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CARDIOVASCULAR heart sounds & murmurs:

N671 Tammy Valenta RN, MSN, PHN Assistant Professor CARDIOVASCULAR heart sounds & murmurs PART 2

Heart Sounds:

Heart Sounds

Heart Sounds:

Heart Sounds Second heart sound, “dub”, occurs when semilunar valves close

Heart Sounds :

Heart Sounds 4

Extra Heart Sounds:

Extra Heart Sounds

Extra Heart Sounds:

Extra Heart Sounds S3 sounds like LUB-DUBAB S3=vibration

Extra Heart Sounds:

Extra Heart Sounds S4 sounds like Belub - dup





Murmurs- Description:

Murmurs- Description Timing/Duration Intensity Quality Pitch Location Pattern/Shape

Murmurs General Principles:

Murmurs General Principles Stenosis = Harsh, turbulent flow Regurgitation = softer, blowing, gurgle Systolic = A/P stenosis, M/T regurg, VSD Diastolic = A regurg or M stenosis

Murmurs – Description Timing/Duration:

Murmurs – Description Timing/Duration

Murmurs – Description Intensity:

Murmurs – Description Intensity

Murmurs- Description Quality , Pitch and location:

Murmurs- Description Quality , Pitch and location Quality Pitch Location

Murmurs – Description Pattern/shape:

Murmurs – Description Pattern/shape Pattern/Shape Crescendo Decrescendo Crescendo-decrescendo Plateau

Mitral Valve Prolapse:

Mitral Valve Prolapse Defined: A bulging of one or both mitral valve leaflets into the left atrium during systole Timing- late systolic Location- apex Characteristics- midsystolic click Associated illness/symptoms- 5% normal population, asymptomatic, sudden death Buzz words-most common valvular lesion, ballooning/floppy valve, Marfan’s syndrome

Mitral Valve Prolapse:

Mitral Valve Prolapse

Mitral Valve Regurgitation:

Mitral Valve Regurgitation Defined: Retrograde flow from the left ventricle through an incompetent mitral valve into the left atrium Timing- holosystolic Location- apex, radiates to left axilla Characteristics- soft, high pitched, blowing Associated illness/symptoms- MV prolapse, MI, rheumatic heart disease, cardiomyopathy, endocarditis Buzz words- radiating

Mitral valve regurgitation:

Mitral valve regurgitation

Mitral Stenosis:

Mitral Stenosis Defined: Obstruction of flow from left atrium to left ventricle because of a narrowed mitral orifice Timing- early diastolic Location- apex Characteristics- “opening snap”, high pitched, crescendo pattern Associated Illnesses- rheumatic fever Buzz words- hx of childhood rheumatic fever, presents with progressive dyspnea, pulmonary edema, hemoptysis

Mitral Valve Stenosis:

Mitral Valve Stenosis “Opening Snap” High pitched Early diastolic Abrupt deceleration of the mitral valve leaflets

what is the aortic valve?:

what is the aortic valve?

Aortic Valve Stenosis:

Aortic Valve Stenosis Defined: Narrowing of the aortic outflow tract causing obstruction of flow from the left ventricle into the ascending aorta Timing- mid-systolic Location- Right 2 nd ICS, radiates to carotids Characteristics- harsh, late peaking crescendo-decrescendo, mid systolic murmur; assoc. thrill, sustained apical impulse Assoc. Illness/symptoms- older age, bicuspid aortic valve, rheumatic fever Buzz words- pulsus parvus et tardus , angina, syncope, heart failure , ejection click

aortic valve stenosis:

aortic valve stenosis

Aortic Regurgitation (Insufficency):

Aortic Regurgitation ( Insufficency ) Defined: Retrograde flow from the aorta into the left ventricle through incompetent aortic cusps Timing- diastolic Location-2 nd and 4 th left ICP’s Characteristics- high pitched, blowing Assoc. Illness/symptoms- aortic root degeneration, rheumatic heart disease, VSD Buzz words- high pulse pressure= bounding pulses

Aortic regurgitation:

Aortic regurgitation


MURMURS INNOCENT vs FUNCTIONAL Some murmurs are common in healthy children or adolescents Increased blood flow velocity and smaller chest makes an audible murmur Innocent no valvular or other pathologic cause generally soft (grade ii) heard at the 2-3 LICS and disappears with sitting no sign of cardiac dysfunction. Functional due to increased blood flow to the heart (as in anemia, fever, pregnancy, or hyperthyroidism) 27


COMMON INNOCENT MURMURS Vibratory or Still’s murmurs http:// Well localized Musical buzzing Variable with position changes Pulmonary flow murmurs Venous hums


PATHOLOGIC MURMURS IN CHILDREN HISTORY Symptomatic SOB Easy Fatigue Failure to Thrive (poor feeding & increased caloric expenditure Cyanosis Pulses: should be palpable and equal: atypical with murmur is pathologic Characteristics of murmurs: Holosystolic or Diastolic Harsh quality Grade 3 or higher An abnormal S2 Maximal murmur intensity at the upper left sternal border A systolic click Increased intensity when patient stands


Question A 30 year-old Hispanic woman reports to her primary care physician complaining of progressive dyspnea. She reports she has a two-year history of progressively worsening shortness of breath on exertion with even modest amounts of activity. Occasionally, a dry cough accompanies her dyspnea. Today, she had a mild episode of hemoptysis, which prompted her visit. She denies fever, chills, or sputum production. Her medical history is significant for a febrile illness with sore throat and joint pain at the age of 15 in Mexico. On examination, she is a well-developed female in no acute distress. A crescendo diastolic rumble is present at the apex of the heart and fine crackles are auscultated at the lung bases. Which of the following is the most likely diagnosis? Mitral stenosis Myocardial infarction Pneumonia Pulmonary effusion Pulmonary embolus


Question A 67-year-old man presents to his doctor’s office for an insurance physical. During blood pressure measurement, the nurse notes that systolic sounds are heard with the cuff completely deflated. The blood pressure is 180/60 mm Hg. Physical examination reveals bounding pulses and a high-pitched, blowing diastolic murmur, heard best along the left sternal border. Which of the following are the most likely diagnosis? A. Aortic regurgitation B. Aortic valve obstruction C. Cardiac Tamponade D. Heart failure E. Hypovolemia


Question A 65-year-old man has had congestive heart failure with increasing pulmonary congestion and edema for several years. He has had increasing peripheral edema involving his lower legs in the last couple of days. His blood pressure is 125/85 mm Hg. He is afebrile. He had been previously healthy all his life with no major illnesses. A serum glucose is 95 mg/ dL . His total serum cholesterol is 185 mg/ dL . The serum creatine kinase is not elevated. The most likely etiology for these findings is: A. Alcoholic cardiomyopathy B. Calcified bicuspid aortic valve C. Tricuspid valve endocarditis D. Aortic dissection calcification E. Amyloidosis

All done!!:

All done!!