Phys Dx Heart

Question 1

S1

Answer 1

During Systole, ventricles contract and aortic and pulmonic valves open and MITRAL AND TRICUSPID CLOSE

Question 2

S2

Answer 2

During Diastole, ventricles relax and blood fills as mitral and tricuspid open. PULMONIC AND AORTIC CLOSE.

Question 3

S3

Answer 3

Sound created during early diastole AS BLOOD RAPIDLY FILLS THE VENTRICLE. RAPID DISTENSION OF THE WALL CAUSES VIBRATION

Question 4

S4

Answer 4

Sound created during late diastole AS ATRIA CONTRACTS AND FORCES LAST BIT OF BLOOD TO VENTRICLE. VIBRATION OF VALVES, PAPILLARY MUSCLES, AND VENTRICULAR WALL.

Question 5

Systolic Murmur

Answer 5

Sound when blood rushes through a narrow leaky valve or wall during systole

Question 6

Diastolic Murmur

Answer 6

sound blood makes when rushing through a narrow, leaky valve or wall during diastole

Question 7

Thrill

What heart conditions cause it?

Answer 7

Palpable Murmur - vibrations caused by a loud murmur

- can be caused by vigorous flow through narrowed opening - AS, VSD

Question 8

Lift/Heave

Answer 8

Cardiac Impulse feels more vigorous than normal and can be felt through chest wall
- ventricular hypertrophy or hyperdynamic ventricular activity

Question 9

Diaphragm vs. Bell

Answer 9

Diaphragm Best for high pitched sounds S1 and S2

Bell best for low pitched sounds S3 and S4

Question 10

Auscultation Area Aortic

Answer 10

2nd ICS at RSB

Question 11

Auscultation Area Pulmonic

Answer 11

2nd ICS at LSB

Question 12

Auscultation Area 2nd Pulmonic

Answer 12

3rd ICS at LSB

Question 13

Auscultation Area Tricuspid

Answer 13

4th and 5th ICS, LSB

Question 14

Auscultation Area Mitral

Answer 14

5th ICS, MCL

Question 15

Bisferiens Pulse

Answer 15

A bisferiens pulse is an increased arterial pulse with a double systolic peak. Causes include pure aortic regurgitation, combined aortic stenosis and regurgitation, and, though less commonly palpable, hypertrophic cardiomyopathy.

Question 16

Pulsus Alternans

Answer 16

The pulse alternates in amplitude from beat to beat even though the rhythm is basically regular (and must be for you to make this judgment). When the difference between stronger and weaker beats is slight, it can be detected only by sphygmomanometry. Pulsus alternans indicates left ventricular failure and is usually accompanied by a left-sided S3.

Question 17

Paradoxical Pulse

Answer 17

Rising pressure with expiration and Systolic pressure decreases during inspiration
common with asthma and COPD

Question 18

Abnormal S1

Answer 18

Normally: S1>S2 at apex and S1<S2 at base:
S1 softer: weaker contractions, emphysematous lungs
S1 louder: diseased AV valve or more forceful closure of AV valve - mitral stenosis, fever, tachycardia

Question 19

Splitting of S2: Physiological vs. Pathological vs. Fixed Splitting

Answer 19

Best heard over Pulmonic Area:

Physiological Splitting of S2: during inspiration, Aortic closure (A2) then Pulmonic Closure (P2)

Pathologic Splitting of S2: during expiration suggestive of Heart disease - can be early aortic closure (mitral regurg) or late pulmonic closure (pulmonic valve stenosis, RBBB)

Fixed Splitting - doesn’t vary with inspiration or expiration (ASD, RV failure)

Paradoxical Splitting - Expiration but not during inspiration and A2 after P2 (LBBB)

Question 20

Ventricular Gallup Rhythm

Answer 20

S1+S2+S3

Question 21

S3 Gallop

When is it physiologic and when is it pathologic?

Answer 21

Physiologic in kids, young adults, and in pregnancy

Pathogic S3: over 40, heart failure, anemia, volume overload, decreased myocardioal contractility

Question 22

Atrial Gallop Rhythm

Answer 22

S1+S2+S4 (S4 aka atrial kick or atrial gallop)

Question 23

S4

when is it pathological?

Answer 23

Uncommon in healthy adults but normal in athletes
Patholig due to resistance in filling ventricles, stiffness of the heart muscle
- HBP, CAD, AS, cardiomyopathy

Question 24

Cardiac Conduction

Answer 24

electrical current that stimulates myocardial contractions

SA node > AV Node > Atrial Septum > Bundle of His> Purkinjie Fibers in the ventricles

Question 25

Normal Sinus Rhythm

Answer 25

60-100bpm

Question 26

Fast Sinus Rhythm

Answer 26

> 100 | Tachycardias (sinus, supraventricular, ventricular, or flutter)

Question 27

Slow Sinus Rhythm

Answer 27

< 60 bmp | Bradycardias (sinus, 2nd degree AV block, complete heart block)

Question 28

Irregular Rhythms

Answer 28

Rhythmically or sporadically irregular: premature Atrial or ventricular contraction Irregularly irregular rhythm: Afib or atrial flutter

Question 29

Ejection Sound

Answer 29

Aortic or Pulmonic Ejection Click High pitched sound after S1, coincident with opening of aortic and pulmonic valves indicates valve disease or dilated aorta/pulmonary artery or pulmonary HTN

Question 30

Systolic Clicks from Mitral Valve Prolapse

Answer 30

abnomal systolic ballooning of part of the mitral valve into the left atrium during systole mid-late systolic clicks often present can be with mitral regurg usually benign

Question 31

Gradations of Murmurs - Know This!

Answer 31

1/6 - barely audible in quiet room 2/6 - quiet but audible 3/6 - moderately loud 4/6 - loud, associated with thrill 5/6 - very loud, audible with steth slightly off chest 6/6 - audible without steth, visible thrill

Question 32

Systolic Ejection Murmur - Know this!

Answer 32

Innocent/physiologic murmur or "flow murmur" From high pressure to high pressure: blood flow across semilunar valves - from high pressure LV to high pressure aorta No stenosis, results from turbulent flow, but no narrowing usually grade 1 or 2/6 May decrease with sitting whooshing at R and LSB, usually crescendo-decrescendo common in kids, pregnancy, anemia, fever, hyperthyroidism BENIGN (Aortic or Pulmonic Stenosis when pathophysiologic)

Question 33

Pansystolic (holosystolic) Murmur

Answer 33

Mitral/Tricupid Regurg High Pressure to Low Pressure Plateau Murmur - same intensity throughout ex mitral and tricuspid regurg and VSD

Question 34

Mitral Insufficiency (regurgitation)

Answer 34

when mitral valve fails to close fully in systole, blood regurgitates from left ventricle to left atrium - can be due to rheumatic heart disease

Question 35

Atrial Septal Defect (ASD)

Answer 35

congenital Left to right shunt Shunt between Left Atrium and Right Atrium with RV enlargement though pulmonic valve systolic ejection murmur fixed splitting of S2

Question 36

Ventricular Septal Defect | Where is it best heard?

Answer 36

``` Harsh systolic murmur at LLSB Blood flows from the high pressure LV to the low pressure RV through a hole Pansystolic LLSB thrill Left ventricle to right ventricle shunt ```

Question 37

Early Diastolic Murmurs

Answer 37

Usually Aortic Regurgitation - Regurgitant flow across leaking semilunar valve (aortic or pulmonic) - usually decrescendo

Question 38

Mid Diastolic Murmur

Answer 38

Mitral/Tricuspid Stenosis | Opening Snap/Diastolic Rumble - the opening of the stenotic AV valve makes a snapping sound

Question 39

Systolic-Diastolic Murmur

Answer 39

Aortic Stenosis and Aortic Insufficiency (regurg) obstruction of outflow of blood into the aorta from the LV and failure to close the aortic valve completely during diastole and consequent backflow of blood into the LV

Question 40

Maneuvers to identify systolic murmurs and the 2 phases

Answer 40

Standing or Strain phase of valsalva: Causes decreased venous return due to decreased BP and TPR thus decreased LV volume Squatting or Release Phase of Valsalva: Causes increased venous return due to increased BP and TPR, thus increased LV volume

Question 41

Bigeminal Pulse

Answer 41

Normal beat alternating with premature contraction | SV of the premature beat is diminished so the pulse is smaller in the premature beat

Question 42

Small weak pulses

Answer 42

Decreased pulse pressure due to decreased SV (heartfailure, stenosis) or increased TPR

Question 43

Large, Bounding Pulses

Answer 43

Increased pulse pressure, rise and fall may feel rapid | causes: increased SV, decreased TPR, fever, anemia, slow heart rate, decreased compliance of the ventricular walls

Question 44

Special Exam: Measuring JVD

Answer 44

Inidcator of Right atrial pressure; Fluid Overload test Prop pt's head at 30 degrees find JVD pulse find maximal pulse pt measure from sternal angle (5cm above RA) JVP > 4cm above the sternal angle (9cm above RM) indicates elevated Right heart pressure

Question 45

Specialized Exam: Hepatojugular Reflux

Answer 45

Fluid overload test Prop pt's head at 30 degrees apply firm pressure over the RUQ observe neck for an increase in JVP, followed by decrease as you remove pressure JVP will increase in all pts, but an excessive increase indicates RHF

Question 46

Position of the PMI

Answer 46

(can examine pt supine or left lateral decubitus) 5th ICS at the MCL, 2.5cm in size should not exceed the width of one intercostal space Cardiac impulse lateral to MCL inidicates LVH

Question 47

Specialized Exam: Cardiac Percussion

Answer 47

Estimate of Cardiac Size | Percuss from the L midaxillary line at the 5th ICS and percuss medially

Question 48

Specialized Exam: Auscultation

Answer 48

Sitting up and Leaning forward: have pt exhale and hold. Listen at the base for murmurs: aortic regurg or pulmonic regurg

Question 49

Specialized Exam: Left Lateral Decubitus Auscultation

Answer 49

Pt rolls to side | Place Bell of steth on apical impulse to hear low heart sounds such as gallops or murmurs