Midterm: Heart exam

Question 1

What is the significance of visible pulsations and/or heaves over the precordium?

Answer 1

(precordium=portion of body over heart and lower chest)
A relatively strong murmur (4/6) might be found
o Visible pulsations/heaves: Right ventricular enlargement

Question 2

Know how to palpate for S1, S2, S3, S4 and thrills (palpable murmurs).

Answer 2

Thrills: palpate with the heel of the hand
S1 and S2 with firm pressure, S3 and S4 with lighter pressure.
Apical impluse at 5th interspace mid clavicular. Easier to palpate weak AI and to hear S3 and S4 in left lateral decubitus.

Question 3

Know how to assess the apical pulse for size and understand the significance of that size.

Answer 3

Located at 5th is midclavicular, find it with one finger, then two and spread them apart until no longer palpable (2-2.5 cm). Try LLDC if too faint. A laterally displaced AI can mean the heart is enlarged. Note intensity.

Question 4

Know how to differentiate S1 from S2 using palpation of the carotid.

Answer 4

The carotid pulse comes right after S1.

Question 5

Which valves make S1 and S2 sounds? Where are these sounds best heard?

Answer 5

S1 is made by mitral and tricuspid valves closing. S2 sound is aortic and pulmonic valves.
S1: apex
S2:base

Question 6

When (and where) is it normal for S1 to split? What constitutes an abnormally split S1?

Answer 6

You may normally hear some splitting in the 5th interspace at the sternal border. Split S1 results from asynchronous closure of mitral (M1) and tricuspid (T1) valves. Abnormal if the split is >60 ms apart. Could be myxoma, ASD, RBBB

Question 7

How does one differentiate a split S1 from an S4 gallop?

Answer 7

S4 is a low-frequency gallop sound that results from a forceful atrial contraction during presystole that ejects blood into a ventricle which cannot expand further.
*** S4 occurs ~90 msec before S1,

Question 8

What is the normal pattern of auscultation? Be able to name regions where each heart valve is best heard.

Answer 8

Carotids with bell for bruits.
Aortic and pulmonic valve on either side of sternum (aortic on right side). 2nd IS
Erbs space—good echo chamber for murmurs , 3 IS
Tricuspid and Mitral areas, 4 and 5 IS
First diaphragm and then bell.

Question 9

What is a bruit? Where and how does one listen for them during the heart exam?

Answer 9

Turbulence in an artery dt narrowing from atherosclerosis. Listen with bell on carotids!

Question 10

What sounds do the bell and diaphragm bring out?

Answer 10

Bell-low pitched

Diaphragm: high pitched

Question 11

What positions will help accentuate certain heart sounds, i.e., aortic regurgitation, S3, and S4?

Answer 11

Left lateral decubitus for S3 and S4.

Sitting and leaning forward, listen on held exhale for aortic reurg.

Question 12

What is physiologic splitting of S2?

How common is physiologic splitting of S2?

Answer 12

Split S2 results from asynchronous closure of aortic (A2) and pulmonic (P2) valves. Normally, the separation of A2 and P2 is ~40 msec during inspiration. Physiological splitting is quite common  Pearl: 52.1% of normal adults in a recent study. Aortic valve closes before pulmonic dt increased filling of RV.

Question 13

What is paradoxical splitting of S2?

Answer 13

split occuring on EXHALE. Results from delayed onset or prolongation of left ventricular systole.

Question 14

Fixed splititng of S2?

Answer 14

results from delayed onset or prolongation of right ventricular systole, or shortened duration of left ventricular systole

Question 15

How does one differentiate a split S2 from an S3 gallop?

Answer 15

S3 results from the impact of inflowing blood against a distended or incompliant ventricle in mid diastole. It is a low-frequency sound occurring ~120-150 msec after S2.

Question 16

What are S3 and S4 sounds? What do they signify? What makes them? Where are they best heard? What bedside maneuvers can intensify them?

Answer 16

S4: is a low-frequency gallop sound that results from a forceful atrial contraction during presystole that ejects blood into a ventricle which cannot expand further.

S3 results from the impact of inflowing blood against a distended or incompliant ventricle in mid diastole. It is a low-frequency sound

Use the bell! Left lateral decubitus and listen around mitral/tricuspid areas.

Question 17

How does one differentiate a pathologic S3 from a physiologic S3?

Answer 17

The most important features differentiating these sounds are the company they keep:
A pathologic S3 keeps bad company (symptoms like shortness of breath, chest pain, orthopnea, signs like wide or displaced apical pulse, peripheral edema, a bottle of nitroglycerin in the hand).

The patient with a normal or physiologic S3 looks fit and is asymptomatic! Common sense wins this hand. ☺

Question 18

What is jugular venous distention? On what side is it measured? How is that done?

Answer 18

• Seeing a visible jugular vein with a pulse high in the column
• On the right side
• Pt at 45 degree angle.
• Using tangenital light. Measure from perpendicular of sternal angle.

Question 19

What is abdominojugular reflux? When is it useful clinically? Know how to use a BP cuff to exert the correct amount of pressure.

Answer 19

Seeing the pulse rise in the jugular vein and remain elevated when pressure applied periumbilically—suggests backed up portal system. Positive fur sublinical RCHF.

20-35 mmHg for 15-30 seconds. . A transient (10 seconds or less) rise in the position of the jugular venous pulse is normal and constitutes a negative test.

Question 20

What characteristics of a murmur do you want to be sure to note when you hear one?

Answer 20

Timing
Configuration
Location
Radiation
Intensity
Quality
Pitch
Hemodynamic changes

Question 21

What is the significance of a diastolic murmur?

Answer 21

Diastolic murmurs usually indicate heart disease.

Third heart sound, S3
Fourth heart sound, S4
Mitral stenosis murmur
Tricuspid stenosis murmur
Aortic regurgitation murmur
Pulmonic regurgitation

Question 22

S3 gallop

Answer 22

An S3 gallop is thought to be produced by rapid diastolic filling of the left ventricle in “stiff” ventricles.
S1∼∼∼∼∼∼∼∼S2 S3
S3 can be heard in healthy children and young adults (up to age 40).
Pathological S3 gallops can be heard in left and right diastolic overload, i.e., mitral and tricuspid regurgitation.

Diminished ventricular compliance like that caused by cardiomyopathies, CHF, or ischemic heart disease can also produce a S3 gallop.

S3 is a low-frequency, often faint sound. Having the patient walk or passively elevating the patient’s legs can aid in its detection.

Question 23

S4 gallop

Answer 23

S4: S4 gallops are thought to be atrial contractions causing a snap.
S4 S1∼∼∼∼∼∼∼∼S2
S4 seldom occurs in normal hearts.
S4 can be caused by conditions that lead to left and right ventricular overload: systemic hypertension, pulmonary hypertension, aortic and pulmonic stenosis.
Diminished ventricular compliance like that caused by cardiomyopathies, CHF, or ischemic heart disease can also produce a S4 gallop.

S4 is often heard during acute myocardial infarction. False positives may occur with splitting S1 and S1 plus ejection sounds.

Question 24

What is the clinical significance of an ejection sound?

Answer 24

Ejection clicks/sounds are high-pitched sounds that occur at the moment of maximal opening of the aortic or pulmonary valves. They are heard just after the first heart sound. Physical maneuvers like valsalva don’t change the timing/quality (differentiate from MVP)

Question 25

Understand how respiration, Valsalva, squatting, and passive leg lifts will affect different types of murmurs.

Answer 25

Inspiration increases murmurs in the right heart

Valsalva decreases venous return and decreases cardiac output

Squatting increases venous return and increases cardiac output

Passive elevation of both legs (15-20 seconds) increases venous return and increases cardiac output

Question 26

effect of inspiration on murmurs:

Answer 26

Mitral valve prolapse—>None
LCHF–> Decreases
Pulmonic stenosis–>Increases
Hypertrophic cardiomyopathy–> none

Question 27

effect of valsalva on murmurs:

Answer 27

MVP–>Earlier click and murmur
LCHF–>Increases
Pulmonic stenosis–>Decreases
HCM–>Louder

Question 28

effect of squatting on murmurs:

Answer 28

MVP–> Delays click & murmur
LCHF–>Decreases
pulmonic stenosis–>Increases
HCM–>none

Question 29

What is the effect of Valsalva on the click and murmur of mitral valve prolapse (MVP)?

Answer 29

Earlier click and murmur

Question 30

Know how to “grade” the intensity of a murmur.

Answer 30

I	Very faint
II	Quiet
III	Moderately loud, non-palpable
IV	Loud with a palpable thrill
V	Very loud with a palpable thrill
VI	Very loud with palpable thrill, heard without stethoscope

Question 31

What are the characteristics of an innocent (functional) murmur?

Answer 31

They are systolic
They are not accompanied by sx of cardiac origin
They occur in the proper timing sequence, (i.e. S2 split on inhalation)