Heart Sounds

Question 1

Splitting of S2 during inspiration, but normal during expiration

Answer 1

Physiological splitting of S2

Question 2

Splitting of S2 during expiration, but normal during inspiration

Answer 2

Paradoxical splitting of S2

Causes: LBBB, aortic stenosis, HOCM

Question 3

Splitting of S2 through inspiration and expiration

Answer 3

Fixed splitting of S2

Hallmark of atrial septal defect (ASD)

Question 4

Low, dull thud in early/mid diastole, heard with bell

Answer 4

S3
Normal in children/young adults
Causes: tensing of chordae tendineae, limitation of longitudinal ventricular expansion during early ventricular filling

Question 5

Low murmur in late diastole, heard with bell

Answer 5

S4
Rarely normal
Causes: atrium contracting against stiffened ventricle (reduced compliance)

Question 6

Low murmurs heard in early (after S2) and late diastole (before S1)

Answer 6

Quadruple rhythm- presence of S3 and S4

Question 7

Extra heart sounds in early and late diastole that run together

Answer 7

Summation gallop- presence of S3 and S4 with a fast heart rate

Question 8

Holosystolic murmur best heard at the cardiac apex, does not get louder during inspiration

Answer 8

Chronic mitral regurgitation

Question 9

Early systolic decrescendo murmur

Answer 9

Acute mitral regurgitation

Question 10

Midsystolic click with late systolic murmur

Answer 10

Mitral valve prolapse (MVP)

Click is later and murmur is shorter with squatting, click is earlier and murmur longer with standing

Question 11

Holosystolic murmur, louder during inspiration

Answer 11

Tricuspid regurgitation

Triad: Carvallo’s sign- louder during inspiration, pulsatile JVD, pulsatile liver

Question 12

Holosystolic murmur best heard at the lower left sternal border, does not get louder with inspiration, harsh quality

Answer 12

Ventricular septal defect (VSD)

Question 13

Crescendo-decrescendo systolic ejection murmur, often heard best at 2nd intercostal space at the right sternal border, radiation to the carotids, louder with squatting, amyl nitrate, softer with standing. valsalva, isometric handgrip

Answer 13

Aortic stenosis
May also have: paradoxical splitting of S2, diminished/absent A2, aortic ejection sound/click (congenital- bicuspid aortic valve)

Question 14

Crescendo-decrescendo systolic ejection murmur, gets louder with valsalva, standing, amyl nitrate, gets softer with isometric handgrip, squatting

Answer 14

Hypertrophic cardiomyopathy

Question 15

Crescendo-decrescendo systolic ejection murmur best heard at 2nd intercostal space on left sternal border, increases during inspiration, no radiation to carotids

Answer 15

Pulmonic stenosis

Ejection sound/click present in congenital PS, gets softer in inspiration

Question 16

Early diastolic decrescendo murmur, “blowing”, high-pitched, heard with diaphragm at 3rd intercostal space at left (or right) sternal border

Answer 16

Aortic regurgitation

May also have: systolic ejection murmur, Austin Flint murmur (diastolic rumble heard with bell at the apex)

Question 17

Mid diastolic crescendo-decrescendo, low-pitched heard with bell at 3rd-4th intercostal space at left sternal border, louder during inspiration

Answer 17

Pulmonic regurgitation

Question 18

Mid diastolic, low-pitched rumble best heard with patient in left lateral recumbent position with bell at the apex

Answer 18

Mitral stenosis

Associated findings: opening snap (high-pitched, early diastole), loud S1

Question 19

Mid diastolic, low-pitched rumble best heard along left sternal border, louder during inspiration

Answer 19

Tricuspid stenosis

Question 20

Continuous, machinery-like murmur

Answer 20

Patent ductus arteriosus

Question 21

Muffled, distant heart sounds

Answer 21

Indication for pericardial tamponade, Beck’s triad- hypotension, JVD, muffled heart sounds

Question 22

Scratchy sound, lower left sternal border, best heard during full held exhalation

Answer 22

Pericardial friction rub, can be systolic, mid-diastolic, presystolic