controlled HTN
most commonly found in someone with:
- uncontrolled HTN
- recurrent myocardial ischemia

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27
Q

when/where is S4 heard best

A
  • heard late in diastole
  • can sound like it is “hooked on” to the front of S1, “pre-systolic”
  • soft, lower-pitched
  • best heard with bell of the stethoscope
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28
Q

S3 and S4 are best heard with diaphragm or bell?

A

bell

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29
Q

stenosis or incompetence: failure of a valve to CLOSE adequately

A

incompetent

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30
Q

stenosis or incompetence: failure of a valve to OPEN adequately

A

stenosis

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31
Q

[stenotic vs. incompetent] valves cause regurgitant murmurs

A

incompetent

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32
Q

[systolic vs. diastolic] heart murmurs are ALWAYS pathologic

A

diastolic

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33
Q

MR. PASS - MVP mnemonic for systolic murmurs

A 
Mitral
Regurgitation
Physiologic (innocent)
Aortic
Stenosis
Systolic

Mitral
Valve
Prolapse

34
Q

mitral regurgitation murmur:
A. holosystolic?
B. crescendo-decrescendo?

A

holosystolic murmur

35
Q

aortic stenosis murmur:
A. holosystolic?
B. crescendo-decrescendo?

A

crescendo-decrescendo systolic murmur

36
Q

(3) systolic murmurs

A
  • mitral regurgitation
  • aortic stenosis
  • mitral valve prolapse
37
Q

mid-systolic click with late systolic murmur

A

mitral valve prolapse

38
Q

MS. ARD diastolic murmurs

A 
Mitral
Stenosis
Aortic 
Regurgitation
Diastolic
39
Q

early diastolic murmur

A

aortic regurgitation

40
Q

late diastolic murmur

A

mitral stenosis

41
Q

Grade 1/6 heart murmur

A

very faint, really need to “tune in” (usually not heard by the PCP unless very thin chest wall, good hearing, and quiet environment - aka not very common to find in primary care)

42
Q

Grade 2/6 heart murmur

A

quiet but immediately heard

43
Q

Grade 3/6 heart murmur

A

moderately loud, but without thrill (about as loud as S1 or S2)

44
Q

Grade 4/6 heart murmur

A

loud with a thrill (tremor or vibration on palpation)

45
Q

Grade 5/6 heart murmur

A

very loud with thrill

46
Q

Grade 6/6 heart murmur

A

audible even without stethoscope

47
Q

tremor or vibration on palpation over the chest wall

A

thrill

48
Q

(4) descriptive characteristics of murmurs

A

harsh, rumble, blowing, musical

49
Q

rumbling murmur, “bowling ball down a gutter”, diastolic

A

mitral stenosis

50
Q

harsh, heard with both bell and diaphragm, crescendo-decrescendo systolic

A

aortic stenosis

51
Q

blowing, high-pitched, early diastolic murmur

A

aortic regurgitation

52
Q

a systolic murmur is likely benign if all of the following are true……

A
  • negative cardiac history (e.g., no chest pain, dyspnea, syncope)
  • grade 3 or less
  • no radiation beyond the precordium (e.g., doesn’t radiate to axilla or carotids)
  • S1 and S2 are intact
  • no heave or thrill with palpation
  • PMI in normal place
  • murmur softens or disappears with supine to standing position change
53
Q

most likely to hear a murmur when a patient is in what position

A

supine (more blood flow in the heart)

54
Q

next step in evaluating a heart murmur that is suspected pathologic

A

echocardiogram

55
Q

a systolic murmur is likely pathologic if even just one of these is true…..

A
  • abnormal cardiac history (e.g., chest pain, dyspnea)
  • higher grade 4 or above
  • radiates beyond the precordium to the neck or axilla
  • S1 and S2 obliterated
  • thrill or heave on palpation
  • PMI displacement
  • murmur increases in intensity with supine to stand position change
56
Q

18yo M presents for sports physical. asymptomatic. no significant PMH.

2/6 harsh systolic murmur, radiates to the neck, softer towards the axilla

heard best over the 2nd intercostal space, right sternal border

somewhat softer with supine to standing position change

you suspect…..

A

aortic stenosis

(congenital if develops in someone this young)

key determining from physiologic here was radiating to the neck

57
Q

82yo F

CC: “i get really dizzy when i walk up a flight of stairs”

no chest pain. +DOE, resolves with rest

BP 110/90

Grade 2/6 harsh systolic murmur with radiation to the neck, loudest along upper sternal border, softer towards axilla. No S3 or S4. No carotid bruit or neck vein distention. +delayed carotid upstroke

you suspect….

A

aortic stenosis s/t calcific aortic stenosis

narrow pulse pressure tells you that she is having trouble getting blood out of her heart, not enough systolic pressure

delayed carotid upstroke tells you having trouble getting blood out of the left ventricle

58
Q

when should the carotid upstroke be felt in relation to S1/S2, normally

A

nearly simultaneously with S1

59
Q

most common cause of aortic stenosis in older adults

A

calcific aortic stenosis

so calcified that it doesn’t open well - can often not close well, too, so may have aortic regurgitation (incompetence) as well

60
Q

how to differentiate carotid bruit vs. radiating murmur

A

CAROTID BRUIT = usually in the context of high grade atherosclerotic disease in the carotids

  • softer
  • usually unilateral
  • different sound than that heard in the chest, different tone

RADIATING MURMUR

  • same sound and timing as that found in the chest
  • usually bilateral
  • usually louder
61
Q

62yo M
PMH: HTN, CHF
asymptomatic

physical exam:
PMI at 5th intercostal space anterior axillary line, sustained impulse

grade 3/6 blowing holosystolic murmur with radiation to the axilla. accentuated by rolling onto left side. softens when going from supine to standing, louder with hand grip. S2 is not preserved. carotid upstroke bilaterally is noted

you suspect….

A

mitral regurgitation s/t LVH

hypertensive heart disease and heart failure = LVH. LVH shifts the PMI laterally, and also pulls apart the mitral valve causing regurgitation on closure

62
Q

27yo F presents for pap test. no significant PMH. physically active runs 5-7 miles 5x per week

meds: OCPs, MVI

physical exam:
BMI 22
mild pectus excavatum (funnel chest)
PMI WNL
Normal S1/S2
mid-systolic click with late systolic murmur. Murmur moves forward (increases in length) with position change from supine to standing

you suspect….

A

mitral valve prolapse

obtain an echocardiogram as a next step

63
Q

S1 should be louder than S2 at the….

A

apex

64
Q

S2 should be louder than S1 at the….

A

base

65
Q

most common cause of sudden cardiac death in young athletes

A

hypertrophic cardiomyopathy (33% of all sudden cardiac deaths; second leading cause was blunt trauma [cardiac concussion])

66
Q

(5) major symptoms to ask about heart disease

A
  • chest pain
  • HF symptoms (e.g., orthopnea, edema)
  • palpitations
  • syncope
  • activity intolerance/DOE
67
Q

do you need antibiotic prophylaxis for any benign/physiologic heart murmurs?

A

no

68
Q

% of thin, healthy adults with a physiologic heart murmur

A

~80%

69
Q

Grade 1-4/6 harsh systolic murmur, usually crescendo-decrescendo pattern, heard best at the 2nd Right ICS, apex, softens with standing. Radiates to the carotids

A

aortic stenosis

70
Q

most common cause of aortic stenosis in young, healthy adults

A

congenital bicuspid aortic valve

71
Q

most common (2) causes of aortic stenosis in older adults

A
  • calcific

- rheumatic

72
Q

grade 1-3/4 high pitched, blowing, diastolic murmur heard best at the 3rd Left ICS, enhanced with forced expiration and leaning forward

A

aortic regurgitation

73
Q

most common (2) causes of aortic regurgitation

A
  • rheumatic heart disease, most commonly
  • tertiary syphilis (rarely)

more common in males

74
Q

grade 1-3/4, low-pitched, late diastolic murmur heard best at the apex, no radiation. Short crescendo-decrescendo rumble like a bowling ball rolling down an alley or distance thunder. enhanced in the left lateral decubitus position and with squatting and coughing

A

mitral stenosis

75
Q

most common cause of mitral stenosis

A

rheumatic heart disease

76
Q

grade 1-3/6 systolic ejection murmur at the pulmonic area with a widely spit S2

A

atrial-septal defect

77
Q

grade 1-4/6 high pitched, blowing, holosystolic murmur often extending beyond S2. often radiates to the axilla, decreases with standing or valsalva, increases with squat or hand-grip

A

mitral regurgitation

78
Q

grade 1-3/6 late systolic crescendo murmur with honking quality heart best at the apex. murmur is preceded by a midsystolic click

A

mitral valve prolapse

79
Q

general principles regarding infective endocarditis prophylactic antibiotics

A
  • infectious endocarditis is far more likely to result from frequent exposure to random bacterias in daily life than it is to be caused by a dental, GI, or GU procedure
  • prophylactic abx likely prevents only an exceedingly small number of cases
  • the risk of antibiotic-associated AEs exceeds the benefit
  • maintenance of optimal oral health and hygiene reduces the risk of infective endocarditis more than prophylactic abx does
80
Q

cardiac conditions associated with the highest risk of adverse outcomes from infective endocarditis for which prophylaxis with dental procedures MAY be reasonable…. (4)

A
  • prosthetic cardiac valve
  • previous infective endocarditis
  • congenital heart disease
  • cardiac transplant recipients who develop cardiac valve disease
81
Q

first line antibiotic regimen for infective endocarditis prophylaxis

A

amoxicillin 2g PO 30-60 minutes before procedure

AGPCNP Board Prep (21 decks)

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