Lecture 6: Cardiac Sounds and Murmurs

Question 1

What is the point of maximal impulse?

Answer 1

Location where cardiac impulse can be best palpated on the chest (normally cardiac apex)
-not always palpable

Question 2

Where is the point of maximal impulse found?

If PMI is displaced laterally what does this indicate?

Answer 2

5th intercostal space at or just medial to left midclavicular line

Left ventricular hypertrophy, MI or heart failure

Question 3

A large point of maximal impulse (>2.5 cm) can be evidence of what?

Answer 3

Left Ventricular Hypertrophy from hypertension or aortic stenosis

Question 4

What does S1 correspond to?

Answer 4

Turbulence created when the mitral and tricuspid valves close

Question 5

What does S2 correspond to?

Answer 5

Closure of the aortic and pulmonic valves

Question 6

What does S3 correspond to?

Answer 6

Abrupt deceleration of inflow across mitral valve
-produced by the large amount of blood striking a very compliant left ventricle
-sounds like Kent-tuck-y
Pathologic in patients >40 years

Question 7

What does S4 correspond to?

Answer 7

Increased stiffness of the left ventricle and decreases compliance
-sounds like ten-nes-see
Pathologic in patients >40 years

Question 8

What does systolic heart failure mean?

Answer 8

Lack of proper ventricular contraction

Question 9

What does diastolic heart failure mean?

Answer 9

Lack of proper ventricular relaxation

Question 10

What is wide physiologic splitting of S2?
Cause?
Conditions?
Where do you listen for splitting?

Answer 10

Increased splitting of S2 during inspiration only

• caused by delayed closure of pulmonic valves (pulmonic stenosis/pulmonary HTN/RBBB/Atrial septal defect) or early closure of aortic valve (mitral regurgitation)
• 2nd left ICS, close to sternal border

Question 11

What is fixed splitting?
Cause?
Conditions?

Answer 11

Wide splitting that does not vary with respiration

-prolonged right ventricular systole seen with atrial septal defect or right ventricular failure

Question 12

What is paradoxical or reversed splitting?
Cause?
Conditions?

Answer 12

Splitting that appears on expiration and disappears on inspiration

• closure of aortic valve is abnormally delayed (A2 follows P2)
• most commonly due to left bundle branch block

Question 13

What are early systolic ejection sounds?
How do you listen for an aortic ejection sound?
How do you listen for a pulmonic ejection sound?

Answer 13

Occurs shortly after S1 that halt aortic and pulmonic valves opening

• best heard at base and apex (with diaphragm)
• best heard at 2nd and 3rd left ICS (with diaphragm)

Question 14

What can cause systolic clicks?

How do you listen to these?

Answer 14

Mitral valve prolapse

-best heart medial to apex and lower sternal border (with diaphragm)

Question 15

What causes opening snaps?

How do you listen for this?

Answer 15

Early diastolic sound

• abrupt deceleration during opening of stenotic mitral valve
• medial to apex along lower left sternal border (with diaphragm)

Question 16

What are systolic murmurs?

Answer 16

Aortic Stenosis and Sclerosis
Innocent Murmur
Hypertrophic Cardiomyopathy 
Ventral Septal Defect
Tricuspid Regurgitation
Mitral Valve Prolapse and Insufficiency

Question 17

What are diastolic murmurs?

Answer 17

Aortic Insufficiency: heard best with bell
Pulmonic Regurgitation
Mitral and Tricuspid Stenosis

Question 18

Describe a grade 1 murmur.

Answer 18

Very faint and might not be heard in all positions

Question 19

Describe a grade 2 murmur.

Answer 19

Quiet but can be heard with stethescope

Question 20

Describe a grade 3 murmur.

Answer 20

Moderately loud

Question 21

Describe a grade 4 murmur.

Answer 21

Loud, with palpable thrill

Question 22

Describe a grade 5 murmur.

Answer 22

Very loud, with thrill

-can sometimes be heard when stethoscope is partly off chest

Question 23

Describe a grade 6 murmur.

Answer 23

Very loud with thrill

-can be heard w/o stethoscope

Question 24

Where are systolic murmurs heard?

Answer 24

Between S1 and S2

Question 25

Where are diastolic murmurs heard?

Answer 25

After S2