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Questions and Answers
What occurs during systole in the cardiac cycle?
What occurs during systole in the cardiac cycle?
- Ventricles contract (correct)
- Atria contract
- Ventricles relax
- Aortic and pulmonary valves close
Which valves are responsible for closing during the S1 heart sound?
Which valves are responsible for closing during the S1 heart sound?
- Pulmonic and tricuspid valves
- Tricuspid and mitral valves (correct)
- Aortic and mitral valves
- Aortic and pulmonic valves
What type of heart murmur occurs with stenotic lesions?
What type of heart murmur occurs with stenotic lesions?
- Systolic murmur (correct)
- Continuous murmur
- Diastolic murmur
- Adventitious murmur
What does the intensity of a heart murmur correlate with?
What does the intensity of a heart murmur correlate with?
What is the primary cause of regurgitation in heart valves?
What is the primary cause of regurgitation in heart valves?
During which phase of the cardiac cycle do the tricuspid and mitral valves open?
During which phase of the cardiac cycle do the tricuspid and mitral valves open?
Which murmur grade is characterized as being very faint and may not be heard in all positions?
Which murmur grade is characterized as being very faint and may not be heard in all positions?
Which heart sound is associated with the closing of the aortic and pulmonic valves?
Which heart sound is associated with the closing of the aortic and pulmonic valves?
Which shape of murmur is characterized by an increase in intensity followed by a decrease?
Which shape of murmur is characterized by an increase in intensity followed by a decrease?
Which dynamic auscultation maneuver is most likely to decrease the intensity of left-sided murmurs?
Which dynamic auscultation maneuver is most likely to decrease the intensity of left-sided murmurs?
What is the consequence of stenosis when valves should be open?
What is the consequence of stenosis when valves should be open?
Which of the following best describes diastole?
Which of the following best describes diastole?
Where might the radiation of a heart murmur typically be felt?
Where might the radiation of a heart murmur typically be felt?
What impact does expiration generally have on left-sided murmurs?
What impact does expiration generally have on left-sided murmurs?
What specifically causes the sound S1 in the heart?
What specifically causes the sound S1 in the heart?
Which characteristic does not apply to heart murmurs?
Which characteristic does not apply to heart murmurs?
Where is the aortic area located for auscultation?
Where is the aortic area located for auscultation?
Which grade of murmur can be heard when the stethoscope is partly off the chest?
Which grade of murmur can be heard when the stethoscope is partly off the chest?
During which phase of the cardiac cycle does S2 occur?
During which phase of the cardiac cycle does S2 occur?
What physiological event leads to the splitting of S2 during inspiration?
What physiological event leads to the splitting of S2 during inspiration?
Heart murmurs are primarily caused by which condition?
Heart murmurs are primarily caused by which condition?
What does regurgitation in valvular disease refer to?
What does regurgitation in valvular disease refer to?
In which area is the splitting of S2 best heard?
In which area is the splitting of S2 best heard?
What pathological process can affect the splitting of S2?
What pathological process can affect the splitting of S2?
Which maneuver worsens mitral valve prolapse and hypertrophic obstructive cardiomyopathy?
Which maneuver worsens mitral valve prolapse and hypertrophic obstructive cardiomyopathy?
What effect does rapid squatting have on mitral valve prolapse?
What effect does rapid squatting have on mitral valve prolapse?
Which pharmacologic maneuver affects only left-sided murmurs?
Which pharmacologic maneuver affects only left-sided murmurs?
Which type of murmur is almost always pathological?
Which type of murmur is almost always pathological?
What effect does hand grip have on aortic stenosis?
What effect does hand grip have on aortic stenosis?
Which of the following murmurs is a diastolic murmur?
Which of the following murmurs is a diastolic murmur?
Which maneuver decreases left ventricular preload?
Which maneuver decreases left ventricular preload?
What is the effect of rapid leg raise on heart murmurs?
What is the effect of rapid leg raise on heart murmurs?
What type of murmur worsens with passive leg raising?
What type of murmur worsens with passive leg raising?
Which murmur best describes aortic stenosis during auscultation?
Which murmur best describes aortic stenosis during auscultation?
What is a common clinical finding associated with mitral regurgitation?
What is a common clinical finding associated with mitral regurgitation?
Which type of murmur is associated with mitral valve prolapse?
Which type of murmur is associated with mitral valve prolapse?
How does standing or performing Valsalva maneuver affect murmurs?
How does standing or performing Valsalva maneuver affect murmurs?
Which finding is associated with aortic regurgitation?
Which finding is associated with aortic regurgitation?
What is the quality of a murmur caused by tricuspid regurgitation?
What is the quality of a murmur caused by tricuspid regurgitation?
Which heart sound characterizes mitral stenosis?
Which heart sound characterizes mitral stenosis?
With which maneuver does the intensity of pulmonic stenosis murmurs increase?
With which maneuver does the intensity of pulmonic stenosis murmurs increase?
Which murmur increases with expiration?
Which murmur increases with expiration?
What type of murmur can be described as continuous and machine-like?
What type of murmur can be described as continuous and machine-like?
What is the pitch of the murmur typically associated with tricuspid stenosis?
What is the pitch of the murmur typically associated with tricuspid stenosis?
Which type of heart murmur is increased with squatting?
Which type of heart murmur is increased with squatting?
Which clinical condition is associated with pulmonary hypertension?
Which clinical condition is associated with pulmonary hypertension?
Which murmur is worsened by maneuvers that increase preload?
Which murmur is worsened by maneuvers that increase preload?
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Study Notes
Anatomy of the Heart
- The angle of Louis is at rib 2.
- The aortic area is at the 2nd ICS at the right sternal border.
- The pulmonic area is at the 2nd ICS at the left sternal border.
- The tricuspid area is at the 4th ICS at the left sternal border.
- The mitral area is at the 5th ICS at the midclavicular line.
Cardiac Cycle
- Systole is ventricular contraction, the aortic and pulmonic valves open, the tricuspid and mitral valves close.
- Diastole is ventricular relaxation, the atria contract and ventricles fill, the tricuspid and mitral valves open, the aortic and pulmonic valves close.
Normal Heart Sounds
- S1 (LUB) occurs at the beginning of systole and is caused by the closure of the atrioventricular valves.
- S2 (DUB) occurs at the beginning of diastole and is caused by the closure of the semilunar valves.
- S1 is louder at the apex of the heart.
- S2 is louder at the base of the heart.
Physiologic Splitting of S2
- S2 normally splits during inspiration.
- This is because the decrease in intrathoracic pressure increases venous return, which increases blood volume in the right ventricle, causing the pulmonic valve to stay open longer.
- A2 is heard before P2.
- Splitting of S2 is best heard in the pulmonic area.
Pathologic Splitting of S2
- P2 normally closes slightly after A2 during inspiration.
- Various pathologic processes can affect the timing or sequence of valve closure.
Heart Murmurs
- A heart murmur is an audible vibrations caused by increased turbulence of blood flow in the heart.
- Causes: Valvular disease, regurgitation (backflow of blood), stenosis (obstruction of forward blood flow).
Characteristics of Murmurs
- Timing: Systolic or diastolic.
- Shape: Crescendo, decrescendo, plateau.
- Location: 2nd, 4th or 5th ICS.
- Radiation: Axilla, carotids.
- Intensity: Grade I-VI.
- Quality: Blowing, harsh, rumbling, musical.
- Pitch: Low, medium, high.
Murmur Intensity
- Murmur intensity does not correlate with disease severity.
Dynamic Auscultation Maneuvers
- Respiration: Inspiration worsens right-sided murmurs, expiration worsens left-sided murmurs.
- Valsalva/Standing: Decrease in left ventricular preload, decrease in left ventricular afterload, decrease in right ventricular preload.
- Rapid Squatting/Leg Raise: Increase in left ventricular preload and right ventricular preload, no effect on afterload.
- Hand grip: Increase in left ventricular afterload.
Systolic Murmurs
- Aortic Stenosis: crescendo-decrescendo murmur heard at the right 2nd ICS, radiates to the carotids.
- Pulmonic Stenosis: crescendo-decrescendo murmur heard at the left 2nd ICS, radiates to the left shoulder and neck.
- Mitral Regurgitation: holosystolic murmur heard at the apex, radiates to the left axilla.
- Mitral Valve Prolapse: Late crescendo murmur preceded by a midsystolic click heard at the apex.
- Tricuspid Regurgitation: holosystolic murmur heard at the left lower sternal border, radiates to the right of the sternum.
Diastolic Murmurs
- Aortic Regurgitation: Early decrescendo murmur heard at the left midsternal border, radiates to the apex.
- Pulmonic Regurgitation: Early decrescendo murmur heard at the left 2nd ICS, radiates along the left sternal border.
- Mitral Stenosis: Decrescendo murmur following an opening snap heard at the apex.
- Tricuspid Stenosis: Decrescendo murmur following an opening snap heard at the left lower sternal border.
Rules to Remember
- Inspiration worsens right-sided murmurs.
- Hand grip worsens left-sided regurgitations.
- Rapid squatting and leg raise increase preload.
- Standing and Valsalva decrease preload.
- Maneuvers that decrease preload improve most murmurs.
- Maneuvers that increase preload worsen most murmurs (exceptions: MVP and HOCM).
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