Physical Exam

Question 1

Early diastolic sounds

Answer 1

OS->pericardial knock->S3

OS first after S2 (end of cycle in systole) - abrupt opening of mobile but stenotic MV
interval between S2 and OS decreases as LAP rises ie worse MS (prior to filling of LV)

2nd sound is pericardial knock - MV open and is high pitched sound of blodo hitting LV wall

S3 - rapid filling of LV that occurs later than impact sound of pericardial knock - S3 normal in children - means HF in adults (louder with inspiration)

S4 - low pitched sound of atrial filling during diastole
no s4 with afib or increased atrial pressure

Question 2

Continuous murmur of AV connections

Answer 2

PDA
ruptured sinus of valsalva aneursym
AVM
coronary fistula
peak at S2 and continue to diastolie

Question 3

OS

Answer 3

diastolic murmur with pre-systolic accentuation in MS - with AF no presystolic component

Question 4

AR/PR

Answer 4

early descresendo murmur in diastole

Question 5

AR

Answer 5

blowing decrescendo diastolic murmur
paradoxic split of S2 - delayed aortic valve closure from LVEDP elevation
austin flint - due to early closure of MV with AR- fxn MS
LATE DIASTOLIC RUMBLE - austin flint mrumur (functional MS from early closure of MV 2/2 AR) - sounds like MS - NO OPENING SNAP (differentiates from MS)

Question 6

HOCM

Answer 6

increased murmur
squat to stand
valsalva

Question 7

Aortic Stenosis

Answer 7

Murmur decreases with squat to stand and with valsalva
paradoxically split or absent 2nd heart sound
delayed occurance and diminshed carotid impulse
(parvus and tardus)
late peaking systolic ejection murmur

Question 8

ASD

Answer 8

Fixed split S2
Soft systolic ejection murmur Left upper sternal border
iRBBB

Question 9

PS

Answer 9

wide split S2
Systolic murmur
high pitched ejection click

Question 10

Ebsteins

Answer 10

TR murmur 3/6 holosystolic - inc’s with respiration

Loud mid systolic click (sail sign)

Question 11

AR

Answer 11

increased with handgrip/amyl/squatting nitrate (lowers afterload)

Question 12

MS

Answer 12

murmur increases with inc’d HR

low pitched diastolic rumble with opening snap at apex (bell)

Question 13

S4

Answer 13

Late diastolic before S1
low pitched - cardiac apex bell
forceful atrial contraction
(forceful situps will accentuate)
Dec'd LV compliance (stiffer) - HTN

Question 14

S3

Answer 14

early diastole just after S2
low pitched - bell at apex
can be physiologic in children and young adults
if over 40 then look for HF

Question 15

BAV

Answer 15

high pitched early systolic click
at apex
doesn’t vary with repiration or maneuvers

Question 16

HCM

Answer 16

harsh systolic murmur
decreases with squatting/handgrip
increases with standing

Question 17

MVP

Answer 17

mid systolic click
late systolic murmur
squatting click and murmur move later

Question 18

ebsteins

Answer 18

pan systolic murmur - lower left sternal edge
increases with inspiration
(TR)

Question 19

ASD

Answer 19

fixed split S2
systolic ejection murmur
2nd left ICS

Question 20

VSD

Answer 20

holosystolic
left of sternum 4th to 5th ICS
palpable thrill
no respiratory variation

Question 21

Pericardial rub

Answer 21

S1, S2 then two or 3 component rub (sounds like rubbing/squishing fluids)

Question 22

PDA

Answer 22

2nd left ICS

continuous machine like murmur (continuous whorling)