Cardiology Basics and Heart Sounds

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Questions and Answers

What type of murmurs often occur with regurgitant flow across the AV valves?

Pansystolic (Holosystolic) murmurs

What condition is often indicated by a late systolic murmur?

Mitral valve prolapse

What do early diastolic murmurs typically reflect?

Regurgitant flow across incompetent semilunar valves

Middiastolic and presystolic murmurs reflect turbulent flow across which valves?

The AV valves Signup and view all the answers

What type of murmurs do congenital patent ductus arteriosus and AV fistulas produce?

Continuous murmurs that are nonvalvular in origin Signup and view all the answers

Where is a murmur best heard that often originates at or near the aortic valve?

In the 2nd right interspace Signup and view all the answers

Where does the murmur of aortic stenosis often radiate to?

The neck Signup and view all the answers

In mitral regurgitation, where does the murmur often radiate to?

The axilla Signup and view all the answers

An identical degree of turbulence would cause a louder murmur in which type of person?

A thin person Signup and view all the answers

What is a fully described example of a murmur?

A medium-pitched, grade 2/6, blowing decrescendo diastolic murmur Signup and view all the answers

Right-sided heart murmurs generally increase with inspiration.

True Signup and view all the answers

Left-sided heart murmurs generally increase with inspiration.

False Signup and view all the answers

What does PMI stand for?

Point of Maximal Impulse Signup and view all the answers

The PMI is located on the right side of the chest in __________.

situs inversus and dextrocardia Signup and view all the answers

What does a PMI >2.5 cm indicate?

left ventricular hypertrophy (LVH) from hypertension or aortic stenosis Signup and view all the answers

What conditions result in lateral displacement of the PMI?

Left Ventricular Hypertrophy (LVH) or ventricular dilatation from myocardial infarction (MI) or heart failure. Signup and view all the answers

In most adults over age 40, the diastolic sounds of S3 and S4 are pathologic.

True Signup and view all the answers

What does an S3 heart sound correspond to?

an abrupt deceleration of inflow across the mitral valve Signup and view all the answers

What does an S4 heart sound correspond to?

increased left ventricular end diastolic stiffness Signup and view all the answers

What occurs during systole?

The left and right ventricles contract and eject blood into the aorta and pulmonary artery. Signup and view all the answers

What happens during diastole?

The ventricles relax and blood flows from the atria into the ventricles. Signup and view all the answers

Which heart sound is produced by the closure of the mitral valve?

S1 Signup and view all the answers

Which heart sound is produced by aortic valve closure?

S2 Signup and view all the answers

What are the two types of heart failure as categorized currently?

Heart failure with preserved ejection fraction (EF) and heart failure with reduced EF. Signup and view all the answers

What are signs and symptoms of acute myocardial infarction (MI)?

Classic exertional pain, pressure, or discomfort in the chest, shoulder, back, neck, or arm. Signup and view all the answers

Acute coronary syndrome includes which conditions?

unstable angina, non-ST elevation MI, and ST elevation infarction. Signup and view all the answers

Causes of chest pain in the absence of coronary artery disease include?

Microvascular coronary dysfunction and abnormal cardiac nocioception. Signup and view all the answers

What condition presents with anterior chest pain often described as tearing or ripping?

Acute Aortic Dissection Signup and view all the answers

What should be done if there are symptoms of irregular heart action?

Obtain an ECG. Signup and view all the answers

What may transient skips and flip-flops in a patient's history indicate?

Possible premature contractions. Signup and view all the answers

What are 'a waves' in Jugular Venous Pulsations associated with?

Increased resistance to right atrial contraction, for example, in tricuspid stenosis. Signup and view all the answers

What does an absent 'a wave' indicate?

Atrial Fibrillation Signup and view all the answers

Increased 'v waves' occur in conditions such as?

Tricuspid regurgitation and atrial septal defects. Signup and view all the answers

What does the examination of the carotid pulse include?

Amplitude and contour, and presence of thrills or bruits. Signup and view all the answers

A unilateral pulsatile bulge is indicative of?

A tortuous and kinked carotid artery. Signup and view all the answers

What may cause decreased carotid pulsations?

Decreased stroke volume from shock or MI. Signup and view all the answers

What happens when pressure is applied to the carotid sinus?

It may cause reflex bradycardia or a drop in blood pressure. Signup and view all the answers

In cardiogenic shock, how does the carotid pulse feel?

Small, thready, or weak. Signup and view all the answers

How is the carotid pulse described in aortic regurgitation?

Bounding. Signup and view all the answers

In aortic stenosis, how is the carotid upstroke described?

Delayed. Signup and view all the answers

What is a paradoxical pulse?

It varies with respiration. Signup and view all the answers

What do alternately loud and soft Korotkoff sounds signal?

Pulsus alternans. Signup and view all the answers

What is the highest systolic pressure during the respiratory cycle known as?

The pressure when Korotkoff sounds are first heard. Signup and view all the answers

What does a difference of ≥10 mm Hg to 12 mm Hg in systolic pressure indicate?

A paradoxical pulse. Signup and view all the answers

Where are thrills in aortic stenosis transmitted to?

The carotid arteries. Signup and view all the answers

What usually causes bruits?

Atherosclerotic luminal stenosis. Signup and view all the answers

How common is asymptomatic carotid stenosis in the United States?

∼1% for stenoses occluding 75% to 90% of the lumen. Signup and view all the answers

How does Mitral Stenosis present on auscultation?

Low-pitched extra sounds such as an S3, opening snap, diastolic rumble. Signup and view all the answers

What does Aortic Regurgitation present as on auscultation?

A soft decrescendo higher-pitched diastolic murmur. Signup and view all the answers

S1 is diminished in __________.

1st degree heart block Signup and view all the answers

S2 is diminished in __________.

Aortic Stenosis Signup and view all the answers

What does the presence of a thrill indicate?

Changes the grading of a murmur. Signup and view all the answers

What is important to keep in mind when palpating impulses from the RV?

Palpation is less useful in patients with a thickened chest wall or increased AP diameter. Signup and view all the answers

In dextrocardia, where is the heart situated?

In the right chest cavity. Signup and view all the answers

In full situs inversus, where are the major organs located?

The heart, trilobed lung, stomach, and spleen are on the right, and the liver and gallbladder are on the left. Signup and view all the answers

What percentage of adults can palpate the apex beat in the supine position?

25% to 40% Signup and view all the answers

What may pregnancy or a high left diaphragm cause regarding apical impulse?

Shift the apical impulse upward and to the left. Signup and view all the answers

What conditions may lead to lateral displacement of the apical impulse?

Heart failure, cardiomyopathy, and ischemic heart disease. Signup and view all the answers

What does lateral displacement from the midclavicular line suggest?

Increased left ventricular volume and low left ventricular EF. Signup and view all the answers

In the left lateral decubitus position, a diffuse PMI with a diameter >3 cm suggests?

Left ventricular enlargement. Signup and view all the answers

What might a hyperkinetic high-amplitude impulse signify?

Hyperthyroidism, severe anemia, pressure overload, or volume overload of the left ventricle. Signup and view all the answers

What does a diffuse sustained low-amplitude (hypokinetic) apical impulse indicate?

Heart failure and dilated cardiomyopathy. Signup and view all the answers

What does a brief early to mid-diastolic apical impulse represent?

A palpable S3. Signup and view all the answers

What does a sustained left parasternal movement beginning at S1 suggest?

Pressure overload from pulmonary hypertension. Signup and view all the answers

What may hyperinflation of the lungs prevent during examination?

Palpation of the hypertrophied RV. Signup and view all the answers

What does a prominent pulsation in the Pulmonic Area indicate?

Dilated or increased flow in the pulmonary artery. Signup and view all the answers

What may a pulsation in the Aortic Area suggest?

Dilated or aneurysmal aorta. Signup and view all the answers

What characterizes a markedly dilated failing heart?

A hypokinetic apical impulse displaced far to the left. Signup and view all the answers

What position accentuates left-sided S3 and S4 heart sounds?

Left lateral decubitus position. Signup and view all the answers

How can the soft diastolic decrescendo murmur of aortic regurgitation be best heard?

Ask the patient to sit up, lean forward, exhale completely, and briefly stop breathing after expiration. Signup and view all the answers

What happens to S2 when either A2 or P2 is absent?

S2 is persistently single. Signup and view all the answers

What does expiratory splitting of S2 suggest?

A valvular abnormality. Signup and view all the answers

What causes persistent splitting of S2?

Delayed closure of the pulmonic valve or early closure of the aortic valve. Signup and view all the answers

What does a loud P2 indicate?

Pulmonary Hypertension Signup and view all the answers

What is the most common extra heart sound?

The systolic click of mitral valve prolapse. Signup and view all the answers

What do diastolic murmurs usually represent?

Valvular Heart Disease. Signup and view all the answers

What do systolic murmurs suggest?

Valvular disease but can be physiological flow murmurs. Signup and view all the answers

What should murmurs during pregnancy be evaluated for?

Possible risk to the mother and fetus. Signup and view all the answers

From where do midsystolic murmurs typically arise?

Blood flow across the semilunar (aortic and pulmonic) valves. Signup and view all the answers

Study Notes

Point of Maximal Impulse (PMI)

The PMI marks the cardiac apex, usually in the 5th intercostal space near the left midclavicular line.
Displacement of PMI lateral to the midclavicular line indicates left ventricular hypertrophy (LVH) or myocardial dilatation.
PMI size over 2.5 cm suggests LVH due to hypertension or aortic stenosis.
Aortal conditions like situs inversus and dextrocardia can shift PMI to the right side.

Heart Sounds and Impacts

Diastolic sounds S3 and S4 are often pathologic in adults over 40, linking to heart failure and myocardial ischemia.
S3 indicates rapid filling of the left ventricle, while S4 occurs with stiff ventricle conditions.
S1 and S2 are heart sounds marking valve closures; S1 occurs during ventricular contraction, whereas S2 marks relaxation.

Heart Failure Classifications

Heart failure is categorized into preserved and reduced ejection fraction, impacting treatment approaches.

Myocardial Ischemia and Symptoms

Classic acute myocardial infarction (MI) symptoms include exertional chest pain and discomfort, with atypical symptoms more common in older women.
Acute coronary syndrome encompasses unstable angina and both ST-elevation and non-ST elevation MI.

Palpitation Indicators

Signs of irregular heartbeats necessitate ECG to assess conditions like atrial fibrillation.
Palpitation clues include skips, sudden onset of rapid beating, and regular rapid rates suggestive of heart dysfunction.

Jugular Venous Pulsations

Prominent JVP a waves indicate increased resistance seen in conditions like tricuspid stenosis and severe AV block.
Absent a waves signal atrial fibrillation, while increased v waves indicate tricuspid regurgitation or atrial septal defects.

Carotid Pulse Assessment

Carotid pulse evaluation includes inspection of pulsations and palpation for thrills or bruits, essential for assessing cardiac function.
Decreased carotid pulsations suggest diminished stroke volume due to shock or arterial occlusion.
A bounding carotid pulse signals aortic regurgitation, while a delayed upstroke indicates aortic stenosis.

Various Murmurs and Their Significations

Diastolic murmurs often signify valvular heart disease, while systolic murmurs can be physiological or suggest cardiopathies.
Pansystolic murmurs are typical of regurgitant flow across AV valves, like in mitral regurgitation, while late systolic murmurs indicate mitral valve prolapse.

Auscultation Techniques

Certain positions can accentuate heart sounds and murmurs: left lateral decubitus for left-sided S3 and S4, and sitting forward for aortic regurgitation detection.
Notably, the second heart sound (S2) may be persistently single in serious valve diseases, indicating potential pathologies.

Importance of Blood Pressure Measurement

Korotkoff sounds during blood pressure assessment provide insight into cardiac health; discrepancies can indicate underlying issues.
A paradoxical pulse (10-12 mm Hg difference) signals potential cardiac tamponade or severe pulmonary conditions.

Additional Cardiac Conditions

Bruxism and murmurs from conditions like patent ductus arteriosus exhibit continuous sounds, requiring careful evaluation in various patient populations.
Thickening of the chest wall can obscure heart sounds, emphasizing the importance of proper patient positioning during assessments.

General Observations

Various respiratory and positional changes can impact heart dynamics, indicating the importance of comprehensive evaluations for accurate diagnostics.
Age and gender differences in symptom presentation necessitate tailored approaches in diagnosing and managing cardiac conditions.

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Description

This quiz covers essential concepts in cardiology, including the Point of Maximal Impulse (PMI), heart sounds, and classifications of heart failure. Understand the significance of PMI's location, the implications of heart sounds in adults, and the treatment considerations for different types of heart failure. Test your knowledge on myocardial ischemia and its symptoms.