Auscultation of the Heart

Question 1

S1

Answer 1

M1 and T1, best heart at lower left sternal border

Question 2

when is normal splitting of s1 heard

Answer 2

complete RBBB

Question 3

Describe s1 in mitral stenosis

Answer 3

at early stage, s1 intensity is increased when valve leaflets are still pliable in hyperkinetic states and with short PR intervals
in late stages - s1 becomes softer - leaflets are rigid and calcified with contractile dysfunction, b adrenergic receptor blockers and long PR intervals

Question 4

S2

Answer 4

A1 and P1

Question 5

physiologic splitting of S2

Answer 5

the A2 -P2 interval increases during inspiration and narrows in expiration
components are best heart at second left ICS in supine position

Question 6

other causes of A2-P2 interval widening

Answer 6

complete RBBB - delayed pulmonic valve closure

Severe MR because of premature aortic valve closure

Question 7

describe heartsound in pulmonary hpn

Answer 7

unusually narrow but physiologic splitting of s2 with increased intensity of P2 comparedto A2 indicates PA hpn

P2 can be heartd at most sites across the pericardium

Question 8

describe S2 in ostium secundum ASD

Answer 8

fixed splitting , the A2 P2 interval is wide and unchanged with respiration

Question 9

Reverse or paradoxical splitting

Answer 9

consequence of a pathologic delay in aortic valve closure asmay occur with Complete LBBB, RV apical pacing,severe aortic stenosis,HOCM,MI

Question 10

Nonejection clicks which occur after upstroke of carotid pulse

Answer 10

MVP

Question 11

what happens in standing in MVP

Answer 11

ventricular preload AND afterload decrease and the click/murmur move closer to S1

Question 12

what happens in squatting in MVP

Answer 12

ventricular preload and afterload increase - the prolapsing mitral valve tenses later in systole and the click and murmur move away from s1

Question 13

Mitral stenosis

Answer 13

High-pitched opening snap (OS) a short distance after S2 (diastolic)

Question 14

what is a pericardial knock

Answer 14

high pitched early diastolic sound that corresponds in timing to abrupt cessation of ventricular expansion after AV valve opening and to the prominent y descent in JV waveform in pxs with constrictive pericarditis

Question 15

tumor plop

Answer 15

rarely heard with atrial myxoma

low-pitched sound from daistolic prolapse of tumor across the mitral valve, sometimes with diastolic murmur

Question 16

S3

Answer 16

occurs at rapid filling phase of ventricular diastole
may be present in children/ adolescents
also systolic heart failure in older pxs

Question 17

S4

Answer 17

occurs during atrial filling phase of ventricular diastole - presystolic ventricular expansion; common in pxs with accentuated atrial contribution to ventricular filling (LV hypertrophy)

Question 18

palpable thrill is what grade

Answer 18

grade 4 or higher

Question 19

acute severe MR

Answer 19

decrescendo, early systolic murmur (steep rise in pressure within the noncompliant atrium)

Question 20

Severe MR

Answer 20

posterior mitral leaflet prolpase or flail radiates anteriorly and to the base

anterior leaflet involvement radiates posteriolry and to the axilla

Question 21

acute TR with normal PA pressures

Answer 21

early systolic murmur increases with inspiration audible at lower left sternal border, with regurgitant CV waves

Question 22

Aortic stenosis or sclerosis

Answer 22

causes most midsystolic murmurs in adults

Question 23

midsystolic murmurs

Answer 23

AS, HOCM, pulmonic stenosis large ASD, left to right shunt

Question 24

A late, apical systolic murmur indicates

Answer 24

MVP

Question 25

explain the presence of apical systolic murmur in acute myocardial ischemia

Answer 25

MR is caused by apical tethering and mal-coaptation of leaflets due to structural and functional changes of the ventricle and mitral annulus

Question 26

holosystolic murmurs found in

Answer 26

chronic MR, VSD

Question 27

differentiate holosystolic murmurs in MR and VSD

Answer 27

MR best heard at cardiac apex; VSD best heard at mid-left sternal border with palpable thrill

Question 28

Chronic AR

Answer 28

Diastolic murmur - highpitched descrescendo, early to mid diastolic murmur

Murmur is softer and shorter in acute AR - includes tachycardia, soft s1, absence of peripheral findings of diastolic runoff

Question 29

Murmur in pulmonic regurgitation

Answer 29

heard at left sternal border; associated with annular enlargement from chronic PA hpn (Graham steell murmur)
signs of RV overload present
invariably present after TOF repair

Question 30

Classic cause of mid to late diastolic murmur

Answer 30

Mitral stenosis; may be silent in low CO and large habitus pxs

Murmur best heartd at apex, low pitched; with OS in early stage

Question 31

low pitched mid to late apical diastolic murmur

Answer 31

associated with AR (Austin flint murmur)

Question 32

how can AR be distinguished with MS

Answer 32

response to vasodilators and presence of associated findings

Question 33

other causes of mid diastolic murmurs -

Answer 33

atrial myxoma, complete heart block, acute rheumatic mitral valvulitis (Carey Coombs murmur)

Question 34

right sided events except pulmonic ejection sounds - increase in inspiration, decrease in expiration;

Answer 34

left sided events behave oppositely - 100% sensitivity, 88 % specificity

Question 35

what murmurs will increase in response to increase LV afterload (handgrip, vasopressor administration) and decrease after exposure to vasodialting agents (amyl nitrite)

Answer 35

MR, VSD, AR

Question 36

Describe murmur in HOCM

Answer 36

softer and shorter with squatting;
longer and louder on rapid standing
also increases in Valsalva maneuver

Question 37

Aortic stenosis vs MR - regarding change in intensity of systolic murmur in the first beat after premature beat

Answer 37

if there is change in intensity of systolic murmur after a premtaure beat - more likely to be AS because of enhanced LV filling / forward flow acceleration hence increase in gradient and louder murmur vs in MR - there is minimal further increase in mitral valve flow or change in gradient

Question 38

Gallavardin effect

Answer 38

murmur in aortic stenosis is well transmitted to the apex

Question 39

probability of HF was best predicted by

Answer 39

past history of HF (LR 5.8)
PND ( LR 2.6)
s3 (LR 11)
AF (LR 3.8)

Except PND - same features predicted HF in concomitant pulmonary dse

Question 40

Dyspnea or discomfort in lateral decubitis

Answer 40

Trepopnea - accounts for right sided pleural effusions

Question 41

Bendopnea

Answer 41

shortness of breath noticeable when bending forward; higher RA and PCWP

Question 42

when is HF likely to be preserved

Answer 42

when pxs are female, older, increased BMI

Question 43

Four signs used to predict elevated filling pressures

Answer 43

JV distension
AJR sign
S3/S4,rales
pedal edema

Question 44

Provides the readiest bedside estimate of LV filling pressure

Answer 44

JVP

Question 45

EStimated RA pressure higher than 12 and 2 pillow orthopnea provided prediction of PA wedge pressure >22mHg - compared favorably iwth BNP levels

Answer 45

ESCAPE trial

Question 46

In pxs with chronic HF, how many will lack rales despite elevated PA wedge pressures

Answer 46

75-80%

Question 47

Audible phases of Valsalva maneuver

Answer 47

Phase I and IV

Question 48

Abnormal response to Valsalva in HF patients:

Answer 48

1) absence of phase IV overshoot - decreased systolic function
2) square-wave response -elevated filling pressures independed of EF